Open-window thoracostomy in pleural empyema

Open-window thoracostomy (OWT) was performed in 21 cases of empyema. The indications were postpneumonectomy empyema with (n = 6) or without (n = 1) fistula, early recurrent empyema after decortication (n = 6), chronical empyema in ull elderly patients with (n = 5) or without fistula (n = 2), and total unilateral lung gangrene with a large fistula of the main bronchus after radiotherapy and chemotherapy (n = 1). All cases presented with severe sepsis, eight of them with acute septic shock, and six with signs of multiorgan failure. Three to five ribs were resected, the muscles and skin were sutured to the ribs confining the window located at the lowest point of the empyema cavity, while the intercostal muscles of the resected ribs were used to close fistulae. The cavity was packed with dressings every day. In all cases, the sepsis subsided immediately after OWT. With the exception of one patient with postpneumonectomy empyema, who died of contralateral pneumonia on day 36, no surgery-related complications were seen. Four further patients died of unrelated causes 2, 4, 5, and 7 months, respectively, after OWT. In one of them, the OWT had been closed. Up to this time, obliteration and closure of the cavity has been carried out in 7 cases by using thoracoplasty (n = 2) or predicled muscle flaps (n = 5) either in the early course or after a delay of 11 to 23 months, with fair functional and cosmetic results. In one further case, operative closure has been planned. In seven of the eight remaining patients, four of whom declined further operations, the cavities closed spontaneously, despite their initial size after intervals of between 11 and 21 months.     

Benefits of early aggressive management of empyema thoracis

BACKGROUND: The end-target of the management of thoracic empyema is to obtain early rehabilitation by re-expansion of the trapped lung resulting from intrapleural infected material. Our aim was to shorten the hospitalization time and to prevent a possible thoracotomy by using video-assisted thoracoscopy initially. METHODS: Seventy patients with parapneumonic empyema were prospectively studied between January 1997 and June 2004. The patients were randomly divided into two groups. In group I (n = 35 patients), a chest tube was inserted into the patients after pleural content was evacuated and fibrins were debrided using video-assisted thoracoscopy. In group II (n = 35 patients), tube thoracostomy was carried out without using a video-assisted thoracoscope. Both groups were compared in terms of hospitalization time, open surgery for decortication and complications. RESULTS: There was no statistically significant difference between the groups from the point of view of age and sex (P > 0.05). In group I, 17.1% of the patients underwent open decortication, whereas in group II, 37.1% of the patients underwent the same procedure (P < 0.05). Whereas average hospital stay in group I was 8.3 days (range, 7-11 days), it was 12.8 days in group II (range, 10-18 days; P < 0.05). There was one bronchopleural fistula in group I, and there was one bronchopleural fistula and one death in group II. CONCLUSION: Video-assisted thoracoscopic evacuation and chest tube insertion in situ is a new therapeutic approach for pleural empyema that shortens hospital stay and reduces the necessity of open decortication.     

Surgical treatment for chronic pleural empyema

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

Descending necrotizing mediastinitis with sternocostoclavicular osteomyelitis and partial thoracic empyema: Report of a case

We present herein the case of a 50-year-old woman in whom descending necrotizing mediastinitis originating from an anterior neck abscess spread to the left upper bony thorax, resulting in osteomyelitis of the left sternocostoclavicular articulation and left partial thoracic empyema. Transcervical mediastinal irrigation and drainage was performed with aggressive antibiotic therapy, followed by resection of the left sternocostoclavicular joint and debridement of the anterior mediastinum. The patient had an uneventful postoperative course, and her left arm and shoulder mobility was well preserved.     

Pneumatoceles in postpneumonic empyema: an algorithmic approach

Purpose

The aim of the study was to determine the natural course and select appropriate therapy for pneumatocele (PC) in children with postpneumonic empyema.

