Surgical policy in tuberculous pleurisy

Two hundred and eighty seven cases of tuberculous pleurisy are analyzed. According to the pleural contents, four phases of development of this disease are identified. These include: 1) free pleurisy; 2) partially encysted pleurisy; 3) encysted pleurisy, and 4) adhesive pleurisy. An algorithm of use of draining procedures and surgical interventions depending on the phase of pleurisy is proposed. Among other things, indications for thoracoscopy that was performed in 66 patients with tuberculous pleurisy for its therapy were stated. Thoracoscopy is ineffective in adhesive pleurisy, in the presence of a rigid residual cavity in particular, and thus preference should be given to thoracotomy with pleurectomy and decortication of the lung. This operation was made in 39 cases. Timely use of draining procedures and surgical interventions make it possible to achieve recovery from tuberculous pleurisy over shorter periods of time and with minimal residual changes.     

Pleurectomy and decortication in chronic tuberculous pleuritis and pleural empyema

The study covered 105 patients with chronic tuberculous pleurisy and empyema who had undergone surgery. Reparative pleurectomies with lung decortication were made in all the patients. Four groups of patients operated on in different periods were analyzed. The paper presents clinical, morphological, and instrumental evidence for indications for surgery. The best outcomes were achieved in patients with a 3-4-month history (100% efficiency with recovered ventilation function). The total efficiency of pleurectomy and decortication was 92.4% without fatal outcomes.     

Thoracic surgical spectrum of HIV infection

The thoracic surgeon is often called on to diagnose or treat a variety of disorders associated with human immunodeficiency virus (HIV) infection. Surgical mediastinal exploration through cervical and anterior approaches is a safe and valuable modality in appropriately selected patients with unexplained mediastinal lymphadenopathy. Open lung biopsy is used in a small subset of HIV-infected patients with undiagnosed diffuse or multifocal pulmonary disease, with an anticipated diagnostic yield of more than 70%. The biopsy can be performed either thoracoscopically or via thoracotomy, based on the expertise and discretion of the surgeon. Open lung biopsy should be used very selectively and in patients with bronchoscopically confirmed diagnoses who are failing optimal medical therapy, because the impact on outcome is minuscule and because open lung biopsy is best avoided altogether in patients with established respiratory failure. Patients with acquired immune deficiency syndrome (AIDS) have an increased incidence of pneumothorax, often associated with Pneumocystis carinii pneumonia. Depending on the clinical scenario, tube thoracostomy, pleurodesis, or pleurectomy may be used. Thoracic empyema in AIDS patients requires urgent intercostal drainage and close clinical surveillance to discern the need for decortication or rib resection and open drainage. A surgical approach to pyogenic lung abscess or invasive aspergillosis is occasionally useful. Although it is controversial whether the incidence of lung cancer is increased in patients with HIV infection, HIV-positive patients with early stage nonsmall-cell lung cancer who are otherwise surgical candidates should undergo resection, especially in the era of highly active antiretroviral therapy.     

Tuberculous empyema

The clinical courses of 35 tuberculous empyema patients were investigated retrospectively from November 1990 through November 1995. Most patients had nonspecific symptoms and signs but with far-advanced pulmonary parenchymal lesions in their chest roentgenographs. The effusions showed neutrophilic leukocytosis with a 60% positive culture rate for Mycobacterium tuberculosis. Multidrug resistant strains were found in 7 out of 18 cultures. All patients received chemotherapy and eight of them underwent additional surgical management. Twenty-two (62.9%) patients had been treated successfully and one patient is still under treatment. The remaining 12 patients either died during treatment or defaulted; and four (11.4%) of them had died of tuberculosis. We conclude that the treatment outcome of tuberculous empyema is less satisfactory than that of pulmonary tuberculosis, however, modern multidrug chemotherapy with repeated drainage and opportune surgical interventions could be in prospect of successful treatment of tuberculous empyema.     

