Presence Of Bronchopleural Fistula Research Articles

Differential Approach for the Management of Chronic Pleural Empyema in the Presence of Broncho-Pleural Fistula

Gritsiuta, Andrei I. MD, PhD; Bracken, Alexander DO; Petrov, Roman V. MD, PhD, FACS Author Information

Surgical outcome of empyema thoracis patients with special correlation to pre-operative contrast-enhanced computerized tomography (CECT) thorax morphometry.

Empyema thoracis is a very common disease. The surgical outcome of empyema patients depends upon various factors. To the best of our knowledge, there is no study in literature describing the surgical outcome of patients in relation to the contrast-enhanced computerized tomography (CECT) thorax morphometric findings. In this study, we examined the surgical outcome of empyema thoracis patients in relation to both clinical and radiological findings. It is a prospective hospital-based study conducted between October 2016 and August 2018. A total of 30 patients, who underwent decortication during the study period, were included. They were divided into three performance groups (excellent performance, average performance and poor performance groups) according to the outcome. The surgical outcome was correlated with the pre-operative clinical, radiological, intra-operative and post-operative parameters. Intra-operative ability to complete decortication, intra-operative expansion of the lungs and presence of broncho-pleural fistula were significantly different between the three performance groups. Duration of the disease, pre-operative duration of antitubercular therapy (ATT) intake and duration of pre-operative intercostal drain (ICD) were statistically insignificant between groups. In computed tomography (CT) morphometry, residual lung volume of the involved lung and volume of empyema were found to be significantly different between the performance groups. The residual volume of the involved lung (expressed in terms of the percentage of lung volume of the normal opposite lung) can predict the complete expansion of the lung with sensitivity of 71% and specificity of 70%. The pre-operative residual lung volume of the involved lung, empyema volume, completeness of decortication, intra-operative expansion of the lung and presence or absence of broncho-pleural fistula can determine the surgical outcome in empyema thoracis patients.

Management of Chronic Empyema Cavity in Cachectic Patients: Review of 30 cases

Background: An empyema, or empyema thoracis, is a collection of purulent material in the pleural space. The management and presentation varies considerably by managing physician, geographic location, and economic resources.                                                                                                                                                                                                                                 Objectives: The aim of this study was to re‐emphasize the importance of open drainage in the treatment of advanced thoracic empyema and to assess it's effectiveness in patients who did not respond to more conservative treatment  like tube thoracostomy and/ or are not fit for major surgical interventions like thoracotomy.   Patients and Methods: The current retrospective study was carried out in the Cadiothoracic and Vascular  Unit in Ibn- Al-Nafees Teaching Hospital ( Iraq / Baghdad )   &  AL-Hussein Teaching Hospital ( Iraq / Thi-Qar )  from April 2009 to February 2017. The  number of patients included in the study was (30) patients. Most of our patients were too cachectic to tolerate thoracotomy for decortication or more aggressive treatment. We treated them by open drainage with rib resection.Thoracoplasty was added to some of them.   Results: The highest incidence of chronic non-resolving empyema cavity was among patients between (41-60) years old. The commonest type of surgical procedure applied on patients was Elloeser flap whithout   thoracoplasty. Certain Co-morbidities could be recognized in patients with chronic empyema cavity like D.M., Hypertension, Ischemic heart disease & Malignancy. The duration after which the open drainage system closes varies widely between the patients depending on several factors like ( size of chronic empyema cavity, the presence of co-morbidities, adherence to antibiotics, the presence  of bronchopleural fistula, etc…).   Conclusion: The surgical procedure of Modified Elloeser flap was very effective in treatment of chronic empyema cavity in patients who did not respond to more conservative treatment  like tube thoracostomy and/ or are not fit for major surgical interventions like thoracotomy. Open drainage should not be ignored as one of  the therapeutic options in treatment of advanced thoracic empyema. It might be the best therapeutic modality in cachectic patients where the facilities for more aggressive treatment are not possible.

