Intrapleural fibrinolytic treatment of multiloculated postpneumonic pediatric empyemas

BACKGROUND: Progression of empyema, with the development of fibrinous adhesions and loculations, makes simple drainage difficult or impossible. The appropriate management remains controversial. Intrapleural fibrinolytic treatment to facilitate drainage of loculated empyema instead of open thoracotomy has been advocated since the 1950s. The aim of this study was to assess the effectiveness of intrapleural fibrinolytic treatment in postpneumonic pediatric empyemas. METHODS: In our clinic, we used intrapleural fibrinolytic agents in 72 pediatric patients with multiloculated empyema between 1994 and 2002. Streptokinase, 250,000 U in 100 mL of 0.9% saline solution (59 patients), and urokinase, 100,000 U in 100 mL of 0.9% saline solution (13 patients), were instilled daily into the chest tube, and the tube was clamped for 4 hours followed by suction. This treatment was continued daily for 2 to 10 days until resolution was demonstrated by chest radiograms or computed chest tomography. RESULTS: The rate of drainage after fibrinolytic treatment was increased 73.77%. Treatment was ineffective in 14 (19.44%) of 72 patients who underwent fibrinolytic instillation. Treatment was discontinued because of allergic reaction and pleural hemorrhage in 1 patient, and because of development of bronchopleural fistula in another one. The regimen was completely successful in 43 (59.72%) patients, and partially successful in another 15 (20.83%). Twelve of those patients who had failure eventually required decortication and recovered completely. One patient died of sepsis and pleural hemorrhage; another patient died because of food aspiration. CONCLUSIONS: In all patients with loculations except those with a bronchopleural fistula, intrapleural fibrinolytic treatment should be tried. Thus, the majority of children with loculated empyemas can be treated successfully without invasive interventions, such as thoracoscopic debridements or open surgery.     

Surgical strategy of complex empyema thoracis.

BACKGROUND: The optimal treatment of empyema thoracis has been widely debated. Proponents of pleural drainage alone, drainage plus fibrinolytic therapy, video-assisted thoracoscopic surgical (VATS) debridement, and open thoracotomy each champion the efficacy of their approach. METHODS: This study examines treatment of complex empyema thoracis between June 1, 1994, and April 30, 1997. Twenty-one men and 9 women underwent 30 drainage/decortication procedures (14 open thoracotomies and 16 VATS) in treatment of their disease. Effusion etiology was distributed as follows: infectious-14; neoplastic-associated-7; traumatic-3; other-6. RESULTS: The mean preoperative hospital stay was 14 +/- 8.8 days, (11.4 +/- 6.5 days for VATS vs 16.8 +/- 10.2 days for thoracotomy). Hospital stay from operation to discharge for thoracotomy patients was 10.0 -/+ 7.2 days (median 8.5 days) and for VATS patients 17.6 -/+ 16.8 days (median 11 days). These differences were not statistically significant. Duration of postoperative thoracostomy tube drainage was 8.3 -/+ 4.6 days for thoracotomy patients and 4.7 -/+ 2.8 days in the VATS group (p = 0.01). Operative time for the thoracotomy group was 125.0 -/+ 71.7 minutes, while the VATS group time was only 76.2 -/+ 30.7 minutes. Estimated blood loss for the thoracotomy group was 313.9 -/+ 254.0 milliliters and for the VATS group 131.6 -/+ 77.3 milliliters. Three of the 30 patients (10.0%) required prolonged ventilator support (>24 hours). Morbidity included one diaphragmatic laceration (VATS group) and one thoracic duct laceration (thoracotomy). Two VATS procedures (6.7%) required conversion to open thoracotomy for thorough decortication. CONCLUSIONS: The surgical approach to empyema thoracis is evolving. In the absence of comorbid factors, the significantly lower requirement for chest tube drainage time in the VATS patients suggests that this modality is an attractive alternative to thoracotomy in the treatment of complex empyema thoracis.     