Thoracic malignancies in patients with chronic tuberculous empyema

OBJECTIVES: To clarify features of thoracic malignancies occurred in patients with chronic tuberculous empyema. MATERIALS AND METHODS: We analyzed clinicopathological data of 15 patients with thoracic malignancies who had chronic tuberculous empyema, encountered at Tokyo National Hospital during the period from 1977 to 2002. RESULTS: There were 13 men and 2 women, with a mean age of 67 years. Most of all (13/15) patients had history of surgery for tuberculosis including artificial pneumothorax (9 cases). Malignancies consisted of pyothorax-associated lymphoma (PAL; 9 cases), lung cancer (4 cases), malignant fibrous histiocytoma (1 case), and angiosarcoma (1 case). There were no differences in background factors between PAL patients and the other patients. Common symptoms were chest pain (10 cases), fever (7 cases), and bloody sputum (4 cases) and it seemed that these symptoms were more evident in patients with PAL than in patients with other diseases. Plain chest X-ray films often failed to detect the tumor, and the diagnosis was often obtained by sputum cytology, bronchofiberscopy, transcutaneous biopsy, and resection with support of CT and/or MRI films. On radiographs, all tumors located in empyema cavities or around empyema walls, and a pulmonary mass adjacent to the empyema wall was characteristic of lung cancer. PAL showed certainly good outcome; 40% 5-year survival rate with resection or chemoradiotherapy. On the other hand, all of lung cancer cases were diagnosed at stage III, and had poor outcome, and the remaining patients with the other malignancies also had poor outcome. CONCLUSION: Clinicians should keep in mind occurrence of several thoracic malignancies during the follow-up of patients with chronic tuberculous empyema.     

112例结核性脓胸的外科治疗分析

目的 探讨结核性脓胸的外科治疗效果和手术适应症。 方法 总结北京胸科医院1999年1月-2008年底手术切除的112例结核性脓胸的临床疗效。全组包括：结核性全脓胸49例、肺结核合并结核性全脓胸1例、结核性包裹性脓胸53例、肺结核合并结核性包裹性脓胸3例、结核性脓胸合并支气管胸膜瘘6例。 结果胸膜纤维板剥脱术67例、胸膜全肺切除术10例、胸膜肺叶切除术4例、胸膜肺部分切除术6例、胸膜纤维板剥脱+胸廓成形术18例,其他手术7例。总治愈率95.0%,手术并发症率12.5%,死亡率0.9%。 结论 患者一旦发展成慢性结核性脓胸应及早外科治疗,手术是治疗慢性结核性脓胸的唯一有效方法 。     

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.     

Long-term outcomes after lung-sparing surgery for epithelial mesothelioma

BackgroundThis observational study evaluates retrospectively the long-term outcomes after pleurectomy/decortication for pleural mesothelioma, with and without the resection/reconstruction of diaphragm and pericardium.MethodsData from 155 consecutive patients undergoing lung-sparing surgery for epithelial pleural mesothelioma were reviewed. Selection criteria for surgery were cT1-3, cN0-1, good performance status, age <80 years. Perioperative Pemetrexed-Platinum regimen was administered as induction in 101 cases (65.2%) and as adjuvant treatment in 54 cases (34.8%). Extended pleurectomy/decortication was performed in 87 cases (56.12%). In 68 patients (43.87%) standard pleurectomy/decortication was performed without resection/reconstruction of diaphragm and pericardium, when tumour infiltration was deemed absent after intraoperative frozen section. The log-rank test and Cox regression model were used to assess the factors affecting overall survival and recurrence free survival.ResultsMedian follow-up was 20 months. The 2- and 5-year survival rate was 60.9% and 29.2% with a median survival of 34 months. An improved survival was observed when standard pleurectomy/decortication was carried out (P=0.007). A significant impact on survival was found comparing the TNM-stages (P=0.001), pT (P=0.002) and pN variables (P=0.001). Multivariate analysis identified the pN-status (P=0.003) and standard pleurectomy/decortication (P=0.017) as predictive for longer survival. The recurrence-free survival >12 months was strongly related to the overall survival (P<0.001). The macroscopic complete resection (P=0.001), TNM-stage (P=0.003) and pT-status (P=0.001) are related to relapse.ConclusionsWithin multimodal management of pleural mesothelioma, lung-sparing surgery is a valid option even with more conservative technique. A benefit for a longer survival was observed in the early stage of disease, with pN0 and when pleurectomy/decortication is carried out, preserving diaphragm and pericardium. Recurrence is not affected by the type of surgery, and a recurrence-free interval >12 months is predictive of an increased survival when the macroscopic complete resection is achieved.     