Materials and Methods

Records of 134 children treated for postpneumonic empyema between October 1997 and June 2003 were reviewed retrospectively, and 58 (43%) of them were found to have PC. Their chest x-rays and computed tomography scans as well as patient profiles were evaluated to assess the size, location, course, and complications. Clinical course, treatment indications, and results were also reviewed.

Results

The patients were aged from 14 months to 15 years (mean 3.8 years). There were 36 boys and 22 girls. The PC was located on the right hemithorax in 34 patients and on the left in 24. Staphylococcus aureus was the most common isolated infective agent. Of the 58 children, 37 (63.7%) showed complete resolution with improvement of the infection within 2 months. Thirteen PCs had evidences of gradual decrease in size without any indication for invasive approaches, and they resolved completely, with a mean time of 6.1 (ranging from 1-13) months. One tension PC, 3 large PCs (>50% of hemithorax), 1 case with bad tolerance to follow-up, and 2 persistent PCs had no reduction in size on follow-up; a total of 7 patients underwent image-guided catheter drainage procedure, and 5 of them resolved completely. In the last 2 cases, surgical excision was required because of persistent cystic cavity caused by thickened PC wall. One patient whose PC had not been decreasing in size developed findings of severe lung abscess with thickened wall and directly underwent surgery. In none of these patients recurrences or complaints related to PC were noted on their control visits.

Conclusion

Most of these PCs are simple PC and show spontaneous resolution with improvement of the infection within the first 2 months. However, some decrease gradually by time, and close follow-up should be continued in case of complicated PC. Persistent features of chest infection, more than 50% involvement of hemithorax and severe atelectasis, development of broncopleural fistulae (tension PC), and bad tolerance to follow-up remind complicated PC, and they are indications of image-guided catheter drainage procedure. Its failure occurs in PC with thickened wall that does not collapse, as was in our cases with persistent PC and severe infected PC, and thus, this is an indication for surgical excision.     

Video-tube thoracostomy in trauma resuscitation: A pilot study

Background

Complications related to incorrect positioning of tube thoracostomy (TT) have been reported to be as high as 30%. The aim of this study was to assess the feasibility of flexible videoscope guided placement of a pre-loaded chest tube, permitting direct intrapleural visualization and placement (Video-Tube Thoracostomy [V-TT]).

Tumor recurrence at thoracostomy tube insertion sites: a report of two pediatric cases

Recurrence of thoracic malignant tumors at port sites used for thoracoscopic procedures in adults have been described. However, there are no reports of tumor recurrence at thoracostomy tube or thoracoscopic trocar insertion sites after operation for thoracic malignancies in children. The authors report 2 cases of tumor recurrence at thoracostomy tube insertion sites after intraoperative gross spillage of pleuropulmonary blastoma and malignant epithelial thymoma and discuss approaches that may potentially prevent this devastating complication.     

Simultaneous bilateral decortications via video-assisted thoracic surgery for bilateral empyema

IntroductionBilateral empyema is a rare and life-threatening condition that is difficult to treat. We herein report a case of bilateral empyema that was treated with simultaneous bilateral decortications via video-assisted thoracic surgery (VATS).Presentation of caseA 38-year-old female complained of chest pain, dyspnea, and high grade fever lasting two weeks. Computed tomography revealed bilateral notching pleural effusion and pneumonia with atelectasis. Bilateral thoracic drainage was performed. From the right chest, white pus was drained, and Streptococcus anginosus was identified. The left drainage fluid was serous, and no bacteria were identified. We diagnosed the patient with right empyema and left para-pneumonic effusion consequent to pneumonia. Because conservative therapies could not resolve the inflammatory findings, simultaneous bilateral VATS decortications were performed. Both thoracic cavities had loculated pleural effusion. In contrast to the preoperative findings, white pus was found in not only the right, but also the left thoracic cavity. She had an uncomplicated postoperative course and recovered.DiscussionBilateral empyema that has developed to the fibrinopleural phase is difficult to treat with drains alone. Bilateral VATS decortications helped to make a definitive diagnosis and treat both sides simultaneously.ConclusionSimultaneous bilateral VATS decortications should be considered as a feasible and effective procedure for bilateral empyema that is refractory to medical treatment.     

