Instillation of fibrinolytic enzymes in the treatment of pleural empyema

Acute pleural empyema which is not amenable to pleural puncture or closed thoracic drainage should be treated operatively by decortication or, in persistent cavities, by open thoracostomy drainage. In the last 2 years we have instilled 500,000 IU of fibrinolysines (streptokinase and streptodornase) per day into the pleural cavity of 27 patients with pleural infections requiring closed intrapleural drainage. By means of this treatment, pus and fibrinous membranes are liquefied and necrotic tissue is discharge. Therapeutic success is indicated by considerably increased fluid drainage about one hour after instillation. This therapy was performed for an average of 5 days. In 12 patients (44%) pleural empyema could be cured. In the other 15 cases decortication, and in 3 of them open thoracostomy drainage, was necessary. In our opinion intrapleural instillation of fibrinolytic enzymes should be added to the well-recognized method of treatment of pleural empyema, although not replace them.     

Is medical thoracoscopy efficient in the management of multiloculated and organized thoracic empyema?

Background: Pleural empyema can be subdivided into 3 stages: exudative, multiloculated, and organizing. In the absence of clear septation, antibiotics plus simple drainage of pleural fluid is often sufficient treatment, whereas clear septation often requires more invasive treatment. Objectives: The aim of this study was to report our experience and analyze the safety and efficacy of medical thoracoscopy in patients with multiloculated and organizing empyema. Methods: We performed a retrospective study reviewing the files of patients referred for empyema and treated by medical thoracoscopy at our department from July 2005 to February 2011. Results: A total of 41 patients with empyema were treated by medical thoracoscopy; empyema was free flowing in 9 patients (22%), multiloculated in 24 patients (58.5%), and organized in 8 patients (19.5%). Medical thoracoscopy was considered successful without further intervention in 35 of 41 patients (85.4%): all of the 9 patients with free-flowing fluid, 22 of the 24 patients with multiloculated empyema (91.7%), and only 4 of the 8 patients with organizing effusion (50%). Conclusions: Our study confirms that multiloculated pleural empyema could safely and successfully be treated with medical thoracoscopy while organizing empyema can be resistant to drainage with medical thoracoscopy, requiring video-assisted thoracic surgery or open surgical decortications; among this population, the presence of separate 'pockets' not in apparent communication with each other often leads to a surgical approach.     

Stage-by-stage pneumonectomy in pleural empyema]

Staged pneumonectomy tactics in complication of the main lung affection by pleural empyema was described. Surgery was based on an open treatment of empyema cavity before and after the principal surgical stage--pneumonectomy, which was completed by closed treatment using the method of early pleural cavity filling with curative solutions. Use of staged surgical treatment tactics makes it possible to prevent serious postoperative complications such as empyema recurrence and bronchial fistulas. Full clinical effect was achieved in 11 of the 56 operations of staged pneumonectomy in the presence of empyema.     

Treatment of complicated pleural effusion with intracavitary urokinase in children

Intrapleural administration of fibrinolytic agents such as urokinase (UK) has been advocated as an alternative method to manage complicated pleural effusion (CPE). Despite the increasing number of empyemas successfully treated with UK in adults, the experience in children is limited to a few cases. We report the results of image-guided catheter drainage (IGCD) with intracavitary instillation of UK in six children with CPE. Urokinase (25,000-100, 000 IU) was diluted in 20 mL of normal saline and instilled into the pleural cavity via a percutaneously placed drainage catheter. After 4 hr, the clamped catheter was released and connected to water-seal suction at a negative pressure of 20 cm H(2)O. UK instillation was repeated daily until no further drainage occurred. During IGCD, repeated radiographic and ultrasound imaging determined the location and amount of any remaining pleural fluid. Mean duration of hospital stay before initiating UK therapy was 4.3 days. Mean duration of catheter drainage before initiating UK therapy was 3.5 days, and the mean total drainage was 86 mL. All patients had an increase in chest tube drainage within 24 hr after the first instillation of UK. The mean net total drainage after UK instillation was 281 mL, most of the drainage being occurring in the first 2 days of treatment. Mean hospital stay following UK treatment was 5.8 days, and the average total duration of hospital stay was 13.8 days. No complications and no adverse events occurred during treatment with UK. Complete resolution of the consequences of the pleural effusion was observed in all patients at follow-up. Our results suggest that IGCD with adjunctive UK therapy is a reliable, simple, and safe approach to treat CPE, and it can reduce the risks associated with thoracotomy and decortication.     

