Pleural Decortication Research Articles

Factors Associated with Residual Pleural Thickening After Chemotherapy in Tyberculous Pleurisy

Background Residual pleural thickening is frequently seen following treatment for tuberculous pleurisy, and pleural decortication is performend occasionally in patients with severe residual pleural thickening. However, predictive factors for the development of residual pleural thickening are uncertain at the initial diagnosis of the tuberculous pleurisy. Therefore, the purpose of this study was to identify the associated factors for residual pleural thickening at initial diagnosis. Methods We separated 63 patients diagnosed as tuberculous pleurisy into two groups; group 1 consisted of patients without residual pleural thickening and group 2 comprised patients with residual pleural thickening at the end of tuberculous pleurisy treatment. We analyzed the clinical characteristics, radiological findings, pleural biopsy and characteristics of pleural fluid between group 1 and group 2. Results The study population and clinical symptoms of the two groups were not significantly different and the duration of symptoms before treatment and the peripheral WBC were similar between the two groups. The presence of pulmonary tuberculosis, pleural fluid loculation or the amount of pleural effusion sid not differ significantly between the thwo groups. The incidence of positive AFB staining(group 1 : 8%, group 2 : 38%) and granuloma(group 1 : 30%, group 2 : 62%) on pleural biopsy specimens was significantly higher in group 2 than in group 1. Pleural fluid WBC and differential count, adenosine deaminase level, pH, preotein level or glucose level did not differ between the two groups. However, group 2 had higher LDH levels (1370±208mg/dl) than group 1 (860±71mg/dl, p<0.05). Conclusion In tuberculous pleurisy, patients with residual pleural thickening following treatment demonstrated a higher incidence of posivive AFB staining and granuloma on the pleural biopsy specimens or higher LDH level in the pleural fluid than patients wihtout residual pleural thickening From these results, we speculate that the amonut of tuberculous bacilli and granuloma are probably correlated with residual pleural thickening in the tuberculous pleurisy.

Casos Clínicos Infección por Nocardia asteroides en un paciente con lupus eritematoso sistémico

Nocardia asteroides infection are unusually observed in systemic Lupus erithematous (SLE) patients. They are generally associated to steroidal and immunosuppressive therapy. We report a 24 years old female with SLE diagnosed in 1994 who developed a severe preeclampsia in her first pregnancy requiring emergency caesarean section. Post partum acute renal failure and type IV lupus nephropathy were treated with hemodialysis, methylprednisolone, cyclophosphamide and prednisone. Three months later, while she was receiving the fourth cyclophosphamide dose, she presented with a pleuro pneumonia and occipital abscess, both caused by Nocardia asteroides. She was treated with cotrimoxazole + cefixime and pleural decortication was required. Five months later, she developed Meningitis caused by Nocardia asteroides and hydrocephalus. She was treated with ceftriaxone, vancomycin, cotrimoxazole and ventricular shunting procedure. Two months later, a retroperitoneal abscess was diagnosed and surgically drained but the patient died, due to a methicillin-resistant Staphylococcus aureus septicemia.

The Effects of the decortication on pulmonary function in tuberculous empyema

Background The purpose decortication is to eliminate the infection focus and to improve the decreased lung function due to chronic empyema. However, lung function is not improved in all cases. It would be clinically useful it we could predict preoperatively whether lung function would improve after decortication. The purpose of this study is to find useful indices for predicting the possible improvement of lung function after decortication. Method The medical records of 37 tuberculous empyema patients who underwent pleural decortication were analyzed retrospectively from 1990 to 1996. The measurements of preoperative and postoperative forced vital capacity(FVC) were used for evaluating the effects of decortication. Results The sex ratio was 29 : 8 (male to female), and the median age was 34 years. The time interval between the formation of empyema and operation was 1 month to 30 years. Postoperative pulmonary function test was performed 5.4±2.6 months later. FVC(forced vital capacity) was significantly increased from 2.77±0.67(L) to 2.95±0.81(L). Interestingly, postoperative pulmonary function was significantly improved in patients who were less than 40 years old, within 4 months after diagnosis of tuberculous empyema, in the group with FVC of less than 60% of the predicted value and in the absence of calcification. Conclusion The improvement of lung function after decortication was expected in patients younger than 40 years old, within 4 months after diagnosis of tuberculous empyema, in the group having less than 60% of the predicted FVC, without calcification.

