Surgical treatment of chronic empyema

Empyema remains challenging for thoracic surgeons. This review covers diverse aspects of acute empyema and chronic empyema and its surgical treatment. The triphasic nature of thoracic empyema (stages I, II, and III) is also addressed. The principles of empyema treatment are early diagnosis and early treatment. For acute empyema (empyema in stages I and II), early surgical intervention, such as video-assisted thoracoscopic débridement, is recommended when conventional chest tube drainage has failed. Radical treatments of chronic empyema (empyema in stage III) include (1) removal of the empyema space (decortication with or without lung resection) and (2) obliteration of the pleural space with muscle flaps or omentum flaps, or by thoracoplasty. Decortication is the procedure of choice for patients with reexpandable underlying lung. When bronchopleural fistula exists in the underlying lung, the fistula should be securely closed. For those patients whose underlying lung cannot be expected to reexpand, the procedure of choice is either concomitant removal of the affected lung with the empyema space or obliteration of the pleural space. For patients who are not eligible for the above-mentioned radical treatment, open-window thoracostomy can be considered. This procedure is not only performed as a definitive treatment of empyema but also as a preparatory treatment for radical procedures. Radical procedures are performed when patients recuperate. Choosing the most suitable operation based on the stages of empyema, the conditions of the underlying lung, and the conditions of a patient holds the key to success.     

Surgical treatment for chronic pleural empyema

(Received for publication on Apr. 19, 1999; accepted on Jan. 7, 2000)     

Surgical treatment of acute and chronic empyema

In conclusion we would emphasize the fact that operation for acute empyema thoracis is not an emergency, second that aspiration or the closed operation should be employed in all cases in which the pleural fluid is not frank pus. Third, that x-ray studies in all pulmonary conditions is not an admission on the part of the practitioner of the lack of knowledge of symptoms and clinical signs but rather indicates his thoroughness in that he wants to see the existing pathology. Fourth, that proper drainage regardless of the method employed will not only cure most cases of acute empyema but will prevent chronic empyema. Fifth, if chronic empyema does occur plastic operation on the chest wall is followed by a lower mortality and better results than any other operation designed to obliterate the empyema cavity.     

Surgical treatment of chronic empyema. A new one-stage operation

The operative results in a series of 92 patients with chronic empyema were reviewed. Of these, 46 had empyema with an underlying fistula, and 46 had empyema without fistulization. Twenty-one underwent decortication, 65 were treated by our technique, and six were treated by a modification of the Eloesser technique. These techniques were employed with priority given in the order just cited. Our technique involves decortication of the visceral peel and obliteration of the dead space by collapsing of the parietal wall without rib resection. Cure was obtained with decortication alone in 20 of 21 patients. Sixty of 65 patients treated by our technique were cured without deformation of the thoracic cage. In all patients treated by the modified Eloesser technique, obliteration of the empyema cavity was achieved secondarily by thoracoplasty combined with a pedicled muscle flap. Postoperative pulmonary function studies demonstrated a significant improvement in vital capacity and forced expiratory volume in 1 second in patients treated by decortication or by our technique. With the modified Eloesser technique, in contract, pulmonary function tended to decline.     

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.     

慢性胰腺炎39例外科治疗体会

目的　探讨慢性胰腺炎病人的外科治疗方法。方法　对本院 1980年 1月～ 2 0 0 0年 12月间 39例接受手术治疗的慢性胰腺炎病人的病史进行回顾性分析。结果　本组病例的病因最多为胆源性 ,其次为胰石性和酒精性。其诊断多依赖于临床表现和影像学改变。手术适应证主要是肿块性胰腺炎、胰管结石、胰腺假性囊肿、顽固性腹痛和无法排除恶性疾病者。手术方式则根据不同的分类来选择 ,不外乎胰管引流或 (和 )胰腺切除术。结论　部分严重的病人通过手术治疗可以缓解腹痛 ,提高生活质量 ,并控制胰腺内、外分泌功能的恶化     

Falcotentorial subdural empyema: analysis of 10 cases

Object  

Parafalcine subdural empyema and those along the superior and inferior surface of the tentorium are rare entities. We present a series of 10 patients where we have attempted to describe the pathophysiology, clinical features, and management of subdural empyema.     

慢性胰腺炎的外科治疗(附40例报告)

目的 探讨慢性胰腺炎(CP)的术式选择。方法 回顾1987年到1996年手术治疗慢性胰腺炎40例。综合CP影像检查特征，以切除术治疗肿块型．胆胰管引流术治疗胆胰管扩张型作为基本的术式选择原剐，并依据术中所见，对复杂型CP联合应用了奥狄括约肌成形．腹腔神经节切除，胆道取石．T管引藏等多种术式。结果 术后27例腹痛消失．胰腺功能无明显恶化。2例分别死于急性胆管炎和上消化道大出血；结论 影像检查可显示CP的主要病理变化．在影像检查的基础上．结合病人的主要症状．选择适当术式；或联合应用多种术式，可改善CP疗效。     

慢性顽固性便秘30例手术治疗分析

目的 研究手术治疗慢性便秘的临床价值、手术适应证及其对肠道功能的影响.方法 结肠慢传输型便秘患者25例,结肠慢传输型便秘合并出口梗阻型便秘患者1例,成人巨结肠致便秘患者4例,均行手术治疗.术后随访记录患者排便情况、并发症、生活质量.结果 所有患者术后无严重并发症及死亡.30例患者术后生活质量均得到明显改善,随访6～36个月,术后3个月内大便次数均增多,平均每日4.5次(3～6次),软便;以后大便次数逐渐减少,1年后每日1～3次成形大便,无一例需服止泻剂.术后2例患者出现粘连性肠梗阻,1例术后出现吻合口漏,其他患者均未出现肠梗阻、腹泻、腹痛、排便失禁等并发症.结论 对排便功能障碍患者,有选择性的行结肠次全切除并盲直肠吻合术,近期疗效理想,特别对于慢传输型便秘疗效较好,但长期疗效尚需进一步研究.     

Pathogenesis and treatment of chronic empyema

In chronic empyema (CE), thickened pleura, collapsed chest wall, and the accumulation of purulent fluid in the thoracic cavity are typical findings. Patients complaints of symptoms with bronchopleural fistula (BPF). On the other hand, there is another type of CE in which the pleural space expands progressively to shift the neighboring lungs, mediastinum, and diaphragm. This type of CE is considered to be chronic expanding hematoma (Reid et al.) occurring in the thoracic cavity. In the empyemic cavity, mycobacterial infection is found approximately in 20-30% of cases, pyogenic bacillus or fungus in about 40%, but the cavity is aseptic in other 30-40%. Although the fundamental treatment procedures include decortication and pleuropneumonectomy, the method of muscle or omental plombage to manage dead space or BPF are far superior functionally in intractable CE. Recently, the methods of plastic and reconstructive surgery have been used to utilize the muscle or omentum more effectively. The classic thoracoplasty procedure should not be undertaken unnecessarily to avoid additional deterioration of respiratory function. Additionally, it should be remembered that malignant lymphoma occurs frequently in the empyemic chest wall.