Current treatment of pediatric empyema

Pneumonia with complicated parapneumonic effusion and empyema is increasing in incidence and continues to be a source of morbidity in children seen in our institution. Current diagnostic modalities include chest radiographs and CT scanning with ultrasound being helpful in some situations. Exact management of empyema remains controversial. Although open thoracotomy drainage is well accepted in children, video-assisted thoracoscopic surgery (VATS) drainage has become more prevalent in the current era. Over the last 4 years, we have treated 58 children with intrapleural placement of pigtail catheters and administration fibrinolytics consisting of tissue plasminogen activator (tPA). Successful drainage and resolution of 54 of the 58 effusions was achieved with percutaneous methods alone. There was no mortality or 30-day recurrence. Mean hospital stay was 9.1 days (range 5 to 21) and mean chest catheter removal was 6 days post placement (range 1.5 to 20). Of the four patients that failed percutaneous tube therapy, 3 underwent video assisted thoracic surgery (VATS), and one had open thoracotomy with decortication. Based on our experience, tPA administered through a small bore chest tube for drainage of complicated parapneumonic effusions has become our standard practice. We reserve VATS for treatment failures and open thoracotomy and decortication for patients with VATS failure.     

Surgical treatment of pleural empyema--changing priorities

The surgical management of pleural empyema and post-traumatic clotted haemothorax is described. The study included 15 cases of post-thoracotomy empyema, 23 of empyema of other aetiology and five of post-traumatic haemothorax. Chest-tube drainage was the first measure in most cases. Post-pneumonectomy empyema was treated with partial thoracoplasty plus omentoplasty (8 cases) or plus myoplasty (1 case). Empyema after lobectomy or bilobectomy (4 cases) or after failed decortication (1 case) was managed with thoracoplasty or, in cases of concomitant wound infection, with open-window thoracostomy followed by thoracoplasty. Empyema after subclavian artery reconstruction (1 case) was cleared by removal of a previously unrecognized foreign body. For early empyema of other aetiology or haemothorax (10 cases in total), treatment comprised debridement by video-assisted thoracoscopic surgery (VATS). VATS was also used to establish suitable pleural drainage prior to elective thoracotomy (2 cases). Decortication and partial parietal pleurectomy were performed for organizing-stage empyema (16 cases). Three of the 15 patients with post-thoracotomy empyema died perioperatively, one died two months postoperatively and one had recurrence of bronchopleural fistula during follow-up. One patient with VATS debridement subsequently required thoracotomy and lobectomy for lung abscess. All the others with VATS or decortication recovered without complications. During follow-up there was no mortality or recurrence of empyema.     

Acute Empyema in Children Treated by Open Thoracotomy and Decortication

Acute nontuberculous empyema treated conventionally by thoracentesis, thoracostomy drainage, and antibiotics has an unacceptably high rate of morbidity and mortality. Early open thoracotomy to eliminate the empyema with decortication of the fibrinous peel and reexpansion of the lung has proven safe and effective for 25 years.The goals of treatment of acute nontuberculous empyema are: (1) to save life, (2) to eliminate the empyema, (3) to reexpand the trapped lung, (4) to restore mobility of the chest wall and diaphragm, (5) to return respiratory function to normal, (6) to eliminate complications or chronicity, and (7) to reduce the duration of hospital stay.Our studies confirm the normal values to be expected in patients who have had complete recovery from the acute empyema, and we lay to rest any concern that decortication might, in time, limit pulmonary function.We present the cases of 21 children who had acute and mature empyemas that were treated by open thoracotomy and decortication, with an average follow-up of 18 years, among whom there were no deaths or complications.     

Surgical treatment of metapneumonic pleural empyema

During a period of 13 years 54 patients have been treated for metapneumonic pleural empyema, namely 3 children (all boys), 31 men and 20 women. One patient was admitted in extremis heavily intoxicated after unsuccessful attempt at closed drainage. He died during thoracotomy for open drainage. All the remaining 53 patients were cured, 3 out of 18 by closed thoracostomy (Bülau), 12 out of 16 by open drainage and 37 by decortication which had to be combined with pulmonary resection 13 times. Local treatment of pleural empyema is aimed at the obliteration of the pleural space. This goal can best be accomplished: in the acute exudative stage of the disease (according to the American Thoracic Society) by closed thoracotomy, in the fibrino-purulent phase by open thoracotomy with rib resection and in the chronic organizing stage by decortication.     