Postpneumonectomy Bronchopleural Fistula Formation and Surgical Management

Bronchopleural fistulas and empyema are the most challenging problems after lung resection. We reviewed 4 cases of successful surgical treatment of postpneumonectomy bronchopleural fistulas. Three of the patients had empyema. Primary suturing and pleural decortication were performed in one patient, decortication and fistula repair with additional omentopexy were carried out in the other 3 patients. Recurrence in one patient was successfully treated by thoracoplasty; the others have had no recurrence on follow-up. We recommend aggressive surgical intervention as the most effective treatment for bronchopleural fistula and empyema after pulmonary resection.

Thoracoscopy in the horse: diagnostic and therapeutic indications in 28 cases.

Thirty-two thoracoscopies were performed in 28 horses. Sixteen horses were affected with pleuropneumonia whereas 12 were affected with various other thoracic conditions. The indications for thoracoscopy was diagnostic in 19 cases, therapeutic in 11 cases and both diagnostic and therapeutic in 2 cases. Twenty-six thoracoscopies were done standing whereas 6 were performed under general anaesthesia. The specific procedures performed during thoracoscopy were exploratory only (7), biopsy of the lung and lymph nodes (10), drain placement into pleural effusions (2) and abscesses (5), exploration prior to thoracotomy (2), transection of pleural adhesions and decortication (1) and window pericardectomy (2). Diaphragmatic hernia repair (2) and partial pneumonectomy (1) were initiated thoracoscopically but conversion to thoracotomy was necessary for completion. Standing thoracoscopy was well tolerated in most horses. Transient exacerbation of pulmonary compromise evidenced by tachypnoea was readily alleviated by reinflation of the lung. Standing thoracoscopy provided good visualisation of the dorsal and lateral structures of the thorax. The ventral thoracic structures and the cranial ventral diaphragmatic surfaces of the lungs were best visualised in dorsal or lateral recumbency under general anaesthesia. Thoracoscopy is a safe and useful diagnostic and therapeutic tool in horses with thoracic diseases.

Intrapleural Fibrinolytic Treatment of Traumatic Clotted Hemothorax

To evaluate the role of intrapleural fibrinolytic treatment (IPFT) in traumatic clotted hemothorax. Between August 1995 and February 1997, 24 patients with traumatic clotted hemothorax were included. Streptokinase (SK), 250,000 IU, or urokinase (UK), 100,000 IU, diluted in 100 mL of saline solution was given daily. We administered 5.0+/-1.8 (range, 2 to 9) doses of SK or 6.25+/-5.97 (range, 2 to 15) doses of UK. Dicle University School of Medicine, Thoracic and Cardiovascular Surgery Department. Complete response, which was defined as resolution of symptoms with complete drainage of fluid and no residual space radiographically, occurred in 15 (62.5%) patients. Partial response, which was defined as resolution of symptoms with a small pleural cavity, occurred in seven (29.2%) patients. Two patients (8.3%) required decortication; they were defined as nonresponders. The mean period of time between the diagnosis and fibrinolytic treatment (FT) was 11.65+/-6.38 (range, 4 to 25) days. There were no complications related to IPFT. There was no mortality during the course of IPFT. The use of intrapleural fibrinolytic agents has resulted in resolution of clotted hemothorax with an overall success rate of 91.7%. We recommend that IPFT should be added to the algorithm for management of clotted hemothorax before proceeding with minithoracotomy or pleural decortication.

Prediction of Pulmonary Parenchymal Reexpansion by Computed Tomography after Pleural Decortication

Twenty-six patients underwent pleural decortication for chronic empyema. All had a computed tomgraphy scan of the chest showing no marked parenchymal destruction. Multiple subpleural linear densities perpendicular to the pleura were seen to various degrees and the sum of the areas of these densities was evaluated for each patient. The thickness of visceral and parietal pleura, nodularity of the empyema wall, presence of calcification, and homogeneity of the inner content of the empyema were assessed. The degree of lung reexpansion was quantified from the ratio of the aerated areas of the affected and unaffected lungs on postoperative chest radiography. Successful lung reexpansion was achieved in 23 patients. The 3 patients in whom lung reexpansion failed required a subsequent pneumonectomy. The thickness of extrapleural fat and the sum of the areas of subpleural linear densities were significantly higher in these 3 patients. In the successful decortication group, the degree of lung reexpansion correlated with the sum of subpleural linear densities and with a noted homogeneity of the inner content of the empyema. Computed tomography appeared to be useful in determining the appropriate surgical method of treating chronic empyema.