New surgical tactics in the treatment of patients with complicated tuberculosis of the lungs and pleura]

Stepwise surgical tactics by using transsternal transepicardial preocclusion of the main bronchus and lung root vessels, opening of the empyema cavity and pneumotomy has been proposed to treat patients with progressive fibrocavernous tuberculosis complicated by pneumothorax and pleural empyema and extended into the thoracic wall. After 1.5-2 months the main stage of the operation, pleuropulmonectomy, is performed. Among the 25 patients operated on, the clinical effect was achieved in 15, 5 patients continued to take treatment, 5 patients died. The first results show that active care may be delivered to patients with complicated pulmonary and pleural tuberculosis who have recently had no hope to be recovered and the process be steady.     

Use of urokinase in childhood pleural empyema

Urokinase is an enzyme with a fibrinolytic effect that facilitates pleural empyema drainage through a chest tube. The aim of this study was to assess the risk of pneumothorax, the need for pleural debridement surgery, the persistence of fever, and the number of days in hospital in a group of children with parapneumonic pleural empyema treated with urokinase. This was an uncontrolled retrospective study on children suffering from parapneumonic empyema. Data collected on 17 children treated with urokinase were compared with 11 children treated prior to the advent of urokinase (the "historic" group). The urokinase was instilled in the pleural cavity over a period ranging from 2-8 days, amounting to a median total dose per kilogram of body weight of 18,556 IU (range, 7,105-40,299). Surgical treatment of the empyema involved drainage tube placement and/or debridement of the pleural cavity. Three children developed pneumothorax during their hospital stay, and one more case occurred 6 months after the child had recovered from his empyema; there were 3 cases of pneumothorax during the acute phase in the "historic" group (P = 0.54). Five children in the urokinase group were debrided and 12 were only drained, as opposed to 9 and 2, respectively, in the "historic" group (P = 0.02). The overall hospital stay was 17 days for the urokinase group, and 24 for the "historic" group (P = 0.02). No bleeding or other major complications were reported in the group treated with urokinase. In conclusion, urokinase treatment does not carry a risk of pneumothorax, while it does reduce hospital stay and the need for pleural debridement.     

肌瓣填塞术治疗慢性脓胸

目的　探讨慢性脓胸的外科治疗经验。方法 采用肌瓣填塞术治疗 8例慢性脓胸。结果6例治愈 ,1例未愈 ,1例复发。结论 肌瓣填塞术是治疗慢性脓胸的有效方法 ,具有胸廓形状不改变或轻度改变的特点。对肌瓣不能填满脓腔者应附加胸廓成形术。     

胸膜纤维板剥脱术治疗慢性结核性脓胸分析

目的：分析胸膜纤维板剥脱术治疗20例慢性结核性脓胸及合并症。方法：所有病例均行胸膜纤维板剥脱术，同时行2例干酪病灶清除，4例空洞清除,2例支气管胸膜瘘修补和1例T12L1椎体结核病灶清除术。结果：脓腔全部灭，空洞清除，瘘口闭合，肺内结核病灶稳定,肺功能明显改善。结论：胸膜纤维板剥脱术是治疗慢性结核性脓胸较理想的手术方法，可以扩大手术适应证。     

Efficacy and safety of iodopovidone pleurodesis in malignant pleural effusions

Background and objective: Pleurodesis is one of the best methods of controlling malignant pleural effusions (MPE), a distressing complication of metastatic disease. In recent studies of a wide range of pleural diseases, iodopovidone was used as a sclerosing agent for pleurodesis and demonstrated good results with low morbidity. The aim of this study was to evaluate the efficacy and safety of iodopovidone pleurodesis in MPE. Methods: A retrospective analysis was performed on patients with MPE who underwent pleurodesis at our institution between 2005 and 2008. All patients underwent instillation of 20 mL of 10% iodopovidone, 80 mL of normal saline and 2 mg/kg of lidocaine through a chest tube, which was clamped for 2 h. The tube was removed when the daily output of fluid was <200 mL. Data on the requirement for additional pleural procedures, adverse events and survival were collected. Results: Sixty‐one pleurodesis procedures were performed in 54 patients. No procedure‐related mortality was observed. Adverse events occurred after 11 (18%) pleurodesis procedures. The most frequent complication was mild thoracic pain that occurred immediately after 10 (16.4%) procedures, and one patient developed pleural empyema that was treated with drainage and antibiotics. A success rate of 98.4% was observed. Except for the patient who developed pleural empyema, none of the other patients had recurrences of pleural fluid or required additional pleural procedures during the follow‐up period (mean of 5.6 months). Conclusions: Iodopovidone pleurodesis was successful and was associated with only a few minor complications. It appears to be a good option for the management of recurrent MPE.     