The role of early limited thoracotomy in the treatment of empyema

On the basis of clinical experience with 80 patients at Denver General Hospital from 1979 through 1984, we devised a three-part classification of empyema. Class I empyema (n = 12) is pleural effusion with pH less than 7.2 and with no bacteria. Patients with this type of empyema were treated with short-duration chest tubes. Further treatment was required in two of 12. There were no deaths. Class II (n = 28) is classic uniloculate empyema. Patients with this category of empyema were treated with chest tubes, with two deaths. Class III (n = 40) is complicated empyema, with multiple loculations. Tube thoracostomy failed more often than not; decortication was required in 10 of 18 patients treated with prolonged tube drainage. Limited thoracotomy for drainage and placement of tubes was done in 22 patients. Five required extension of the thoracotomy and decortication. All 22 had resolution of the empyema with no additional procedures. Limited thoracotomy immediately or during the first week of treatment is recommended for all multiloculated or complex empyemas.     

Management of tuberculous empyema.

OBJECTIVE: In an attempt to establish a treatment protocol for tuberculous empyema, we retrospectively reviewed our experience over a 3-year period. METHODS: Between January 1996 and December 1998, 26 patients (23 male and three female) with an average age of 33.8 years (range 18-61 years) presented with tuberculous empyema. The empyema was right-sided in 13, left-sided in 12 and bilateral in one patient. Patients presented with respiratory symptoms for a mean duration of 4.43 months (range 1-48 months). All patients had a computerized scan of the chest and managed according to the stage of empyema. RESULTS: In patients with exudative empyema (n=4) the fluid was aspirated, but one patient required intercostal tube (ICT) drainage for 6 days. There were four patients with fibrinopurulent empyema treated with thoracoscopic drainage with a mean post-operative stay of 8 days (range 4-12 days). In the organizing stage (n=18), initial drainage with large ICT was performed. The pleura was less than 2 cm in thickness in eight patients, for which repeated installation of streptokinase was performed (three to seven times). Satisfactory results were achieved in six patients (75%) and the remaining two required decortication. Of the ten patients with thick cortex, one required a window and nine had decortication, two of which had additional lobectomy and two had pneumonectomy. All patients fully recovered with no mortality and with a mean duration of drainage of 18 days (range 3-61 days). CONCLUSION: Its stage and the state of the underlying lung should guide surgical treatment for tuberculous empyema. This protocol aims to achieve cure utilizing the least invasive approach and acceptable hospital stay.     

Continuous pleural lavage may decrease postoperative morbidity in patients undergoing thoracotomy for stage 2 thoracic empyema.

OBJECTIVE: To assess the impact of postoperative continuous pleural lavage (PCPL) after thoracotomy for the treatment of stage 2 pleural empyema in relation to postoperative length of stay and morbidity. METHODS: Stage 2 pleural empyema was diagnosed with computer tomography. Conservative treatment including antibiotics and pleural aspiration was introduced. 89 patients treated for stage 2 pleural empyema by thoracotomy, pleural discharge evacuation and irrigation after pleural decortication were identified after unsuccessful conservative treatment for 10 days. Whenever pleural discharge remained opaque after operation, PCPL was administered daily through the cranial chest tube and discharge evacuated through the caudal pleural suction (10-15 mmHg) tube. Risk factors related to pleural pus and patient outcome were sought for. RESULTS: Seventy-seven out of 89 patients (86.5%) had clear empyema discharge immediately after pleural decortication and irrigation. Pleural discharge remained opaque despite surgery in 12 out of 89 patients (13.5%) and PCPL was introduced. Presence of a combination of risk factors for pleural empyema, such as dental caries, alcohol abuse or previous inflammatory reaction, was predictive for persistence of opaque pleural discharge after operation (P<0.05). Need for re-thoracotomies (in 11 cases, P=ns) and postoperative deaths (P<0.05) were related with patients who did not have PCPL. The length of the hospital treatment was 20.1+/-3.1 (days+/-SEM) among patients with PCPL and 19.2+/-1.8 without PCPL before possible re-thoracotomy, respectively (P=ns). CONCLUSIONS: Early postoperative (1 day-11 months) mortality was statistically associated with patients having fibrinopurulent empyema but no PCPL. PCPL is a feasible method to clear pleural pus discharge without prolongation of hospitalization and may be recommended after thoracotomy for patients with fibrinopurulent stage 2 empyema.     