Cytologic diagnosis of primary serous lymphoma.

Lymphomas arising primarily in serosal surfaces have recently been described. Although these "body-cavity" lymphomas usually present as an effusion, the role of cytologic diagnosis has not been fully explored. The authors present seven cases of primary serous lymphoma. All were large cell lymphomas (5 B cell types, 2 T cell types). Three distinct clinical presentations were seen. Four patients had the rapid onset of pleural effusions without an associated mass in the setting of immunodeficiency (3 with AIDS, 1 with Castleman's disease). Cytologic examination of the effusion was positive in all cases for B-cell lymphoma. All four patients died of their disease in less than 6 months. Two other patients with AIDS and T-cell lymphomas both of which were associated with a serosal mass as well as an effusion. Although cytologic examination revealed numerous atypical lymphoid cells, clonality could not be demonstrated. One patient survived for more than 1 year, the other lymphoma was an incidental finding at autopsy. Finally, one B-cell lymphoma arose in a patient with chronic pleuritis. Pleural decortication was required to identify the neoplastic cells. The authors conclude that primary serosal lymphomas have characteristic clinical presentations, and that although cytologic and flow cytometric examination of effusions is necessary for the diagnosis of immunodeficiency associated B-cell lymphomas, tissue biopsy will likely be required in patients with immunodeficiency-associated T-cell lymphomas or lymphomas associated with chronic pleuritis.

Pneumococcal pleural empyemas in children.

Empyema rarely complicates pneumonia. In a 361-bed regional pediatric hospital, 50 pleural empyemas were identified from 1988 through 1994; 17 (34%) occurred in the last 12 months of this period, for which the incidence was 3.3 per 100,000 of the population aged < or = 18 years (P < .05, chi 2 test). A significant seasonal prevalence was observed: 50% of cases occurred in the winter (P < .001, chi 2 test). In contrast with the findings of previous studies, in which empyemas predominantly occurred in infants, the median age of our patients was 7 years; underlying illnesses were present in only 10%, and all had community-acquired disease. Eighty-two percent had chest tubes inserted, 56% required a thoracotomy with pleural decortication, and 2% had a lobectomy. There were no deaths. Streptococcus pneumoniae was isolated in 40% of the cases; specimens in 44% of the cases were sterile. None of the empyemas were associated with Staphylococcus aureus or Haemophilus influenzae type b, and only one was caused by group A streptococcus. Among 13 S. pneumoniae isolates, the rate of resistance to penicillin was 15%; to erythromycin, 15%; to chloramphenicol, 31%; and to cefotaxime, 23%. The penicillin-resistance rate among blood and cerebrospinal fluid pneumococcal isolates was 17% during 1993-1994. Drug-resistant S. pneumoniae is now a recognized cause of pleural empyemas in children.

T-TUBE INTUBATION IN THE MANAGEMENT OF LATE TRAUMATIC ESOPHAGEAL PERFORATIONS

Delayed diagnosis of esophageal perforations can lead to high mortality and morbidity and presents a surgical dilemma. A case report of a bullet wound of the esophagus that was diagnosed late is presented. Placement of a biliary T-tube and pleural decortication were carried out after the perforation was found at esophagoscopy. The patient had no fistula nor esophageal narrowing at discharge 31 days after injury.

The Clinician's Perspective on Parapneumonic Effusions and Empyema

Respondents at an interactive symposium on pleural space infections (n = 339) at the 1991 American College of Chest Physicians Annual Scientific Assembly recorded their personal management preferences for hypothetical patients with empyema. The group's preference was to treat pleural sepsis from an anaerobic multiloculated empyema by pleural decortication (49 percent); however, open thoracotomy with directed chest tube placement (22 percent), chest tube placement with intrapleural streptokinase (14 percent), placement of a single chest tube into the largest pleural loculus (8 percent), and placement of multiple small-bore catheters with computed tomographic guidance (7 percent) all had proponents. In the case of a multiloculated empyema not completely drained by a first chest tube in a nontoxic patient, the preference was drainage by a second chest tube, either a small-bore (42 percent) or a large-bore (36 percent) tube. The heterogeneity of responses suggests that prospective trials comparing treatment modalities are needed.

