Indwelling Pleural Catheter Insertion Following Inefficient Thoracoscopic Decortication in Postpneumonic Empyema: Beneficial or Contraindicated?

Gabor Egri,Rakesh Krishnadas,Peter Froeschle

doi:10.4236/ojts.2013.34025

Abstract

Video assisted thoracic surgery in advanced stage postpneumonic empyema aims for thorough debridement and washout of the pleural space followed by an attempt to release the entrapped lung (decortication). When the latter isn’t successful, and the patient is in a poor performance status, applying tube thoracostomy is the usual routine, to avoid conversion to thoracotomy and open decortication. Tube thoracostomy, however, is associated with complications necessitating further surgery, needs long term follow up and also entails quality of life distorting issues. To overcome these disadvantages, we instead inserted a PleurX&reg indwelling pleural catheter in four patients in the above situation. The method brought success (lung re-expansion and complete or partial pleurodesis) without the need for further surgery or quality of life problems in either patient. Although the use of the indwelling pleural catheter in infected pleural space is not recommended by manufacturers, we noted no complications.

Highlights

Pleural empyema formation in association with pneumonia is a progressive process and has been classified into three stages
In our article we report on four patients with advanced stage empyema, where during video assisted thoracoscopic surgery (VATS), after unsuccessful decortication, we applied a new method to avoid both thoracotomy and thoracostomy
The indwelling pleural catheter (IPC) was left in place for long time but at the end it was removed at 33 weeks, as there was no substantial fluid collection in the “pocket” and the patient hadn’t presented with signs of sepsis, or elevation of inflammatory markers including CRP

Summary

Introduction

Pleural empyema formation in association with pneumonia is a progressive process and has been classified into three stages. All measures must be taken to free the lung from anything that restricts its re-expansion by two procedures: lysis of adhesions and decortication The former is usually straightforward, but thoracoscopic decortication (stripping off the fibrous peel that “traps” the lung in advanced stages) can be challenging and is sometimes impossible. There are patients, who being severely compromised by co-morbidities and the sepsis itself, are too debilitated to withstand the conversion to the above open surgery In their cases decision to perform tube-thoracostomy (partial single rib resection with permanent drain insertion) is generally taken. The unsightly draining system (consisting of a large-bore drain and a bag collecting septic fluid) is worn by the patients at all times. In our article we report on four patients with advanced stage empyema, where during VATS, after unsuccessful decortication, we applied a new method to avoid both thoracotomy and thoracostomy

Patients and Method of Management

Results

Discussion