Pancreatic pleural effusion accompanied by bronchopleural fistula]

In recent years, chronic massive pleural effusions have been increasingly recognized as a serious complication of pancreatitis. We describe the third reported case of a pancreatic pleural effusion accompanied by bronchopleural fistula. A 49-year-old man suffering from chronic alcohol-related pancreatitis was admitted to our hospital complaining of cough and shortness of breath. A chest x-ray film disclosed a large right pleural effusion with an air-fluid level. Ultrasonography and computed tomography of the upper abdomen demonstrated a giant pancreatic pseudocyst in the pancreatic tail and a fistulous tract reaching into the posterior mediastinum via the esophageal hiatus. Thoracentesis revealed sterile hemorrhagic fluid with markedly elevated amylase activity of 20,955 IU/l (pancreatic isozyme, 100%) and no malignant cells. A diagnosis of pancreatic pleural effusion was made. The therapy for pancreatic internal fistula is somewhat controversial. We employed conservative therapy, including hyperalimentation and chest tube drainage that successfully decreased the pleural effusion and closed the fistulous tract. Nonetheless, we were still troubled by a continuous air-leak via the drainage tube. Pleurodesis confirmed the tentative diagnosis of bronchopleural fistula and successfully stopped the air-leak. No re-accumulation of pleural effusion has been seen for 2 years. We concluded that pancreatic enzyme-rich effusions, if long-standing, may be complicated by bronchopleural fistula, thus underscoring the need for urgent drainage and initially conservative management.     

Empyema necessitans in the setting of pneumonia and parapneumonic effusion

Empyema necessitans is a rare complication of pleural space infections and occurs when the infected fluid dissects spontaneously into the chest wall from the pleural space. This process may result from bronchopleural extension of a peripheral lung infection. These cases result from inadequate treatment of an empyema and usually occur after a necrotizing pneumonia or pulmonary abscess. We present two cases of empyema thoracic necessitans.     

Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography

BACKGROUND: Differentiation between pyopneumothorax and lung abscess can be difficult but has important therapeutic consequences. The role of chest ultrasonography in this issue remains undetermined. Sonographic features of hydropneumothorax and/or pyopneumothorax are characteristic and not difficult to recognize. In this study, the authors evaluate the usefulness of a panel of sonographic findings characteristic of hydropneumothorax in distinguishing pyopneumothorax from lung abscess. METHODS: This series included 16 patients with lung abscess and 19 with pyopneumothorax. A diagnosis of lung abscess or pyopneumothorax was based on the following criteria: pus aspiration from the lesion, appropriate clinical setting, thoracic computed tomographic findings, serial follow-up of chest radiograms, and consistent clinical course. The panel of sonographic features suggestive of hydropneumothorax, including the presence of air-fluid level, the curtain sign, loss of gliding sign above the air-fluid level, and the suspended microbubble sign, were recorded and analyzed by a consensus of blinded readers. In addition, sonographic features used to differentiate empyema and lung abscess were also evaluated. RESULTS: The results indicated that the presence of air-fluid level, the curtain sign, loss of gliding sign above the air-fluid level, and the suspended microbubble sign were valuable in distinguishing pyopneumothorax from lung abscess. All four sonographic findings were observed in 17 of 19 patients with pyopneumothorax. In contrast, two or fewer sonographic findings were seen in 16 patients with lung abscess. Our results confirmed that the wall characteristics, shape of the lesion, chest wall angle, and pleural separation were also useful. CONCLUSIONS: The panel of sonographic findings is of considerable value in differentiating pyopneumothorax and lung abscess.     