Reexpansion Pulmonary Edema

Sir.—Reexpansion pulmonary edema (REPE) is an uncommon problem that afflicts the reexpanded lung after evacuation of a large pneumothorax or pleural effusion. There are many accounts of REPE occurring in adults, but to my knowledge, this problem has not been reported in the pediatric population. A boy is described in whom severe unilateral pulmonary edema occurred after evacuation of a large pleural effusion. Patient Report.—An 8-year-old boy weighing 40 kg was admitted for treatment of steroid-resistant nephrotic syndrome. He had no previous neurologic abnormality. The patient's medical history was remarkable for multiple bouts of infection, including a right-sided pneumococcal pneumonia 3 months before admission. One month after the pneumonia, he underwent a right pleural decortication because of recurrent pleural effusion. Two weeks before admission, a chest roentgenogram showed moderate right- and left-sided pleural effusions. During these 2 weeks, he experienced worsening shortness of breath. On admission, the patient

Intercostal arteriovenous fistula due to pleural biopsy.

A 32 year old woman had a pleural biopsy for a left pleural effusion, which showed caseating granuloma typical of tuberculosis. When the fourth biopsy specimen was removed considerable bleeding occurred from the puncture site. Four days later a bruit was audible over the punctured area, radiating to the back. Eight days after the procedure the patient had a massive bleed into the left pleural space. Selective aortic angiography showed an arteriovenous fistula between the 9th intercostal artery and vein and a pseudoaneurysm in the intercostal punctured area. Thoracotomy showed bleeding from the site of the pleural biopsy. The intercostal vessels were ligated and pleural decortication was performed, and the patient recovered uneventfully.

Intercostal arteriovenous fistula due to pleural biopsy.

A 32 year old woman had a pleural biopsy for a left pleural effusion, which showed caseating granuloma typical of tuberculosis. When the fourth biopsy specimen was removed considerable bleeding occurred from the puncture site. Four days later a bruit was audible over the punctured area, radiating to the back. Eight days after the procedure the patient had a massive bleed into the left pleural space. Selective aortic angiography showed an arteriovenous fistula between the 9th intercostal artery and vein and a pseudoaneurysm in the intercostal punctured area. Thoracotomy showed bleeding from the site of the pleural biopsy. The intercostal vessels were ligated and pleural decortication was performed, and the patient recovered uneventfully.

Cryptogenic bilateral fibrosing pleuritis

We describe four patients with bilateral pleural effusions progressing to diffuse progressing to diffuse pleural thickening for which we have been unable to find any evidence of an infective, embolic or occupational aetiology. In order to avoid confusion with diffuse pleural thickening attributable to asbestos-related disease, the term cryptogenic bilateral fibrosing pleuritis is suggested. The patients differed from those with pleural shadowing due to asbestos in that none of them gave a history of asbestos exposure, all were ill, presented with chest pain which was not always pleuritic in character, and had dyspnoea, cough or malaise. They had pleural effusions of variable size, pleural shadowing radiographically and raised sedimentation rates. Computed tomography revealed bilateral extensive pleural thickening in all cases. All four were HLA B44 positive. Histology showed that in all cases the pleura was thickned by fibrous tissue. Both layers were affected and the pleural space was often obliterated. Otherwise the plaural surface was covered by organizing fibrin. Focal collections of lymphocytes were often present when the fibrous tissue abutted on the subpleural fat. No asbestos bodies were seen in any of the cases and in one patient electron microscopic fibre counts showed no excess of asbestos. Pleural decortication was successful in three patients. In one of these, contralateral disease was successfully controlled with corticosteroids, but the fourth patient has not improved on corticosteroids.

Empyema thoracis: a ten-year experience.