胸膜纤维板剥脱术治疗慢性结核性脓胸手术时机的选择

目的探讨胸膜纤维板剥脱术治疗慢性结核性脓胸的最佳手术时机。方法分析2000年至2008年我院采用胸膜纤维板剥脱术治疗不同疾病阶段74例慢性结核性脓胸患者的疗效。结果病史在6周至3个月以内的慢性结核性脓胸患者在手术时间,术中出血量,胸膜纤维板厚度,术后引流量的4方面对比均优于病史大于3个月的慢性结核性脓胸患者。结论胸膜纤维板剥脱术是治疗慢性结核性脓胸的有效方法。病史在6周至3个月以内为患者最佳手术时机,对于诊断未明确、抗痨治疗效果差者,尤其是青少年患者可考虑早期行胸膜纤维板剥脱术。     

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.     

Role and outcome of surgery for pulmonary tuberculosis

The need and outcome of surgical intervention in patients with pulmonary tuberculosis were assessed retrospectively. Between 1993 and 2003, 72 major surgical procedures were performed in 57 patients with pulmonary tuberculosis. There were 44 males and 13 females with a mean age of 34 years. Indications for surgery were: trapped lung in 18 (31.6%), multidrug-resistant tuberculosis in 10 (17.5%), aspergilloma in 10 (17.5%), destroyed lung in 5 (8.8%), massive hemoptysis in 4 (7%), bronchopleural fistula in 3 (5.3%), persistent cavity in 2 (3.5%), and undiagnosed nodule in 5 (8.8%) patients. The most common procedure was lobectomy (31.9%). Other procedures included decortication, wedge resection, pneumonectomy, segmentectomy, and myoplasty. There were 28 complications in 18 patients, including prolonged air leak in 12 (21.1%), residual space in 7 (12.3%), empyema in 5 (8.8%), hematoma in 2 (3.5%), chylothorax and bronchopleural fistula in 1 (1.8%) each. There was no operative death, but one patient died from sepsis late in the follow-up period (mortality, 1.8%). As morbidity and mortality rates are acceptable, surgical intervention can be considered safe and effective in patients with pulmonary tuberculosis.     

Clinical characteristics and outcomes of empyema thoracis in 117 patients: a comparative analysis of tuberculous vs. non-tuberculous aetiologies

BACKGROUND: Empyema thoracis remains a major problem in developing countries. Clinical outcomes in tuberculous empyema are generally believed to be worse than in non-tuberculous aetiologies because of the presence of concomitant fibrocavitary parenchymal disease, frequent bronchopleural fistulae and poor general condition of patients. We performed a prospective study over a 2-year period with the objective of comparing the clinical characteristics and outcomes of patients with tuberculous vs. non-tuberculous empyema. METHODS: Prospective study of all cases of non-surgical thoracic empyema seen at a tertiary care centre in North India over a 2-year period. A comparative analysis of clinical characteristics, treatment modalities and outcomes of patients with tuberculous vs. non-tuberculous empyema was carried out. Factors associated with poor outcomes were analysed using multivariate logistic regression. RESULTS: One hundred and seventeen cases of empyema were seen in the study period of which 95 had non-tuberculous and 41 had tuberculous empyema. Malnutrition and bronchopleural fistulae (BPF) were more common and duration of symptoms longer in the tuberculous empyema group. Time to resolution of fever, duration of pleural drainage and pleural thickening >2 cm were significantly greater as well. Eight (10.5%) patients with non-tuberculous empyema and four (9.8%) with tuberculous empyema succumbed. Presence of a BPF was significantly associated with poor outcomes on multivariate logistic regression analysis. CONCLUSIONS: Tuberculous empyema remains a common cause of thoracic empyema in India though it ranked second amongst all causes of empyema after community acquired lung infections in this study. Tuberculous empyema is associated with longer duration of symptoms, greater duration of pleural drainage and more residual pleural fibrosis.     

