Intrapleural Urokinase to Treat Organized Empyema Thoracis After Failure of VATS Debridement

Abstract

Empyema thoracis is a complex pleural infection disease that can evolve into three pathological phases: exudative, fibrinopurulent, and organized. Each stage presents with its own characteristics and relevant treatment strategies. Organized empyema, defined as pleural fibrosis with peel formation, often requires thoracotomy and decortication to expand the entrapped lung. In chronically ill, debilitated, or elderly patients superimposed with organized empyema, more invasive operative approaches are likely to result in higher procedure-related morbidities and mortalities. On the other hand, less invasive procedures would also be inappropriate because of frequently ineffective drainage or consistent lung encasement (e.g. prolonged catheter insertion, intrapleural fibrinolysis, or thoraco-scopic debridement). Here, we report two elderly patients with concomitant illnesses who developed organized empyema and had no response to nonoperative management. Both patients recovered completely after video-assisted thoracoscopic surgery debridement, proper chest tube placement, and urokinase instillation to resolve residual thick peels. Less invasive surgical treatment combined with the use of fibrinolytic agents may be an option in treating patients with organized empyema who cannot tolerate decortication.