Tube thoracostomy during allogeneic stem cell transplantation does not carry an increased risk for infections or bleeding

BACKGROUND: Candidates for stem cell transplantation may occasionally suffer from massive pleural effusions related to their disease and require tube thoracostomy. The additional risk of this procedure during allogeneic transplantation procedure is not known. METHODS: Four high-risk patients transplanted in our institution during a 2-yr period had chest drainage by tube thoracostomy. The characteristics of the fluid, the clinical course, and the outcome were assessed. RESULTS: A total of nine chest drains were inserted (range 1-5). No bleeding complications related to the procedure were noted. None of the patients developed any clinical signs of local infection at the tube insertion site or within the pleural fluid. All cultures taken from the drained fluid or from the insertion wound were negative. CONCLUSIONS: Tube thoracostomy in itself does not seem to pose additional risks in the transplant procedure, despite all patients in this series being considered to be at high-risk for complications.     

A new technique for muscle flap closure of the empyema space in complicated chronic bronchopleural fistula

OBJECTIVES: It is difficult to close the empyema space once it is opened, especially in cases complicated with a chronic bronchopleural fistula. A muscle flap closure is generally employed to prevent this situation. However, this operation occasionally fails because the space newly recurs around the fistula due to atrophic change occurring in these translocated muscles. The aim of the present new technique was to prevent inspiratory pressure from the inside of the bronchus by bronchial emboli, and help the adhesion between the fistula stump and the muscle flap, even if they have become atrophic and no longer have sufficient volume to fill the entire empyema space. METHODS: We carried out fiberscopic embolism of causative bronchioles followed by muscle flap closure in 4 patients in whom open drainage had already been performed against parapneumonic empyema within the bronchial fistula. The bronchial fistula was plugged from the inside of the bronchus by silicon material, and stainless steel wire was used to connect this plug tightly to the muscle flaps, so that the fistula was sandwiched between them. In all cases, we succeeded in complete closure of the bronchial fistula and empyema space without using the omentum, and there has been no recurrence. CONCLUSION: The presented new technique was beneficial for achieving muscle flap closure of the empyema space with a chronic bronchopleural fistula.     

A treatment protocol for chronic post-pneumonectomy empyema associated with bronchopleural fistula: A single-centre retrospective study

Chronic post-pneumonectomy empyema (CPPE) associated with bronchopleural fistula (BPF) is a potentially fatal complication and remains a surgical challenge. This study aims to propose a treatment protocol for managing this severe disease. From July 2009 to June 2021, 47 CPPE with BPF patients were treated in our department. CT scan with 3D reconstruction was used to detect BPF and to evaluate the location and volume of empyema cavity. Different surgical techniques were used to close BPFs according to they sizes. Multiple pedicled muscle flaps were chosen to fill the empyema cavity, and among them, latissimus dorsi (LD) was the mostly used flap. For cases that regional flaps were not suitable, free flaps were used. Patients were followed-up from 7.9 to 102.8 months. Forty-four patients (93.6%) healed after the operation. Closure of BPFs failed in three patients (6.4%), leading to regional infection. These patients were treated by bronchoscopic application of sealants, continuous drainage and antibiotics, and they eventually healed. Total or partial flap loss was not seen in any of the cases. Treatment protocol was proposed based on these results. CT scan with 3D reconstruction is an effective examination to evaluate pleural cavity defect and BPF. Proper technique to close the BPF and right choice of flap to fulfil the empyema cavity are the two most important key points to treat CPPE associated with BPF patients.     