Video-assisted thoracoscopic surgery in the treatment of complicated parapneumonic effusions or empyemas: outcome of 234 patients

STUDY OBJECTIVE: To review our experience in treatment of complicated parapneumonic effusion and pleural empyema by video-assisted thoracoscopic surgery (VATS). DESIGN: Retrospective chart review. SETTING: Taiwanese medical centers. PATIENTS: A total of 234 patients (108 women, 126 men; median age, 51 years; range, 0.75 to 84 years) underwent procedures for parapneumonic effusion (145 patients) or pleural empyema (89 patients) between May 1995 and December 2003. All patients had chest radiographs, and 188 patients (80.3%) underwent preoperative CT or sonography. More than 85% (200 patients) received preoperative diagnostic or therapeutic thoracentesis, tube thoracostomy, or fibrinolytics. Indications for VATS included empyema refractory to medical control or peel or multiloculated exudates per CT and chest tapping. INTERVENTIONS: Septal lysis and debridement irrigation through one port (31 patients, 13.2%), decortication and debridement through two or three ports (179 patients, 76.5%), or rib resection or larger utility incision for decortication and drainage (24 patients, 10.3%). RESULTS: Mean +/- SD procedural time was 64.3 +/- 22.5 min (range, 26 to 244 min). Sixteen patients (6.8%) needed further surgery for empyema (9 patients required open drainage or thoracoplasty, and 7 patients needed redecortication or repair of bronchopleural fistula). There were no intraoperative deaths and only eight (3.4%) perioperative deaths (< 30 days), which were mostly unrelated to surgery. Of the 234 patients, 202 patients (86.3%) achieved satisfactory results with VATS treatment. Patients requiring open decortication or repeat procedures (40 patients) had a longer mean duration of preoperative symptoms, longer mean duration of preoperative hospitalization, and a higher ratio of pleural empyema (vs complicated parapneumonic effusion) than patients undergoing simple VATS. CONCLUSIONS: VATS is safe and effective for treatment of complicated parapneumonic effusion and pleural empyema. Earlier intervention with VATS can produce better clinical results. A prospective study should be done to identify optimal timing and settings for VATS treatment for both complicated parapneumonic effusion and pleural empyema.     

Cefuroxime vs a dicloxacillin/chloramphenicol combination for the treatment of parapneumonic pleural effusion and empyema in children

The aim of this study was to evaluate the efficacy of cefuroxime, compared with the combination of dicloxacillin/chloramphenicol, for the treatment of children with parapneumonic pleural effusion or empyema. Forty patients, aged 3 months to 5 years, with pleural effusion or empyema were randomized to receive cefuroxime (100 mg/kg/day) IV (n=20) or chloramphenicol (100 mg/kg/day) plus dicloxacillin (200 mg/kg/day) IV (n=20). Both groups were similar in age, days of illness, clinical and radiological findings, and etiology. Most patients (70%) had an empyema at presentation. There was no difference in clinical outcomes, including days to defervescence, duration of respiratory distress, duration of chest tube drainage, and days to discharge from hospital. The complication rates were similar in both groups. Pleural thickening occurred in four patients, bronchopleural fistula in two, and loculated empyema in one patient of each treatment group. Adverse effects attributed to cefuroxime were mild and infrequent. These results suggest that cefuroxime is an effective and well-tolerated alternative for the treatment of children with pleural effusion and empyema.     

Tuberculous empyema

Tuberculous empyema represents a chronic, active infection of the pleural space that contains a large number of tubercle bacilli. It is rare compared with tuberculous pleural effusions that result from an exaggerated inflammatory response to a localized paucibacillary pleural infection with tuberculosis. The inflammatory process may be present for years with a paucity of clinical symptoms. Patients often come to clinical attention at the time of a routine chest radiograph or after the development of bronchopleural fistula or empyema necessitatis. The diagnosis of tuberculous empyema is suspected on computed tomography imaging by finding a thick, calcific pleural rind and rib thickening surrounding loculated pleural fluid. The pleural fluid is grossly purulent and smear positive for acid-fast bacilli. Treatment consists of pleural space drainage and antituberculous chemotherapy. Problematic treatment issues include the inability to re-expand the trapped lung and difficulty in achieving therapeutic drug levels in pleural fluid, which can lead to drug resistance. Surgery, which is often challenging, should be undertaken by experienced thoracic surgeons.     