Percutaneous drainage of liver and splenic abscess

42 patients with solitary (n = 34) and multiple (n = 8) abscesses of the liver (n = 36) and the spleen (n = 6) were treated with ultrasound guided percutaneous interventions. 38 patients (90%) underwent a total of 97 closed abscess aspirations using needles of 0.9 and 1.3 mm in diameter. In 4 cases (10%) percutaneous catheter drainage was performed. Intravenous antibiotics were used in all cases. Those patients with closed abscess aspiration additionally received local injection of aminoglycosides into the cavity. 40 out of the 42 patients could be treated successfully by percutaneous methods for a cure rate of 95.2%. Percutaneous drainage failure occurred in 2.4%. One patient with multiple liver abscesses and catheter drainage died from myocardial infarction (hospital mortality 2.4%). Complications of ultrasound-guided interventions included two minor bleedings, requiring no therapy, and one pleural empyema (complication rate 7.1%). There were no treatment related lethal complications. These results indicate that abscesses of the liver and the spleen up to 10 cm in diameter can be effectively treated by closed (repetitive) needle aspiration and antibiotic therapy with a relatively low rate of complications. About half of our patients with abscesses of more than 10 cm received percutaneous catheter drainage. On the basis of our experience surgical drainage of liver abscesses and splenectomy in splenic abscesses should be restricted to those cases with percutaneous drainage failure.     

Development of a case of Mycobacterium avium complex disease from right pleural effusion]

Moist pleurisy in patients with Mycobacterium avium Complex (MAC) is rarer than tuberculosis. We encountered an extremely rare case of MAC disease in a 75-year-old man who initially had only right pleural effusion. Gaffky VII was detected in the pleural effusion, and Mycobacterium avium was identified by culture and PCR. Although administration of antitubercular agents (RFP, INH, EB, and SM) + CAM and thoracic lavage were repeated, the Gaffky persisted strongly. Accordingly, pulmonary decortication and filling of the cavity with an omental flap were performed as surgical treatments. However, fistulas were formed between the remaining empyema cavity and the surgical wounds. Fenestration was also carried out. Postoperatively, centriacinar abnormalities appeared on computed tomography (CT). It has been reported that MAC disease begins with centriacinar abnormalities and the incidence of the lymphatic developmental pattern was low. Tuberculosis (the idiopathic pleuritis type) is considered to be caused this pattern from the primary infection focus. Therefore, the onset of unilateral effusion is extremely rare in patient with MAC disease, suggesting that the lymphatic developmental pattern occurs less frequently in patients with MAC disease. Furthermore, in this case, we speculated that centriacinar abnormalities were the MAC infection foci and could be detected by CT due to surgical invasion.     

Use of intrapleural streptokinase in the treatment of thoracic empyema

The incidence of pleural effusions in bacterial pneumonia may exceed 40%, a factor that may be related to increased morbidity and mortality. Options in the treatment of complicated pleural effusions or empyema, when unresponsive to closed tube drainage, include repositioning of the indwelling tube thoracostomy or insertion of additional chest tubes, instillation of intrapleural streptokinase, and surgical intervention. The authors describe the course of three patients wherein the use of intrapleural streptokinase was efficacious in effecting prompt drainage of previously inadequately evacuated empyema, thus eliminating the necessity for further invasive intervention.     

Surgical treatment of childhood pleural empyema

From June 1977 to January 1987, 175 patients underwent surgical treatment of childhood pleural empyema. The surgical treatment consisted of tube drainage in 159 (90%) cases, decortication in 31 (17%) cases, pleuropneumonectomy in 2, lobectomy in 1, and partial thoracoplasty in one cases. There were 2 hospital deaths (14 and 26 days after admission). Late recurrences didn't occur, except in one case where a partial thoracoplasty was necessary. During the follow-up of 11 to 120 months (mean 32 months) examinations were done by chest radiographs. We believe that, children with loculated empyema can be treated successfully with antibiotics and chest tube drainage in early stage. The tube drainage is a more effective method than the other surgical procedures. Few patients require open drainage, and further surgery is rarely required.     