Is thoracoscopic decortication sufficient for the treatment of empyema?

Before thoracoscopy became popular in the 1990s, thoracotomy and decortication was the treatment of choice for empyema thoracis not responding to tube thoracostomy. An Institutional Review Board-approved, retrospective review of all patients treated for empyema between September 1, 2006, and August 31, 2009, at Kern Medical Center was conducted. A total of 37 patients (male=33; female=4) with a mean age of 43.7 years were treated. Empyema developed after community-acquired pneumonia (CAP) in 27, traumatic hemothorax (TH) in nine, and other cause in one. For 34 of 36 patients (91%), a thoracoscopic approach was successful. Two of 36 patients required conversion to thoracotomy, whereas one patient required an initial thoracotomy in each case as a result of tenacious adhesions. Mean duration of the chest tube was 4.1 days in patients with CAP and 4.6 days in patients with TH. Mean length of stay after surgery was 6 days for patients with CAP and 9.1 days for patients with TH. Five of 37(13.5%) had complications and one patient died (2.7%). Follow-up was complete for 81.1 per cent of patients, none of whom required a subsequent intervention. Compared with the literature, it appears that the conversion rate to thoracotomy, length of chest tube duration, and postoperative length of stay have decreased as experience has increased.     

Does VATS provide optimal treatment of empyema in children? A systematic review

Purpose

The surgical literature is replete with studies describing methods of treatment for pediatric empyema. The purpose of this report was to perform an evidence-based review of the literature to determine the most effective and appropriate treatment for empyema in infants and children.

Methods

The MEDLINE database was searched for English- and Spanish-language articles published from 1987 through 2002 on the treatment of thoracic empyema in children. Additional unpublished data were obtained by contacting individual study authors. There were no multiinstitutional prospective studies; all were retrospective, institutional series. A true meta-analysis could not be performed because of inherent institutional bias and variability in outcome measures among studies. A Kruskal-Wallis nonparametric test was used to compare methods detailed in the individual studies.

Results

Forty-four retrospective studies with a total of 1,369 patients were available for analysis. Four treatment strategies were compared: chest tube drainage alone (16 studies, 611 patients), chest tube drainage with fibrinolytic instillation (10 studies, 83 patients), thoracotomy (13 studies, 226 patients), and video-assisted thoracoscopic decortication (VATS; 22 studies, 449 patients). Outcome measures common to the majority of studies included length of stay, fever duration, l of antibiotic therapy duration, and duration of chest tube drainage. Patients undergoing early VATS or thoracotomy had shorter length of stay (P = .003). There was a trend for shorter duration of postoperative fever compared with chest tube alone or with fibrinolytic therapy, but this did not reach statistical significance (P = .055). There was no statistical difference in chest tube duration between methods. There was no trend correlating antibiotic use with treatment methods, length of hospital stay, duration of fever, or length of chest tube requirement.

Conclusions

Early VATS or thoracotomy leads to shorter hospitalization. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. A carefully designed, multiinstitutional, randomized study would lead to the development of evidence-based standards that may optimize the treatment of thoracic empyema in children.     

Randomised trial of intrapleural urokinase in the treatment of childhood empyema

BACKGROUND: The role of intrapleural fibrinolytic agents in the treatment of childhood empyema has not been established. A randomised double blind placebo controlled trial of intrapleural urokinase was performed in children with parapneumonic empyema. METHODS: Sixty children (median age 3.3 years) were recruited from 10 centres and randomised to receive either intrapleural urokinase 40 000 units in 40 ml or saline 12 hourly for 3 days. The primary outcome measure was length of hospital stay after entry to the trial. RESULTS: Treatment with urokinase resulted in a significantly shorter hospital stay (7.4 v 9.5 days; ratio of geometric means 1.28, CI 1.16 to 1.41 p=0.027). A post hoc analysis showed that the use of small percutaneous drains was also associated with shorter hospital stay. Children treated with a combination of urokinase and a small drain had the shortest stay (6.0 days, CI 4.6 to 7.8). CONCLUSION: Intrapleural urokinase is effective in treating empyema in children and significantly shortens hospital stay.     