A new technique for one-stage radical eradication of long-standing chronic thoracic empyema

The surgical treatment of chronic long-standing thoracic empyema remains a challenging subject. A simple technique that consumes less operative time, accompanying less bleeding, and that enables eradication of the disease in one stage was devised by the senior author. The technique requires only three major steps: (1) decortication limited to the parietal sides of the peel's sac, (2) cleansing the empyemic cavity, and (3) drainage. To date, six patients have been treated by this method; complete cure was achieved in all. Neither death nor recurrence of the disease has been noted during the follow-up period averaging 24.5 months. The mean operative time was 3.06 hours, mean bleeding volume was 1262 ml, and the mean hospital stay period was 1.14 months. The methods and results of the technique are discussed.     

胸廓造口开窗引流术在结核性脓胸伴支气管胸膜瘘中应用的疗效分析

【摘要】 目的 总结分析胸廓造口开窗引流术(OWT)在结核性脓胸伴支气管胸膜瘘中应用的治疗经验。方法 对我科在2003年至2012年56例结核性脓胸伴支气管胸膜瘘病例采用胸廓造口开窗引流术的外科治疗进行回顾性分析。本组病例胸廓造口开窗换药引流3~12个月后,分别采用Heller胸廓成形术加瘘修补术、胸膜外全肺切除术或余肺切除术、永久的开放性胸廓造口术等方法治疗。结果 全组患者有效地控制胸腔感染后,36例行Heller胸廓成形术加瘘修补术;14例胸膜外全肺切除术或余肺切除术后关闭胸廓造口,其中有5例术后出现围手术期胸腔再次感染并发症发生再次行胸廓造口术;6例患者选择永久的开放性胸廓造口开窗换药引流,无围术期死亡病例发生。结论 对结核性脓胸伴支气管胸膜瘘的患者应用胸廓造口术能有效地控制胸腔感染,降低死亡率,改善身体状况,为二期瘘修补术及消灭残腔手术创造有利条件并提高手术成功率。     

Treatment of tuberculous empyema with multiple fistulae by reexpansion of the affected lung and restoration of its function: Report of a case

We report herein the case of a patient in whom a calcified tuberculous empyema with multiple fistulae was successfully treated by a new surgical approach. Reexpansion of the affected lung which had calcified over 30 years was achieved by covering the multiple bronchial fistulae using the omentum without obliterating the empyema cavity. Although the patient presented with severe aspiration pneumonia, he made a complete recovery and is now leading a better quality of life than before. This new operative method is less invasive and can therefore be performed much more easily on critically ill patients than conventional methods.     

Proper catheter selection for needle thoracostomy: A height and weight-based criteria

Background

Obesity increases the incidence of mortality in trauma patients. Current Advanced Trauma Life Support guidelines recommend using a 5-cm catheter at the second intercostal (ICS) space in the mid-clavicular line to treat tension pneumothoraces. Our study purpose was to determine whether body mass index (BMI) predicted the catheter length needed for needle thoracostomy.

Methods

We retrospectively reviewed trauma patients undergoing chest computed tomography scans January 2004 through September 2006. A BMI was calculated for each patient, and the chest wall thickness (CWT) at the second ICS in the mid-clavicular line was measured bilaterally. Patients were grouped by BMI as underweight (≤18.5 kg/m2), normal weight (18.6–24.9 kg/m²), overweight (25–29.9 kg/m²), or obese (≥30 kg/m²).

Results

Three hundred twenty-six patients were included in the study; 70% were male. Ninety-four percent of patients experienced blunt trauma. Sixty-three percent of patients were involved in a motor vehicle collision. The average BMI was 29 [SD 7.8]. The average CWT was 6.2 [SD 1.9] cm on the right and 6.3 [SD 1.9] cm on the left. As BMI increased, a statistically significant (p < 0.0001) CWT increase was observed in all BMI groups. There were no significant differences in ISS, ventilator days, ICU length of stay, or overall length of stay among the groups.

