Management Of Chronic Empyema Research Articles

Management of chronic empyema thoracis in children, a single center retrospective observational study

Abstract: Background: Chronic empyema thoracis (CET) is common in developing and developed countries despite advancement in diagnostic and therapeutic technologies. Some of the cases of CET can be managed with antibiotics and tube drainage alone, some of them managed with less extensive surgical procedure like video-assisted thoracoscopic surgery (VATS) or open decortication alone, while some of the complicated cases need extensive decortication and debridement of necrotic lung tissue or lobectomy. Our aim is to present our experience of management of cases of chronic empyema thoracis in children. Methods and Material: This is a retrospective observational study of cases, managed at tertiary care center with chronic empyema thoracis. Records of cases of CET admitted, referred or transferred to department of pediatric surgery at our center over last three years were studied. Demographic data, clinical, radiological profile, surgical/ non-surgical intervention, hospital stay, aetiology, outcome was analysed. Follow up was up to the last recorded outpatient visit. This study is a retrospective observational study with small number of cases statistical tool are not used to draw any statistical interference. Results: Twenty-nine cases with median age 3 years, male to female ratio was 25:4 were admitted over three years. Pre-operative bronchopleural fistula was seen in four. Five cases were managed conservatively, twenty underwent decortication alone while four cases required decortication along with lobectomy. Tuberculosis was detected in three cases. A pyogenic organism was identified in ten cases only. Post-operative ventilation was required in three patients. There was no mortality. All thrived well at 12-18 months follow up. Conclusions: Management of chronic empyema should be case based. Cases of CET in children can managed with conservative (with appropriate drainage of cavity, proper antibiotics, and nutritional build-up of child), thoracotomy and decortications alone or some time removal of disease lung also required depending on clinical and radiological finding of cases.

Thoracoplasty in the Management of Chronic Empyema: Experience of a Sub Saharan African Country

Introduction: The current main indication of thoracoplasty is empyema following or not lung resection, when the other surgical methods such as thoracic drainage, pleurostomy and/or pulmonary decortication have failed or are not useful. The authors report the role of thoracoplasty in the management of chronic empyema. Method: Between 2004 and 2015, eight male patients underwent thoracoplasty, in the Department of Thoracic Surgery at the University Hospital of Fann, Dakar, Senegal. The mean age was 40 years old. In all cases, the first step of the treatment was thoracic drainage with Heimlich valve in an ambulatory patient, associated with antibiotic according to the result of bacterial culture. In three patients, thoracostomy was indicated to control local infection before thoracoplasty. Results: Indications for thoracoplasty were refractory post resectionnal lung empyema in 6 cases and chronic primary apical empyema in 2 cases. Bronchopleural fistula was found in 5 patients. We performed three superior partial thoracoplasty, and five enlarged thoracoplasty. A myoplasty, using latissimus dorsi to fill the empyema space, was associated with thoracoplasty in five cases. Bronchopleural fistula cure consisted of a direct X form suture in two cases and of intercostal muscle apposition on the fistula in others ones. Partial scapulectomy, by resection of the inferior third part of the scapula was done in three patients. After a mean follow up of one year, no patient presented with persistence or recurrence of empyema. Then we concluded that they were healed. Conclusion: Thoracoplasty is an efficient procedure for the management of chronic empyema. So it is necessary for each team to established define criteria that will allow a patient to undergo thoracoplasty in order to do not use it for any desperate case of refractory chronic empyema.

Pedicle muscle flap transposition for chronic empyema with persistent bronchopleural fistula: experience of a single clinical center in China.

The management of chronic empyema with persistent bronchopleural fistula (BPF) is a major challenge for surgeons. We report our experience of performing pedicle muscle flap transposition for chronic empyema with BPF in a clinical center in China. The subjects of this study were 13 patients with postoperative chronic empyema and persistent BPF. The surgical procedure performed was chosen according to the degree of infection in the empyema cavity. Patients with mild contamination underwent one-stage cavity decortication with flap transposition, whereas patients with severe infection underwent two-stage surgery including open-window thoracostomy and pedicle muscle flap transposition. Five patients underwent one-stage surgery, followed by an uneventful postoperative course in all except one. The other eight patients underwent two-stage surgery. The fistulas closed spontaneously during the course of dressings and six of these eight patients underwent second-stage surgery uneventfully. A bronchopleurocutaneous sinus developed in the wounds of the other two patients. Pedicle muscle flap transposition is a viable option for chronic empyema with BPF; however, surgical procedures should be selected according to the degree of contamination. For two-stage surgery, obliteration of the cavity should be considered, preferably after closure of the fistula.

Management of chronic empyema with unexpandable lung in poor surgical risk patients using an empyema tube.

Objectives:High preoperative risk precludes decortication and other surgical interventions in some patients with chronic empyema. We manage such patients by converting the chest tube into an “empyema tube,” cutting the tube near the skin and securing the end with a sterile clip to allow for open pleural drainage. The patient is followed serially, and the tube gradually withdrawn based on radiological resolution and amount of drainage.Methods:Between 2010 and 2014, patients with chronic empyema and unexpandable lung, deemed high-risk surgical candidates, had staged chest tube removal, and were included for the study. The volume of fluid drained, culture results, duration of drainage, functional status, and comorbidities were recorded.Measurements and Results:Eight patients qualified. All had resolution of infection. The tube was removed after an average of 73.6 ± 49.73 (95% confidence interval [CI]) days. The mean duration of antibiotic treatment was 5.37 ± 1.04 (95% CI) weeks. None required surgery or experienced complications from an empyema tube.Conclusion:A strategy of empyema tube drainage with staged removal is an option in appropriately selected patients with chronic empyema, unexpandable lung, and poor surgical candidacy.

Comparison of video-assisted thoracoscopic surgery and open surgery in the management of primary empyema

Thoracic empyema is the accumulation of frank pus within the pleural cavity. Its cause is often multifactorial and may include direct contiguous spread of infection, penetrating chest trauma or an iatrogenic cause secondary to surgical instrumentation of the pleural space. Current management of empyema is based on local empirical practice as there is no consensus on an optimal regimen. Over the past decade, surgical management of empyema has attracted great interest, leading to specific recommendations. Video-assisted thoracoscopic surgery (VATS) has revolutionized surgical management of patients with empyema. Thoracoscopic management of empyema includes VATS debridement and decortication. VATS debridement has been employed by many centres as the primary treatment option for early-stage empyema. However, this is still contentious as some surgeons continue to advocate initial trials of chest tube drainage and antibiotic-mediated pleural space obliteration prior to any form of surgery. A more aggressive approach is to move directly to VATS decortication, which has shown great promise in the management of chronic empyema. More complex, mulitloculated empyemas would previously have been managed solely by complex open surgical procedures such as open window thoracostomy or thoracomyoplasty. However, recent studies have shown VATS decortication to produce equivalent resolution rates to the higher morbidity open approaches. A summary of the most recent opinions and results in the thoracoscopic and open surgical management of thoracic empyema is outlined. Early VATS debridement effectively manages simple parapneumonic effusions. VATS decortication has equivalent efficacy to open decortication at managing both chronic and early-stage empyemas.