自体肌皮瓣植入治疗慢性结核性难治性脓胸(附12例报告)

目的 总结自体肌皮瓣植入治疗慢性结核性难治性脓胸的经验。方法 2004年1月至2017年12月共有12例患者因慢性结核性难治性脓胸于上海市肺科医院行自体肌皮瓣植入治疗。伤口换药清洁后,既往有同侧手术史者,行肌皮瓣移植填充手术;既往无同侧手术史者,行肌皮瓣移位填充手术。术前行三联(异烟肼、利福平、吡嗪酰胺)常规标准化抗结核药物治疗3个月以上,术后维持抗结核药物治疗12个月。耐药结核病依据药物敏感性试验(简称“药敏试验”)结果进行调整。患者均为男性;中位年龄52.5岁(26.0~65.0岁)。7例因肺结核病变既往行肺切除术(2例全肺切除);5例开窗时存在支气管胸膜瘘(BPF),引流等保守治疗无法治愈,再行胸壁开窗,并进行长期换药。其余5例无既往手术史,因慢性结核性难治性脓胸保守治疗(引流等)无法治愈,肺无法复张,进行开窗换药。结果 全组患者无死亡,术后均未发生呼吸道并发症。5d内顺利拔除胸腔引流管,术后3~6周出院。中位随访时间9个月,11例患者无脓胸复发和肌皮瓣坏死,1例患者脓胸局部复发(取出老式封堵器,开窗换药后于非水肿期采用新型谢氏封堵器置入,准备二次肌皮瓣填入)。结论 将特种材料(记忆合金支架)、显微外科技术、抗结核药物治疗、结核性脓胸传统手术相结合,运用自体肌皮肌瓣植入治疗慢性结核性难治性脓胸具有良好的临床效果。     

Pneumonectomy for destroyed lung or chronic tuberculous empyema]

Fourteen patients underwent pneumonectomy for destroyed lung or tuberculous empyema at the Shimada Municipal Hospital from September 1980 to December 1985. Mean age was 61 and ten patients were males. Cough and sputum (in 12 cases) and hemosputum or hemoptysis (in 8 cases) were common complaints. Three patients had complications in the immediate postoperative period: hemorrhagic shock, pulmonary embolism and contralateral pneumothorax. They were treated conservatively. The postoperative course was uneventful in the other patients and all complaints were reduced or disappeared. And lung function improved in 3 cases with chronic empyema compressing the mediastinum. In conclusion, pneumonectomy is one of the radical operation for destroyed lung or chronic tuberculous empyema with low pulmonary function and complaints. And the critical level are 40% of %VC and 25% of FEV1.0/pr. %VC in preoperative pulmonary function.     

Ten-year experience with mycetomas in patients with pulmonary tuberculosis

We studied 33 consecutive patients with tuberculous pulmonary cavities complicated by fungus balls to evaluate their treatment. Nineteen had surgical resection for massive or recurrent bleeding or possibility of tumor. One patient died of postpneumonectomy empyema (30-day surgical mortality, 5 percent). Fourteen had no surgery. No patient died of hemoptysis. Respiratory failure contributed most often to death. Hepatic complications and other problems of alcoholism were also prominent. Good results can be obtained by resection in these severely ill patients if care is taken to preserve functioning pulmonary tissue and to avoid complications of alcoholic hepatic disease. Within these constraints, tuberculous cavities complicated by mycetomas should be resected for massive or recurrent hemoptysis.     

Late exudative complications of collapse therapy for pulmonary tuberculosis

In a retrospective study of 15 patients who were treated with collapse therapy for pulmonary tuberculosis on an average 30 years previously, we found 16 instances of exudation in the residual pocket: four were sterile and without fistula, ten had bronchial fistulae, one had an esophageal fistula, and one was a tuberculous empyema without fistula. Among the 11 exudations with bronchial or esophageal fistulae, none contained tubercle bacilli, six were infected with pyogenic microorganisms, and five remained sterile. In 12 cases, the diagnosis was suggested by chest x-ray film. Four of nine exudates which remained sterile and three of the seven infected ones could be stabilized by conservative measures; the others required a decortication, sometimes with parenchymal resection. This study shows that in late exudative complications of old collapse therapy, an initial conservative treatment can be curative in about 45 percent of the cases.     