胸腔镜在渗出性胸腔积液中的临床研究

目的研究内科胸腔镜在渗出性胸腔积液检查中的高效性、安全性、并发症。方法 2013年12月至2015年8月128例渗出性胸腔积液患者,随机分为A组、B组,各组64例。A组胸腔积液行常规检查,B组行内科胸腔镜检查。结果 A组:36例为结核性,24例为恶性,3例为炎性或脓胸,1例患者病因不明确,5例患者需手术诊断。B组:40例为结核性,21例为恶性,3例炎性或脓胸,3例需手术诊断。恶性肿瘤患者45名(35.2%,P0.01),结核性胸膜炎患者76人(59.4%),炎性或脓胸患者6人(4.7%),1人病因不明确(0.7%)。其中腺癌占28例,鳞癌5例,小细胞癌9例,恶性间皮瘤3例。内科胸腔镜并发症较少(7%,P0.05)。结论内科胸腔积液诊断尤其针对反复或持续性胸腔积液患者,是一种高效、微创、安全的检查手段。     

Pleural Lavage: A Novel Diagnostic Approach For Diagnosing Exudative Pleural Effusion

Patients with pleural effusions frequently present a diagnostic and therapeutic challenge. The diagnosis is based on the interpretation of the results of thoracentesis or pleural biopsy. When a malignant tumor metastasizes to the pleura, tumor cells can be seeded over the mesothelial surface or in the subserous layer. In the former situation, tumor cells are abundant in pleural fluid, but in the latter, few malignant cells are exfoliated into the pleural cavity, and microscopic deposits may not be visualized at thoracoscopy. Pleural lavage cytologic study at the time of thoracoscopy has not been studied. The purpose of this study was to assess the value of thoracoscopic pleural lavage as an adjuvant in the diagnostic workup of patients with exudative pleural effusions. Fifty patients with exudative pleural effusions were investigated by pleural fluid cytologic findings, Abram's pleural biopsy, thoracoscopy, and pleural lavage cytologic findings. After aspiration of all pleural fluid, 300 mL saline was instilled into the pleural cavity and then recovered for cytologic analysis. The final diagnoses were 32 malignant (64%), 15 tuberculous (30%), and 3 idiopathic (6%) effusions. In the malignant group, thoracoscopic biopsy had the highest yield (94%) followed by lavage cytologic analysis (84%), fluid cytologic analysis (62%), and biopsy with Abram's needle (50%). The sensitivity of combined thoracoscopy and lavage cytologic analysis was 96%. In the patients with tuberculous pleuritis, the yield from the pathologic examination of the biopsy specimen was 93% with thoracoscopy and 60% with the Abrams needle. The diagnostic yield with cytologic analysis on pleural lavage fluid is significantly higher than that on pleural fluid. This is probably because the cells in the lavage fluid are fresher and better preserved than those in the regular pleural fluid, which may have undergone degenerative changes, yielding false-negative results. Pleural lavage cytologic analysis should be performed in patients with suspected malignant pleural effusion who are subjected to diagnostic thoracoscopy, because it may provide additional information to thoracoscopic biopsy. Accepted for publication: 21 November 2000     

Role of surgical treatment in thoracic empyema with bronchopleural and/or thoracic empyema]

Sixty-nine patients with thoracic empyema treated surgically were experienced from May, 1978 through December, 1990. Thirty-nine cases had bronchopleural and/or thoracic fistula. Thirty-two patients were associated with pulmonary tuberculosis, of whom fourteen had tuberculous empyema and eighteen were sequelae of pulmonary tuberculosis or tuberculous pleurisy. The remainder were postoperative, postpneumonic, and posttraumatic empyemas. Of fourteen patients who developed postoperative bronchopleural fistula, there were ten patients who had lobectomy or pneumonectomy for lung cancers. Omental pedicle flap method, in which empyema space was filled with the omentum and pedicled muscle flap, was performed on 19 patients with bronchopleural or thoracic fistula or both. Fifteen patients were cured successfully by single-stage procedure, though there was one operative death due to aspiration pneumonia, and two recurrences which were treated by muscle plombages. There was another patient who had multiple surgical procedures in the past resulting in partial recurrences, but the fistula of this patient subsequently closed without reoperation. Postoperative decrease of %VC, FEV1.0/PVC were minimal. Treatment of long standing bronchopleural fistula is a difficult problem, and our omental pedicle flap method is relatively simple and safe which can be most suitably applied to those patients in whom other procedures have failed and to those with poor pulmonary functions.     

