Video-assisted thoracoscopic surgery for children with stage II empyema

Children with stage II empyema often fail traditional medical management, frequently succumbing to the effective albeit morbid clutches of thoracotomy. Video-assisted thoracoscopic surgery (VATS) has been recently introduced as a viable and potentially less morbid alternative to open thoracotomy. We review our VATS experience in children with empyema, assessing surgical outcome. Between August 1996 and March 1999, 13 patients at our institution with stage II empyema that did not respond to conventional medical management underwent a modified VATS with decortication. Data from retrospective chart review reflects intraoperative findings and postoperative course, including average time to defervescence, removal of thoracostomy tube, and hospital discharge. VATS was completed in all 13 patients. All intraoperative cultures of pleural fluid and fibrinopurulent debris obtained at VATS showed no growth. The average time to defervescence was 2.2 days (range, 0-4 days) and to removal of thoracostomy tube 3.6 days (range, 2-5 days). Average total chest tube days in patients with pre-VATS thoracostomy (n = 6) was 14.5 days (range, 8-37 days) versus 3.1 days (range, 2-5 days) in patients (n = 7) who underwent primary VATS (t test, p < 0.05). The average time to surgical discharge after VATS was 5.8 days (range, 3 to 19 days). All patients were well on follow-up clinic visits without delayed complications. VATS can be performed safely and effectively in children with stage II empyema, thus avoiding the morbidity of open thoracotomy and decortication. Importantly, early application of VATS significantly relieves patients of unnecessary days of thoracostomy drainage.     

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.     

Thoracic problems associated with hydatid cyst of the dome of the liver.

Twenty patients with hydatid cyst of the dome of the liver are presented. In ten there were significant associated intrathoracic complications including pleural effusion, pleural empyema, erosion through the diaphragm into lung, various degrees of pneumonitis or pulmonary abscess, or severe destruction of both diaphragm and right lower pulmonary lobe. Bronchobiliary fistula was demonstrated at operation in five patients. Four patients had obstructive jaundice due to intrabiliary rupture of a liver hydatid. In 19 patients the cysts in the right lobe of the liver were evacuated through a right thoracotomy and incision of the diaphragm. In four of these, additional pulmonary resection was carried out. In one patient with left pleural empyema, tube drainage followed by rib resection was instituted. Two patients had common duct drainage for relief of obstructive jaundice. In 13 patients the ectocyst cavity was drained; in seven it was filled with saline and closed. One patient required evacuation and open packing of the right upper quadrant and lower right hemithorax. Thoracotomy is mandatory in patients with hydatid cyst of the dome of the liver for easier approach to the cyst and for management of coexisting intrathoracic complications.     

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。     

Relevance of group Milleri streptococci in thoracic surgery: a clinical update

Group Milleri streptococci (GMS), a heterogeneous group of streptococci, are associated with purulent infections. This study was a retrospective analysis of all consecutive thoracic infections of GMS between 2001 and 2004. Of 246 surgical GMS infections, thoracic infections accounted for 4.5 per cent, including 10 pleural infections (eight empyemas and two infected pleural effusions) and one mediastinal infection. The etiology of pleural infection was parapneumonic (7), second to esophageal perforation (1), liver transplantation (1), and liver resection (1). Polymicrobial infections were present in 64 per cent. All patients underwent removal of the infected masses, including drainage (3), thoracoscopic decortication (5), thoracotomy with debridement (2), and incision with drainage (1). The case fatality rate was 9 per cent (there was one patient with congestive heart disease unfit to undergo surgical empyema evacuation) and the recurrence rate was 27.3 per cent (three patients). Combined antibiotic/surgical treatment was successful in all other cases. GMS isolates were susceptible to clindamycin and all beta-lactam antibiotics except ceftazidime, but were resistant to aminoglycosides. If found intrathoracically, GMS frequently progress to severe empyema. Therefore, timely removal of pleural collection by percutaneous drainage or surgical intervention seems indicated. If surgery is required, thoracoscopic decortication may be the preferred approach.     

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.     