Omentoplasty in treatment of early bronchopleural fistulas after pneumonectomy

This study was undertaken to assess the efficacy of omentoplasty in 12 cases of bronchopleural fistula after pneumonectomy. All fistulas formed within 16 days after the primary operation (median, 7 days). In 10 cases, omentoplasty was performed within 10 hours of diagnosis; the other 2 cases were treated at 28 and 31 hours. The greater omentum was mobilized through a laparotomy and secured tightly around the bronchial stump using original principles of fixation. After omentoplasty, dehiscence of the bronchial stump was observed in 5 (42%) patients, but owing to reinforcement with greater omentum, recurrence of the fistula was observed in only one case. In 3 patients, recurrence of pleural empyema did not lead to the return of the bronchopleural fistula. Hospital mortality was 8.3% (one patient). In patients without bronchopleural fistula recurrence, the median postoperative hospital stay was 31 days. Early omentoplasty for bronchopleural fistula after pneumonectomy is an effective procedure that eliminates purulent bronchopleural complications completely within the shortest possible period of time.     

Pleural Aspergillosis with Bronchopleurocutaneous Fistula and Costal Bone Destruction: A Case Report

A 65-year-old man who, when young, had had tuberculosis treated by therapeutic pneumothorax, consulted his family physician for a constitutional syndrome and dyspnea. At this time radiologic studies showed left pleural effusion with bilateral calcified plaques, an infiltrate in the upper left lobe, and a picture compatible with aspergilloma, all suggesting semi-invasive aspergillosis. The patient failed to show up for his followup visit, so no therapy could be started or further diagnostic tests ordered. One month later he was admitted to this hospital for a bronchopleural fistula (empyema necessitatis) with subsequent spontaneous hydropneumothorax and costal bone involvement. The patient underwent surgery because of his rapid worsening condition. Biopsy examination revealed a large pleural aspergilloma. Despite immediate antifungal therapy, the patient died. We believe this to be the first report of pleural Aspergillus with a bronchopleurocutaneous fistula and costal bone destruction.     

Management des parapneumonischen Ergusses und des Pleuraempyems

Approximately 50,000 patients annually develop parapneumonic effusions in Germany. These effusions are of prognostic significance in pneumonia. Thus urgent diagnosis by imaging procedures and diagnostic thoracentesis is indicated. Based on diagnostic criteria, parapneumonic effusions can be classified as uncomplicated and complicated effusions and finally pleural empyema. Management strategies include the administration of broad-spectrum antimicrobial therapy covering gram-positive, gram-negative and anaerobic bacteria and the sufficient drainage of the infected pleural fluid. Adequate drainage procedures include thoracentesis, chest tube insertion, application of local fibrinolytics and thoracic surgery. Their application should be selected after individual risk stratification including the assessment of the pleural space anatomy and appearance as well as microbiological and biochemical analysis of the pleural fluid.     

肺结核全肺切除近期并发症的治疗

目的 探讨肺结核全肺切除后并发症的诊断和治疗.方法 对北京胸科医院胸外科2000年9月至2010年9月经全肺切除治疗的206例肺结核患者术后近期手术并发症及其治疗效果进行回顾性分析.结果 206例中发生近期手术并发症的26例,术前病变类型:毁损肺12例,肺叶切除后余肺毁损4例,结核性支气管狭窄1例,肺结核合并脓胸2例,肺结核合并支气管胸膜瘘3例(经支气管镜检查证实),空洞型肺结核2例,肺结核合并大咯血2例.26例中左肺15例,右肺11例.入院查痰为痰菌阳性7例.26例中术后14个月内急性呼吸衰竭5例,经呼吸机治疗,3例治愈,2例死亡;术后3个月ARDS 2例,经呼吸机治疗,1例治愈,1例死亡;术后20 d胸腔内出血7例,2例治愈,5例死亡;术后4年脓胸8例,全部治愈;术后50 d支气管胸膜瘘4例,2例治愈,1例未愈,1例死亡.结论 药物治疗是结核病的重要治疗方法,但部分肺结核患者仍需要外科手术治疗,全肺切除可以提高重症肺结核的治愈率,绝大多数手术并发症均可治愈.