Conclusion

As BMI increases, there is a direct correlation to increasing CWT. This information could be used to quickly select an appropriate needle length for needle thoracostomy. The average patient in our study would require a catheter length of 6–6.5 cm to successfully decompress a tension pneumothorax. There are not enough regionally available data to define the needle lengths needed for needle thoracostomy. Further study is required to assess the feasibility and safety of using varying catheter lengths.     

One-stage pedicled omentum majus transplantation into thoracic cavity for treatment of chronic persistent empyema with or without bronchopleural fistula

Objective: Assessment of the present results of surgical treatment for chronic persistent empyema with or without bronchopleural fistula (BPF) using one-stage pedicled omentum majus transplantation into the thoracic cavity. Methods: From November 1979 to December 1996, 50 patients with chronic persistent empyema were treated by pedicled omentum majus transplanted into the thoracic cavity. There were 35 men and 15 women, and the age range was 15–58 years. Empyema had been present for 0.5–18 years. Twenty-six of 35 cases with chronic tuberculous empyema and six of 15 cases with chronic bacterial empyema suffered from concomitant BPF (n=32). In the latter, the most common organisms were Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli. Results: There were no perioperative deaths. Two cases had a significant air leak on the first postoperative day. One of them underwent rethoractomy 30 h after the initial operation to stop the fistula using intrathoracic omentum. Thoracic dead space disappeared in most of the operated cases and a sterilized dry cavity remained in some cases. Conclusions: One-stage pedicled omentum majus transposition is a safe and easy procedure for chronic persistent empyema and BPF, it breaks down residual or recurrent inflammatory foci mechanically and closes the BPF effectively with minimal deformity of the chest wall.     

经皮穿刺插管治疗肺脓肿和局限性脓胸：附16例报告

应用经皮穿刺脓腔、置入细尼龙管引流和给药的方法治疗肺脓肿及局限性脓胸１６例，插管时间７～１５天，疗效满意，无并发症。该方法操作简便、安全，引流充分，创伤小，不限制病人活动。对内科治疗无效的肺脓肿，早期应用可能避免肺叶切除；对局限性脓胸是一种适应证广、可获得满意疗效的针对性治疗方法。     

A new method for continuous pericardiocentesis—Percutaneous pericardial drainagevia a sheath-introducer—

A technique of percutaneous pericardial drainage (PPD) utilizing a catheter introducer system, is described herein. This technique combines the accuracy of the surgical method with the simplicity of the ‘blind’ method, and has been clinically applied with safety and success.     

The anterior to midaxillary line between the 4th or 5th intercostal space (Buelau position) is safe for the use of thoracostomy tubes in preterm and term infants

Objectives:  Thoracostomy tubes are widely used in neonatology. Complications occurred significantly more frequently in infants, especially neonates, than in adults. Principally, the access is the modified Buelau position which takes place in the anterior axillary line at the 4th or 5th intercostal space above the margin of the ribs.
Aim:  This study seeks to determine the characteristics and topographic conditions of the anatomical structures at the ventral and lateral thoracic wall in the preterm and term neonate.
Background:  Fifteen formalin-fixed stillborns were prepared (nine male, six female, 28–43 weeks gestational age).
Methods/Materials:  The anatomical preparation involved the complete thoracic wall region.
Results:  In all preparations, a venous vessel was detected at the lateral wall and was identified as v. thoracoepigastrica without accompanying artery. Arteria (a.) and vena (v.) thoracica interna were regularly found close to the sternal plate on both sides between rib and fascia. With increasing gestational ages the course of the v. thoracoepigastrica varied significantly between the left and right thoracic wall. It was demonstrated that the v. thoracoepigastrica regularly arose within the abdominal or thoracic subcutaneous fat and drained into the v. subclavia. The variance between its course was almost 5–12 mm to the lateral or medial side. At both thoracic sides, no other organs or organ structures except lung parenchyma could be detected when using the Buelau position.
Conclusions:  The anterior to midaxillary line between the 4th or 5th intercostal space (Buelau position) is safe for the use of thoracostomy tubes in preterm and term infants.