Video-thoracoscopic and open surgical management of thoracic empyema

PURPOSE: To evaluate the outcomes of video-thoracoscopic and open surgical management of patients with thoracic empyema. METHODS: We studied 122 patients retrospectively who underwent surgery for thoracic empyema in our hospital between January, 1999 and January, 2005. Patients' medical records, surgical procedures, and outcomes were reviewed. The study identified 97 affected men and 25 affected women with a mean age of 54 years (range 16-78 years). The empyema was parapneumonic in 95 patients (78%). RESULTS: Forty-four patients who had stage II empyema underwent video-assisted thoracic surgery (VATS). The procedure was converted to thoracotomy in 13 patients (29.5%); the morbidity and mortality rates of VATS were 13% and 0, respectively. Seventy-eight patients had stage III empyema and, along with those 13 who were converted, underwent thoracotomy for decortication. The associated morbidity rate was 12%, and the mortality rate was 6.6%. Thoracotomy was considered successful in 90 of 91 patients (99%); one patient needed a reoperative thoracotomy for an organ space/surgical site infection with pus in the pleural cavity. CONCLUSIONS: Many treatment modalities are available for thoracic empyema, depending on the results of appropriate clinical and laboratory investigations. In fibrinopurulent empyema, VATS debridement is safe and effective, with minimal morbidity and no deaths. Lung decortication via thoracotomy is the only option for organized empyema and is associated with a substantial mortality rate.     

COMPLICATIONS OF BUSH THORACOTOMY IN THE HIGHLANDS OF PAPUA NEW GUINEA

Bush thoracotomy is still practised in the South Western Highlands of Papua New Guinea, by traditional bush doctors. These bush thoracotomies are performed with the aim of letting out the ‘bad bloodRsquo; that is believed to have collected in the body cavities following injuries. During a 3 year period between 1989 and 1992, 183 patients with complications of bush thoracotomy were treated at the Sopas Hospital in the Highlands of Papua New Guinea. Of these patients, 55 had chest wall infections only, without any pleural involvement. Of the patients with empyemas. 14 were treated by decortication of the empyema with one death and all remaining patients were treated by drainage procedures with one death. We recommend early treatment by adequate drainage of the empyema and, where feasible, early decortication. Continuing education to eradicate the procedure, and provision of adequate surgical facilities for management of complications, should be the long-term aim for this continuing problem.     

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.     

The controversial role of decortication in the management of pediatric empyema

Open surgical procedures for pleural empyema remain controversial in children. The pediatric literature generally recommends a prolonged trial of antibiotics and closed tube thoracostomy drainage. We report a favorable experience with a selective approach to open drainage in 22 children, many of whom had an empyema already organizing at admission. Open drainage was considered in children whose conditions failed to improve after 3 to 5 days of therapy with antibiotics and closed drainage. The method of drainage was selected according to the pathologic phase of the empyema: five children with fibrinopurulent empyema were successfully managed by limited decortication, and 17 with organizing empyema received decortication. Clinical improvement was usually dramatic; most of the children became afebrile by postoperative day 3 and were discharged by postoperative day 10. There were no deaths. Three children (14%) had complications of postoperative air leak or infection. Streptococcus pneumoniae (5) and Hemophilus influenzae (3) were the most common single pathogens. The presence of anaerobic bacteria in 8 of 22 children (36%) was associated with rapid organization of the empyema and the need for decortication. Decortication procedures have a low risk and are effective in children with empyema. They should be considered as definitive therapy, rather than as a last resort.     

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.     

Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication

Objective: We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with chronic postpneumonic pleural empyema. Methods: From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3 years, range: 17–82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment. Results: Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain (p < 0.0001), postoperative air leak (p = 0.004), operative time (p < 0.0001), hospital stay (p = 0.020) and time to return to work (p < 0.0001). The analysis of postoperative pain at 6 months follow-up showed no significant differences among the different groups. Conclusions: In the light of our experience, videothoracoscopic decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.     

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.     