Over a ten-year period, 50 patients with thoracic empyema have been treated at the Metropolitan Nashville General Hospital, where a systematic, stepwise approach to the management of empyema has been followed. The initial step was thoracentesis; if this failed to resolve the empyema, dependent thoracostomy tube drainage was used. Closed thoracostomy drainage was converted to open drainage when closed drainage failed to obliterate the empyema cavity. When all other measures failed, thoracotomy with pleural decortication was done. Of the 27 patients who had empyema as a consequence of pneumonia, most (14) were successfully treated with open empyema tube drainage, though five required decortication. Eight of the ten posttraumatic empyemas resolved with open drainage, but pleural decortication was necessary in the remaining two cases. Nine patients had postoperative empyemas; six were managed with open drainage, and three resolved with closed thoracostomy drainage. Of the four remaining empyemas, two resolved with closed drainage and two required open drainage. Treatment was successful in 85% of cases, with six deaths (15%). This experience with empyema shows that early, staged surgical management is successful in most cases. In our experience, the causative organism had no bearing on outcome. Resolution of the condition was possible only after adequate drainage and obliteration of the empyema space was accomplished.

Decortication of the lung.

From 1972 to 1982, 161 patients underwent pleural decortication because of pleural callosity with or without empyemic residual cavities. Indications were: Sanitation of infection sites and improvement of respiratory function. Of the patients, 73.3% had non-specific and 22.4% tubercular empyema. Postoperative complications included 8.7% wound infections and 1.2% recurring empyema. Operative mortality was 1.2%. To estimate pulmonary function, the preoperative values of blood gas analysis, vital capacity, forced expiratory volume and maximal voluntary ventilation were assessed and compared with those obtained early postoperatively and after one year in 75 patients. The average values of these measurements showed no significant improvement in postoperative pulmonary function. A relatively slight improvement (mean 13.8%) showed only in those patients who had a preoperative reduction of vital capacity of more than 40%. The indication for decortication to improve pulmonary function alone is questionable. As a rule it is based upon 2 factors--both elimination of infectious foci and improving function.

Early pleural decortication for thoracic empyema in immunosuppressed patients

Patients with empyema and impaired immune response often remain in a toxic condition after tube thoracostomy because the infection is not localized and walled off satisfactorily. Consequently, the reported mortality rate is extremely high. Despite the expectation of a high mortality rate from thoracotomy and débridement in this category of critically ill patients, we were forced to perform pleural decortication in eight patients after lesser procedures had failed. They were immunodeficient because of (1) high-dose steroids (HDS) for sagittal sinus thrombosis, (2) HDS for systemic lupus erythematosus, (3) HDS for chronic myelogenous leukemia and myelofibrosis, (4) HDS for multiple myeloma, (5) hemolytic anemia with pulmonary infiltrates, (6) chemotherapy for Hodgkin's disease, (7) diabetes mellitus with Kimmelstiel-Wilson disease, and (8) diabetes mellitus with chronic glomerulonephritis. Six of the eight patients survived and were discharged with completely healed incisions 3 to 6 weeks after operation. This compares well with the survival rates reported by others. Although risky, the over-all survival rate may be better with thoracotomy and decortication than with prolonged tube drainage and open drainage in immunodeficient patients with empyema, and the period of morbidity is shortened considerably.

Failure of tube thoracostomy for post-traumatic empyema: an indication for early decortication.

Post-traumatic empyema has occurred in seven patients despite chest tube drainage and antibiotics. Early pleural decortication resulted in complete recovery of all patients with early discharge from the hospital in most instances. The surgical procedure is technically simple to perform if carried out before the organization of the pleural exudate. Criteria are offered for early decortication of the lung for post-traumatic empyema. They are: 1) Residual air-fluid levels despite chest tube drainage. 2) A clinically deteriorating course with evidence of infection or sepsis arising from the pleura. 3) Pleural restriction with inadequate expansion of the lung resulting in compromised ventilatory function. 4) Failure of chest tubes to allow for resolution of pleural contamination within 14 days of injury. If such indications are employed, excellent results can be anticipated from early decortication of post-traumatic empyema.

Surgical therapy of empyema in children.

Pleural empyema was diagnosed in 69 infants and children over a ten-year period (1960 to 1970). In 52 of 69 cases, a specific organism was recovered by culture or gram stain of the pleural fluid.<i>Staphylococcus</i>organisms were the etiologic agent in 75% of these cases. Seven patients were treated by thoracocentesis alone. Closed-tube drainage and/or rib resection was done in 62 patients. An indicated decortication was done for three patients. The overall mortality was 7% with a 3.2% mortality since 1963 when staphylococcal specific antibiotics were introduced. Pleural empyema in infants and children can be well treated by adequate tube drainage and appropriate antibiotic therapy with a low morbidity and mortality, and pleural decortication is only rarely indicated in this age group.