Decortication in paediatric empyema, comparative study of early vs late intervention

Background

A retrospective study was conducted at Govt Medical College, Jammu in the pediatric patients who were referred to Cardio Thoracic and Vascular Surgery department with thoracic empyema and were taken up for thoracotomy and decortication Our experience showed that early intervention gave better results than in group with delayed intervention.

Material and methods

Between January 2003 and 2011, 76 patients underwent pleural decortication in pediatric age group presenting with thoracic empyema who did not respond to conservative management. 45 patients were male and 31 patients were female. They were initially evaluated with routine chest radio graphs and with Computed Tomography (CT) chest. Diagnosis of thoracic empyema was made in these cases with radio graphic evidence and was substantiated with pleural fluid cultures 62 underwent early intervention whereas 14 had delayed intervention.

Results

62 (84 %) patients underwent early decortication (within 4 weeks of Intercostaltube insertion) whereas 14 (16 %) cases were taken up for delayed decortication beyond 1 month due to unavoidable reasons like delayed referral, high grade fever or because of other co morbid diseases. In early group all patients responded well to early decortications. 6 (10 %) patients required secondary intervention that included 4 (6.4 %) patients due to recurrence of empyema or lung collapse after surgery & 2(3.2 %) patients required lung resection. and the mean hospital stay was 12 days In late intervention group, it was found that the operative time increased, the duration of chest drain also increased due to air leak/increased drainage leading to increased hospital stay (16 days) and 6 (42 %) patients required secondary intervention.

Conclusion

Early decortication is an effective surgical treatment for thoracic empyema as It facilitates early evacuation and mechanical decortication of pleural space with no additional morbidity and leads to reduced time for chest tube drainage and shortens hospital stay.     

Suction drainage: a new approach to the treatment of empyema.

Thirteen patients with empyema thoracis were treated with a new suction drainage technique. The method entails passing a catheter into the empyema cavity under ultrasound guidance and using strong suction to drain loculated pus. Eight patients had no recurrence after a single treatment and one patient had no recurrence after two treatments. The procedure was a useful palliative measure in two patients with malignant disease who subsequently died. In one patient failure of the lung to expand after the procedure showed the need for thoracotomy. In one other patient the empyema recurred and decortication was required.     

Surgical therapy of pleural empyema

In the period from January 1976 to December 1986, 31 (56.3%) out of 55 patients with pleural empyema were treated, after failure of conservative treatment with antibiotic drugs, pleural puncture and tube drainage. Twenty-two patients were submitted to a posterolateral thoracotomy with debridement in the early stage or decortication in the later stage of empyema thoracis. There was no relapse of empyema in this group, but 7 patients suffered from air leakage for 7 to 19 days (mean 12 days). One patient needed rethoracotomy after debridement for continuous bleeding. Nine patients were treated in a first step with limited thoracotomy in local anaesthesia with or without costotomy. There were 5 relapses of empyema in this group. The average time of hospitalization was for the debrided cases 13.6 days and for the decortication group 19.6 days. The conservatively treated group remained during 39.5 days in the hospital.     

Is open thoracotomy still a good treatment option for the management of empyema in children?