Using of fibrinolytics in the treatment of complicated parapneumonic effusion and empyema in children

Bacterial pneumonia is associated with a high incidence of pleural effusions in children. These parapneumonic effusions usually resolve spontaneously if patients are treated with appropriate antibiotics. However, a small percentage of parapneumonic effusions will become complicated, either loculated non-purulent fluid or an empyema. The traditional therapeutic approaches for complicated parapneumonic effusions includes catheter drainage and systemic antibiotics. Tube drainage often fails if the fluid is loculated by fibrinous adhesions and surgical operation require. Intrapleural administration of fibrinolytics is an effective treatment for complicated parapneumonic effusions and pleural empyemas, improving the drainage without causing systemic fibrinolysis or local hemorrhage. The global success rate were between 44% and 100%, in most cases more than 80%. Both streptokinase and urokinase have been used for this purpose but there are few reports of their use in the children. Intrapleural streptokinase and urokinase are equally efficacious in treating complicated parapneumonic effusions and empyemas. Intrapleural instillation of fibrinolytics is an effective and safe mode of treatment for complicated parapneumonic effusions and pleural empyemas, and may reduce the need for more invasive surgical procedures.     

Treatment of sonographically stratified multiloculated thoracic empyema by medical thoracoscopy

INTRODUCTION: In cases of empyema, some form of intervention, either chest tube drainage, thoracoscopy, video-assisted thoracic surgery (VATS), or thoracotomy, with or without pleural fibrinolysis, is required. What the best approach is and when and how to intervene is a matter of debate. STUDY OBJECTIVE: To analyze the safety and outcome of medical thoracoscopy in the treatment of multiloculated empyema. METHODS: We report a retrospective series of 127 patients with thoracic empyema treated with medical thoracoscopy from 1989 to 2003 in three hospitals in Switzerland and Italy. All patients had multiloculated empyema as identified by chest ultrasonography. In the absence of multiloculation, or in case of fibrothorax, simple chest tube drainage or surgical VATS/thoracotomy were performed, respectively. RESULTS: Mean age +/- SD was 58 +/- 18 years (range, 9 to 93 years). In 47%, a microbiological diagnosis was made. Complications occurred in 9% of patients (subcutaneous emphysema, n = 3; air leak of 3 to 7 days, n = 9). No mortality was observed. Forty-nine percent of patients received postinterventional intrapleural fibrinolysis. Medical thoracoscopy was primarily successful in 91% of cases. In four patients, the insertion of an additional chest tube or a second medical thoracoscopy was required. Finally, 94% of patients were cured by nonsurgical means. Six percent of patients required surgical pleurectomy, mostly through thoracotomy. CONCLUSION: Multiloculated empyema as stratified by ultrasonography can safely and successfully be treated by medical thoracoscopy.     

Empyema thoracis: a review of a 4 1/2 year experience of cases requiring surgical treatment

During the period January 1985 to June 1989, 53 cases of empyema thoracis were treated surgically at Papworth hospital regional cardio-thoracic centre. Of these, 47 patients underwent thoracotomy and decortication as their primary surgical treatment. The remaining six patients were treated by rib resection. Prior to surgical referral 20 of these had undergone previous tube drainage for a mean period of 18 days (range 7-42 days). The principle cause of empyema was broncho-pulmonary infection. In 57% of cases no organisms were isolated from pleural debris or fluid. In the remainder, a variety of organisms were encountered. Early surgical drainage and freeing of the underlying lung met with good results and no deaths in the uncomplicated group. The median duration of postoperative chest drainage for the whole group was 7 days (mean 12 days) and median postoperative in-hospital stay was 13 days (mean 20 days). This is in stark contrast to the duration of hospitalization of patients prior to surgical referral (mean 103.6 days). There were five deaths. All occurred in patients with severe debilitating associated illnesses. In these patients initial drainage of the empyema space with a tube or by rib resection may have allowed recovery prior to more major surgery.