78例结核性脓胸的外科治疗

目的 探讨外科治疗结核性脓胸的方法及治疗效果。 方法 回顾分析2007年1月至2012年12月航天中心医院胸外科和北京胸科医院胸外科78例患者的手术治疗情况和手术疗效。 结果 术后肺复张良好67例（85.9%）;肺复张较差11例（14.1%）,及时行纤维支气管镜吸痰后肺复张。术后发生并发症7 例（9.0%）,包括术后胸腔内出血1例,伤口感染1例,药物性肝炎伴水电解质紊乱1例;均经相应治疗痊愈。呼吸衰竭4例,经呼吸机抢救3例成功,1例死亡,病死率1.3%。术后抗结核治疗6个月至2年,1例患者6个月后肺部感染,经抗炎治疗好转。术后随访2年,77例患者均好转。 结论 外科手术治疗结核性脓胸可以取得满意疗效。     

Chronic tuberculous empyema with bronchopleural fistula resulting in treatment failure and progressive drug resistance

We treated five patients with a past history of tuberculous pleural infection that led to chronic, quiescent, loculated empyema. Reactivation of TB was associated with formation of BPF and recovery of drug-susceptible Mycobacterium tuberculosis from sputum. All patients had recurrence of positive sputum cultures that yielded tubercle bacilli resistant to drugs they were receiving. The lungs demonstrated gross thickening with calcification of both visceral and parietal pleura. Two patients underwent retreatment chemotherapy followed by decortication-empyemectomy and lung resection surgery; both are now culture-negative for TB. One patient received retreatment chemotherapy but refused surgery; he remains clinically stable with negative sputum cultures. Two other patients' organisms became drug-resistant and they remain sputum-culture positive. We believe that thick, calcified pleural walls limit penetration of drugs into the infected empyema space, resulting in suboptimal drug concentrations and drug resistance. Intensified chemotherapy and surgical intervention should be considered in these cases.     

耐药肺结核病的外科治疗（附40例报告）

４０例耐药肺结核病人，经肺切除或附加胸廓成形术治疗。病变以空洞和肺毁损为主。二药以上耐药率８７．５％，对ＲＦＰ的耐药率８０％。半数以上病人合并对侧肺病灶。手术并发率１５％，其中脓胸瘘管并发率７．５％。术后痰菌阴转率８７．５％，无手术死亡。出院随访３５例，３４例痰菌复查阴性，２０例恢复正常工作。     

The role of surgery in the treatment of chronic empyema]

For the last ten years we had 56 patients operated for the empyema which occupied almost all the thoracic cavity. We evaluated their postoperative pulmonary functions and their sequelae. The pathological features of the resected lung and empyema wall were also examined. Surgical procedures consisted of 25 extraperiostal air plombage, 14 pleuropneumonectomy, 8 decortication, and 9 other procedures (lobectomy, muscle-flap, omental flap, and others). Preoperative %VC of patients with extraperiostal air plombage, those with pleuropneumonectomy, those with decortications and those with other procedures were 59.6 +/- 12.6, 46.4 +/- 11.1, 63.0 +/- 10.1, and 53.8 +/- 11.7 respectively. Of 11 patients who developed severe respiratory impairments (%VC less than 40 and/or FEV 1/VC predicted less than 30) post operatively, 4 had extraperiostal air plombage, 4 had pleuropneumonectomy, and 3 had other procedures. In general, degree of respiratory impairment was more severe in patients who underwent multiple surgical procedures. Of 18 patients who survived 5 years or more, %VC was under 50% in 9, and of those nine patients five had 30% decrease in VC compared to the preoperative values and there were 2 patients with extraperiostal air plombage in whom extreme shrinkage and deformity of hemithorax were observed though they had neither additional surgeries nor recurrences. Hemangioma was often seen on the walls of empyema and in some they became so large as to cause mediastinal shift. There were patients with round atelectasis, which, we thought, could have caused abscess or inflammatory granuloma.