BACKGROUND: The incidence of pediatric postpneumonic empyema increases, and there is little consensus on its management. Open thoracotomy has been linked with high morbidity and prolonged hospitalization. Our aim was to review the outcome after open thoracotomy and to provide a set of data for comparison with other treatment modalities. METHODS: Forty-four children (median age, 8 years, 2 months to 16 years) undergoing surgery for postpneumonic empyema between 1993 and 2002 in our unit were studied. RESULTS: The median time from onset of symptoms to admission in a pediatric unit was 8 days (range, 2 to 63 days), the median time from pediatric admission to surgical referral was 3 days (range, 0 to 19 days), and the median time from surgical admission to thoracotomy was 1 day (range, 0 to 2 days). Eight children had a chest drain before surgical admission. Six patients, who were referred late (19 to 69 days), had lung abscesses. A limited muscle sparing thoracotomy (44 patients), formal decortication (36 patients), lung debridement (5 patients), and lobectomy (1 patient) were performed. After thoracotomy, median time to apyrexia was 1 day (range, 0 to 27 days) and drain removal was 3 days (range, 1 to 16 days). A pathogen was isolated in 21 patients. There were no deaths. Four children with abscesses remained septic and had lobectomies (2 patients) and debridements (2 patients). The median postoperative hospital stay was 5 to 53 days. One child had postpneumonic empyema develop and had decortication 3 months postoperatively. At follow-up, all children were doing well and had satisfactory radiographs. The Kaplan-Meier 5-year and 10-year survival rate, freedom from any reoperation, and freedom from hospital readmission were 100%, 87%, and 98%, respectively. CONCLUSIONS: Open thoracotomy remains an excellent option for management of stage II-III empyema in children. When open thoracotomy is performed in a timely manner there is low morbidity and it provides rapid resolution of symptoms with a short hospital stay. However, delayed referrals may result in advanced pulmonary sepsis and a protracted clinical course. The late results are encouraging. Use of thoracoscopy or fibrinolysis should be considered on the basis of their own merit, not on the assumption of probable adverse outcomes after thoracotomy.     

The surgical management of empyema thoracis in substance abuse patients: a 5-year experience

Postpneumonic empyema (EMP) may develop in substance abuse patients, requiring prolonged hospitalization. An algorithm that provides quality care and a rational basis for timely surgical intervention would be advantageous. We report our five-year experience with EMP in substance abuse patients and present such a treatment plan. Sixty-one substance abuse patients were treated for EMP. Posteroanterior, lateral, and decubitus x-ray studies were obtained before treatment to assess fluid movement. Chest tubes were placed to drain frank pus and to obtain material for positive smears. X-ray studies and computed tomography were done 24 hours later to assess parenchymal pathology and to detect any multiple loculations. Thirty-three substance abuse patients recovered following initial tube thoracostomy and 7 after a second chest tube was introduced. Twenty-one had multiple loculations and underwent thoracotomy. Twenty of the 21 required extensive debridement or decortication, or both; 2 required lobectomy and 1 pneumonectomy. Chest tubes were removed on an average of 6 +/- 1.5 days. Average postoperative stay was 10.7 +/- 2 days. There were 2 early deaths and 1 late death and no recurrent EMP. Bacteriology findings were nonspecific and often polymicrobial. We conclude that early thoracotomy can be lifesaving in the presence of a benign clinical course.     

Minimally invasive surgery in the treatment of empyema: intraoperative decision making

BACKGROUND: Pneumonia, parapneumonic effusions, and empyema continue to be significant health problems, especially in elderly individuals. Minimally invasive thoracic surgery in the treatment of empyema has been demonstrated but has not been well defined. Furthermore, it has not been determined how to choose patients who can be treated with thoracoscopy versus thoracotomy. We report the results of a strategy in which all patients were initially approached with thoracoscopy and converted to open decortication only if the lung could not be inflated to fill the chest. METHODS: A total of 172 patients underwent decortication for empyema over a 5-year period. Thoracoscopic decortication was attempted in all patients; patients were converted to open decortication if access to the pleural space was not possible, or if the lung could not be mobilized sufficiently to reach both the chest wall and the diaphragm. Proportions were compared using the chi(2) test. RESULTS: Of the 172 patients, 66 successfully underwent decortication with thoracoscopic techniques only. The remaining 106 patients required complete thoracotomy. No difference was found in the reoperation rate; 3 of 106 open thoracotomy patients underwent reexploration for recurrent empyema, whereas two of 66 thoracoscopy patients required reoperation for hemothorax (p = 0.347). There was a tendency for thoracoscopic patients to require reoperation for bleeding (p = 0.08); both patients taken back to the operation room for bleeding had undergone thoracoscopic pleurectomy. Eleven of 166 patients (all explored with open thoracotomy) died after decortication, for a mortality rate of 6.6%. All of these patients had gone to surgery from the intensive care unit. CONCLUSIONS: Using the criteria of complete expansion of the lung surface to the chest wall and diaphragm allowed accurate selection of patients who could undergo complete thoracoscopic decortication without risk of recurrent empyema. Computed tomographic scans did not help to predict which patients would require open procedures. Thoracoscopic patients were more likely to require reoperation for bleeding if thoracoscopic pleurectomy was performed.     