Abstract：

Objective To explore the diagnosis and management of short-term complications after pneumonectomy for pulmonary tuberculosis.Methods The clinical data and management of short-term complications in patients with pulmonary tuberculosis after pneumonectomy were retrospectively reviewed and analyzed.Results From September 2000 to September 2010, 206 patients with pulmonary tuberculosis underwent pneumonectomy, of whom 26 experienced complications shortly after the surgery.Postoperative acute type Ⅱ respiratory failure occurred in 5 within 14 months post-operation, acute respiratory distress syndrome (ARDS) in 2 within 3 months post-operation, chest hemorrhage in 7 within 20 days postoperation, empyema in 8 within 4 years post-operation, and bronchopleural fistula in 4 cases within 50 days post-operation.Of the 7 cases with chest hemorrhage, 2 were cured and 5 dead.All the 8 cases with empyema were cured.Of the patients with bronchopleural fistula, 2 were cured, 1 failed, and 1 was dead.Conclusions Pneumonectomy for pulmonary tuberculosis carries a higher risk of developing serious complications such as chest hemorrhage, acute type Ⅱ respiratory failure and bronchopleural fistula.Most complications can be managed successfully if diagnosed and treated early.     

The prognostic value of loculations in parapneumonic pleural effusions

Forty-eight patients with pleural effusions who had sonographically directed thoracocentesis were evaluated retrospectively for radiologic findings, pleural fluid chemistries, and outcome. Loculation was found to be a radiologic marker of diagnostic and prognostic significance. The presence of loculations correlated with exudative pleural fluid chemistries, but no radiologic finding was specific for empyema. "Extreme" pleural fluid chemistries were associated with loculation, but not with empyema. Patients with loculated effusions had larger effusions, longer hospitalizations, and more frequent tube thoracostomy procedures than patients with nonloculated effusions. Light's criteria for tube thoracostomy were found to be unreliable in patients with loculated parapneumonic effusions or in patients treated with prolonged antibiotic therapy prior to thoracocentesis.     

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。     

Late complications of collapse therapy for pulmonary tuberculosis

STUDY OBJECTIVES: Collapse therapy for pulmonary tuberculosis involved placement of various materials to occupy space and keep the lung collapsed. Complications are encountered decades later. PATIENTS AND METHODS: Between 1980 and 1997, we treated 31 patients with a history of pulmonary tuberculosis in whom collapse therapy had been used and who later developed complications related to their treatment. Pyogenic empyema was present in 24 patients, pleural calcifications with bronchopleural fistula was present in 3 patients, pleural calcification with nonresolvable pneumothorax was present in 1 patient, and migration of a foreign body with formation of subcutaneous mass occurred in 3 patients. All patients with empyema were treated with antibiotics and tube drainage of pus. In addition, Lucite balls were extracted in 4 patients, lung decortication was performed in 6 patients, thoracoplasty was performed in 2 patients, and fenestration was performed in 16 patients. Bronchopleural fistulas were closed with sutures and reinforced with intercostal muscle flap in three patients; in one patient with pleural calcification and nonresolvable pneumothorax, tube drainage was attempted. In three patients with subcutaneous mass due to paraffin migration, paraffin was extracted. RESULTS: Pulmonary decortication (six patients) and thoracoplasty (two patients) resulted in elimination of empyema. Extraction of Lucite balls resulted in lung expansion and elimination of empyema in three of four patients; draining sinus remains in one patient. Fenestration resulted in elimination of empyema in 12 of 16 patients, with 3 patients with residual draining sinuses and 1 patient with remaining empyema. All bronchopleural fistulas closed with intercostal muscle flap remained closed. Following extraction of paraffin blocks, infection developed in one patient. During the follow-up period, three patients died, all of unrelated causes. CONCLUSIONS: Delayed complications of collapse therapy for tuberculosis should be treated without delay. Pressure on adjacent structures or their erosion presents danger and mandates immediate extraction; however, there is no need for routine removal of every residual plombe. Further increase in the number of multiple-drug resistant strains may force the return of collapse therapy.     