Current indications and results of pulmonary decortication for nontuberculous chronic empyema

Pulmonary decortication for nontuberculous chronic empyema has become a rare operation, whose indications and results are now rarely analysed and discussed. The authors report a series of 40 consecutive decortications performed over a period of 15 years. PATIENTS: 40 patients treated by pulmonary decortication over 15 years for nontuberculous chronic empyema secondary to pneumonia (27 cases; 2/3 of cases), post-traumatic haemothorax (5 cases), iatrogenic infection after pleural tap (5 cases) and septicaemia (3 cases). Chronic empyema had been present for an average of 6 months (1 to 60 months). Decortication was performed for drainage of persistent pleural suppuration in 22 cases and to release the encysted lung in 18 cases. Decortication, always comprising parietal pleural stripping and visceral decortication, lasted an average of 3 hours (2 to 8 hours), and was accompanied by mean bleeding of 1 litre (of 200 ml to 3.41). RESULTS: 27 patients (67%) had an uneventful postoperative course, with drainage for 6 days and a mean hospital stay of 13 days. 13 patients (33%) developed various complications, mainly re-expansion defects (10 cases), responsible for pyothorax in 4 cases, 3 of which required secondary drainage. One patient died from intestinal obstruction in a context of peritoneal carcinomatosis (operative mortality: 2.5%). 25 patients were reviewed with a mean follow-up of 54 months, with complete pulmonary re-expansion in 23 cases (92%) and a residual pouch in 2 cases. Vital capacity (VC) was evaluated in 8 patients, with a mean improvement of 40% (15 to 66%) in 6 patients, stable VC in one patient, and a 25% reduction in the last patient, a smoker and with chronic bronchitis. CONCLUSION: Pulmonary decortication is an effective, but relatively major operation to treat chronic encysted empyema. Encystment must be prevented by effective drainage of empyema, now facilitated by the possibility of early videothoracoscopic pleural debridement.     

Video-assisted evacuation of empyema is the preferred procedure for management of pleural space infections

BACKGROUND: Empyema remains a cause of morbidity and mortality. Thoracoscopy has proved its versatility in the management of pleural space disorders. The suitability of video-assisted thoracic surgery (VATS) for decortication in the management of the fibrotic stage of empyema is unclear. METHODS: VATS evacuation of empyema and decortication was performed on seventeen patients presenting with pleural space infections. A retrospective review was performed and constitutes the basis of this report. RESULTS: VATS evacuation of empyema and decortication was successfully performed in 13 of 17 patients. Blood loss was 325 +/- 331 cc. Mean hospital stay was 18 +/- 10 days. Postoperative hospitalization was 11 +/- 7 days. Chest tubes remained in place for 7 +/- 3 days. There were no operative mortalities. CONCLUSIONS: Video-assisted evacuation of empyema and decortication is an effective modality in the management of the exudative and fibrinopurulent stages of empyema. An organized empyema should be approached thoracoscopically, but may require open decortication.     

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.     

Management of multiloculated empyema thoracis in children: thoracotomy versus fibrinolytic treatment.

OBJECTIVE: 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 recently. The aim of this study was to evaluate the effectiveness of the intrapleural fibrinolytic application. METHODS: In our clinic we used urokinase in 28 patients and performed thoracotomy and decortication in another 43. The two groups of patients had similar characteristics. Mean age was 10.2 (range: 3-14 years). All had undergone medical treatment and tube thoracostomy. Empyema severity score (ESS) was measured in all. RESULTS: Fibrinolytic treatment, and thoracotomy and decortication had complete response rates of 67.8 and 100%, respectively. Treatment was ineffective in six (21.4%) out of 28 patients who underwent urokinase instillation; they recovered after thoracotomy. In three (10.7%) patients, partial resolution was observed. One patient died of sepsis and pleural hemorrhage. Mean hospital stay after urokinase was 10.7 (range: 6-17) days. In the thoracotomy group, all patients recovered completely. No deaths occurred. Postoperative complications were incisional infection in two patients, atelectasis in one and reoperation after hemorrhage in one. Mean hospital stay after surgery was 9.5 (5-19) days. The ESS of cases operated on was lower postoperatively (0.3 versus 0.8). CONCLUSION: Continued conservative therapy risks morbidity and mortality. Thoracotomy-decortication can be used successfully and must remain the preferred method in the treatment of multiloculated pediatric empyema.     

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.     

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.     

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.