Videothoracosopy in diagnosis and surgical treatment of tuberculosis

From 1993 to May 2001, 795 psychiatric patients were treated including 563 with pleural effusion, 98 with multiple or solitary tuberculoma, 69 with tuberculous empyema, 14 with fibrotic-cavitary tuberculosis, 51 with disseminated tuberculosis. Mean age of the patients was 32 years. Survey of pleural cavity with pleural or lung biopsy was performed in 691 patients. In tuberculoma 14 lobectomies were performed, 23 patients underwent atypical lung resection without stapler (including with precise technique). Bilateral on-stage interventions were made in 32 patients. In empyema necrectomy and lung decortication were performed. 14 patients underwent videocavernoscopy with sequestrectomy and cavity drainage. In disseminated tuberculosis lung biopsy without staplers was usually performed. Aerohemostasis was achieved with plasma stream. One patient with empyema and one patient with pleural effusion died (lethality was 0.25%). Rate of postoperative complications was 7.5% in tuberculoma and 1.5% in disseminated tuberculosis. Conversion to thoracotomy was necessary in 3 (3%) patients with tuberculoma and 12 (17%) patients with empyema. Mean hospital stay was 4 days after diagnostic surgery and 7 days after lung resection. In pleural effusion diagnosis was verified in 98% cases, in disseminated tuberculosis--in 100%. Videothoracoscopy is the best diagnostic method for pleural effusion and disseminated forms of lung tuberculosis and operation of choice in tuberculoma and empyema. Videothoracoscopy in tuberculosis is highly effective and associates with low rate of postoperative complications and lethality.     

Empyema thoracis: a problem with late referral?

BACKGROUND--Patients are often referred to thoracic units for management of empyema after the acute phase has been treated with antibiotics but without adequate drainage. This study evaluates the effects of delay in surgical treatment of empyema thoracis on morbidity and mortality. METHODS--Thirty nine consecutive patients were studied from January 1991 to June 1992. Two groups (group 1, 16 patients; group 2, 23 patients) were compared depending on the time spent under the care of other specialists before referral to the thoracic unit (group 1, seven days or less; group 2, eight days or more). The reasons for delay in referral were analysed. RESULTS--Four patients were treated conservatively with chest drainage alone (all in group 1). Thirty five patients required rib resection and drainage of their empyema (group 1, 12 patients; group 2, 23 patients). Nineteen (all in group 2) of the 35 patients who had rib resections went on to have decortication. The commonest cause of empyema was post-pneumonic (37 out of 39 patients). Staphylococcus aureus was the commonest organism isolated. Misdiagnosis (five patients), inappropriate antibiotics (six patients), and inappropriate placement of chest drainage tubes (three patients) all contributed to persistence and eventual progression of empyema. The overall mortality was 10% and mortality increased with age. The median stay in hospital was 9.5 days (range 7-12 days, n = 4) for patients treated with closed tube drainage only; 18 days (range 10-33 days, n = 16) for patients who had undergone rib resections and open drainage; and 28 days (range 22-49 days, n = 19) for patients who underwent decortication. The likelihood of having a staged procedure (antibiotics, closed tube drainage, open drainage with rib resection, and finally decortication) increased when closed tube drainage was persevered with for more than seven days. The total hospital stay was positively related with the time before referral for surgical treatment. Anaemia, low albumin concentrations, and worsening liver function were found in group 2 compared with group 1. CONCLUSIONS--Early adequate operative drainage in patients with empyema results in low morbidity, shorter stays in hospital, and good long term outcome. These patients should be treated aggressively and early referral for definitive surgical management is recommended.