A case of Mycobacterium intracellulare infection with chronic empyema

A 83-year-old man had been treated for pulmonary infiltration was referred to a nearby hospital because of slight fever and cough. His chest radiograph and CT showed right chronic empyema, and in which pleural aspirate was smear positive for acid-fast bacilli and positive for PCR-Mycobacterium intracellulare. He was diagnosed as chronic empyema caused by M. intracellulare. A month later exacerbation of bronchopleural fistula was observed and M. intracellulare infection expanded into the lung. He was treated with combined use of ethambutol, rifampicin, clarithromycin, and streptomycin for six months, and his chest radiograph showed improvement, however, finally he died as he was in advanced age and emaciation due to chronic lung infection.     

Chronic lung sepsis: lung abscess,bronchiectasis, and empyema

Chronic lung infections including lung abscess, bronchiectasis, and empyema remain serious medical diseases despite the availability of antimicrobial agents. Recent publications contribute to our understanding of disease pathogenesis and management of these entities. The microbial pathogen of lung abscess may be different comparing immunocompetent with immunocompromised patients, supporting a concept for aggressive diagnostic investigations and targeting of specific potential pathogens. The use of surgery in bronchiectasis may be declining, but surgical intervention remains an important strategy with favorable outcomes, especially in cases of focal bronchiectasis. For empyema, maintaining a high index of clinical suspicion may allow for diagnostic thoracentesis in patients with pleural effusions and allow initiation of appropriate tube thoracotomy drainage and use of fibrinolytics. With appropriate management, morbidity and mortality may be limited and outcomes generally favorable.     

Post pneumonectomy empyema with bronchopleural fistula--a successful management using pedicled intercostal muscle flap on an atypical mycobacteriosis following the irradiation

A 48-year-old woman underwent a right pneumonectomy for advanced mycobacterial disease (M. avium Complex), which followed the postoperative radiotherapy against a malignant schwannoma of the right lower chest wall treated seven years ago. On the 13th postoperative day, re-suture of the bronchial stump was performed urgently because of early bronchopleural fistula development. On the heels of that, reclosure of the bronchial fistula with coverage of the stump by parietal pleural flap was performed on the forty-first post operative day. On the 110th day, however, open drainage with thoracoplasty was performed because development of insidious aspergillous empyema was detected. Since then, local instillation of amphotellisin B, with an oral administration of antifungus drug was started. After succeeding to control the mycotic infection, reclosure of the bronchofistula, covered with pedicled intercostal muscle flap were performed on the 280th postoperative day and extraperiostal air-plombage for reducing empyema cavity. Postoperative course was uneventful and the patient was discharged one year later. With respect to pathogenetic relationship between radiation pneumonitis and feasibility of infection to atypical mycobacteria, preoperative radiotherapy and concurrence of postoperative bronchofistula, and some problems on management of empyema bronchofistula were briefly discussed.     

A case of Aspergillus empyema with bronchopleural fistula

Pleural aspergillosis is not a common disease and we recently experienced a case of Aspergillus empyema with bronchopleural fistula. A 76 year-old man was admitted to our hospital with productive cough and fever. Chest X-ray films showed infiltration in the right lower and left middle field and rather lucent area (clearing) in the right lower lung. Antibiotic therapy was administered but no improvement was obtained. Chest CT scan and right bronchography revealed empyema in the right back portion and bronchopleural fistula in the right lower lobe. Needle aspiration biopsy was performed and Aspergillus fumigatus was isolated from pus. A diagnosis of Aspergillus empyema with bronchopleural fistula was made. We began intrapleural administration of miconazole and empyema was improved partially. For the complete treatment, right lower lobectomy and decortication were performed, but unfortunately he died of acute pneumonia 16 days after operation.     

Parasitic Diseases of the Pleura

Parasitic infections are prevalent in certain parts of the world and may cause pleural involvement, which often goes unrecognized. Common parasites involving the pleura include Entamoeba histolytica, Echinococcus granulosus and Paragonimus westermani. Amebiasis can cause empyema with “anchovy sauce” pus, reactive pleural effusions and bronchopleural fistula with hydropneumothorax. Echinococcosis may result in pleural thickening, pneumothorax, secondary pleural hydatidosis and pleural effusions. Paragonimiasis may cause chylous and cholesterol pleural effusions, pleural thickening and pneumothorax. Less commonly, pulmonary eosinophilia, or Loeffler’s syndrome, caused by Ascaris lumbricoides, Ancylostoma duodenale and Necator americanus and tropical pulmonary eosinophilia caused by Wuchereria bancrofti and Brugia malayi may involve the pleura. This article provides a comprehensive review of parasitic infections involving the pleura. A high index of suspicion in the appropriate clinical setting is required to facilitate prompt diagnosis and treatment of these diseases.     

The role of fiberoptic bronchoscopy in evaluating the causes of pleural effusions

To evaluate the diagnostic merit of fiberoptic bronchoscopy in pleural effusions, we performed fiberoptic bronchoscopy in addition to thoracocentesis and closed pleural biopsy in 140 patients who were admitted for diagnostic investigation of the causes of pleural effusions. The patients were divided into subgroups based on clinical features and roentgenographic findings of chest x-ray films. In 39 patients, the pleural effusions were due to various nonneoplastic disorders and in 95 patients it was caused by malignancy. In six patients, the causes of the pleural effusions remained undetermined. A final diagnosis was made by pleural examination in 68 patients, by fiberoptic bronchoscopy in 58 patients, and by either one or both in 100 patients. In 82 patients who had no hemoptysis, a final diagnosis was made by pleural examination in 57 cases and by fiberoptic bronchoscopy in 11 cases only. The diagnostic yield of fiberoptic bronchoscopy (47/58) was superior to that of pleural examination (11/58) in 58 patients presenting with hemoptysis. In 74 patients who had pleural effusions as the sole roentgenographic abnormality, the final entity was established by pleural examination in 45 and by fiberoptic bronchoscopy in 12. The diagnostic merit of fiberoptic bronchoscopy was significantly higher in 59 patients who had concurrent pulmonary abnormalities on their chest roentgenograms. A final diagnosis was made in 43 cases by fiberoptic bronchoscopy in comparison with 21 cases by pleural examination. For patients with unknown pleural effusions, fiberoptic bronchoscopy was more likely to yield a diagnosis than thoracocentesis with closed pleural biopsy in those who had hemoptysis or pulmonary abnormality on chest x-ray films, whereas the reverse applied when these features were absent.     

Transforming growth factor beta-1 level in pleural effusion

OBJECTIVE: Transforming growth factor-beta1 is an important immunomodulator. The diagnostic role of TGF-beta1 has not been systematically investigated in pleural effusion. METHODOLOGY: A prospective clinical study of 45 patients (23 men, 22 women; mean age 49 +/- 21 years) with pleural effusion was performed. Of these patients, 19 had malignant pleural effusion, 14 had tuberculous pleural effusion, seven had empyema/parapneumonic pleural effusion, and five had transudative pleural effusion due to congestive heart failure. The concentrations of TGF-beta1 were measured by ELISA in all pleural fluid samples and in serum samples only from patients with malignant and tuberculous pleural effusions. RESULTS: The median TGF-beta1 levels of malignant, tuberculous and empyema/parapneumonic pleural effusions were 7.25 ng/mL, 7.81 ng/mL, and 9.75 ng/mL, respectively. There was no significant difference between them. The median TGF-beta1 level was 5.62 ng/mL in the transudate pleural effusion group and it was significantly lower than that in the empyema/parapneumonic group (P < 0.05). The pleural fluid TGF-beta1 levels did not correlate with cell profiles of the pleural fluid. The median serum TGF-beta1 levels in malignant and tuberculous pleural effusion groups were 7.38 ng/mL and 7.38 ng/mL, respectively. There was no significant difference between the levels of TGF-beta1 in paired samples of serum and pleural fluid. CONCLUSIONS: This study shows that TGF-beta1 concentrations in exudative pleural effusions are higher than those in transudative effusions secondary to congestive heart failure but TGF-beta1 concentrations do not assist in differentiating exudative effusions.