CLEARING THE CAVITY: A CASE OF POSTPNEUMONECTOMY EMPYEMA

SESSION TITLE: Surgery cases SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/07/2018 04:45 PM - 05:45 PM INTRODUCTION: Post-pneumonectomy Empyema (PPE), is a rare but dangerous complication. Hypothesized to be the result of microbial infection via Bronchopleural fistula (BPF) vs. direct muco-cutaneous infection. Management of this pathology varies from debridement and antibiotics to thoracoplasty. Presented is a case of PPE in a patient who underwent pneumonectomy for the treatment of metastatic colorectal cancer. CASE PRESENTATION: A 53-year-old male with prior history of metastatic colorectal cancer treated with chemotherapy and managed surgically with right pneumonectomy four years prior presented to the emergency department with five days of worsening right sided chest pain, cough, fevers, and chills. On physical exam the patient was noted to have a right chest wall palpable mass with crepitation. A computed tomography angiogram of the chest was performed showing worsening accumulation of fluid in the prior known post-surgical hydropneumothorax. Additionally, new extension of air into the surrounding soft tissue was observed, a condition called pneumothorax neccesitans (Image 1). Antibiotics were started and a surgical chest tube was placed which drained foul-smelling purulent brown fluid. Polymicrobial cultures grew methicillin-resistant staphylococcus aureus, streptococcus anginosus, streptococcus mitus, bacteroides caccae, and fusobacterium species. Video assisted thorascopic surgery (VATS) was converted to thoracotomy with creation of Eloesser flap. While irrigating the hemithorax with saline copious bubbles were seen indicating a BPF. Post-operative course complicated by pseudomonal wound infection being treated with levaquin. DISCUSSION: PPE occurs in 2%-16%(1) of post-pneumonectomy patients. Although it is rare, mortality has been reported as high as 72%(2) and management can often be complicated. The majority of PPE are due to microbial infection via BPF. The presence of BPF in patients with PPE has been documented to be 80%-100%. Other theories include direct microbial invasion of the wound. Monomicrobial infections are more common than polymicrobial, with staphylococcus and streptococcus being the most frequent culprits. A 2015 expert consensus statement published by the European Association of Cardiothoracic Surgeons suggests that for simple PPE without fistulae, conservative management can be performed with pleural space irrigation, fenestration or VATS debridement alongside antibiotics. During VATS the surgeon has the opportunity to identify an underlying BPF for closure. In the case of BPF presence or complicated PPE intervention may require more invasive techniques such as thoracoplasty. (3) CONCLUSIONS: With a high mortality rate and complex management, PPE should be addressed swiftly and with cardiothoracic involvement at time of diagnosis. Drainage and antibiotics are the cornerstones to management but many cases require more expert invasive surgical intervention. Reference #1: Stern, Jean-Baptiste, Ludovic Fournel, Benjamin Wyplosz, Philippe Girard, Malik Al Nakib, Dominique Gossot, and Agathe Seguin-Givelet. "Early and delayed post-pneumonectomy empyemas: Microbiology, management and prognosis." The clinical respiratory journal (2017). Reference #2: Jadczuk, Eugeniusz. "Postpneumonectomy empyema." European journal of cardio-thoracic surgery 14, no. 2 (1998): 123-126. Reference #3: Scarci, Marco, Udo Abah, Piergiorgio Solli, Aravinda Page, David Waller, Paul Van Schil, Franca Melfi et al. "EACTS expert consensus statement for surgical management of pleural empyema." European journal of cardio-thoracic surgery 48, no. 5 (2015): 642-653. DISCLOSURES: No relevant relationships by Elizabeth Awerbuch, source=Web Response No relevant relationships by Anupam Gupta, source=Web Response no disclosure on file for Terence McGarry; No relevant relationships by Michael Megally, source=Web Response

Riboto piopneumotorakso gydymas vakuumine žaizdų gydymo sistema

Penkiasdešimt dvejų metų vyras dėl dešinio riboto piopneumotorakso buvo hospitalizuotas į Krūtinės chirurgijos skyrių, nes konservatyvus gydymas buvo neveiksmingas. Dėl persistuojančios bronchopleurinės jungties padaryta pleurostoma. Vienuoliktą pooperacinę parą bronchopleurinė jungtis savaime išnyko, todėl buvo nuspręsta naudoti vakuuminę žaizdų gydymo sistemą. Aktyvios aspiracijos sistema per sidabru impregnuotą kempinę naudota 15 dienų (kempinės keistos kas penkias dienas). Po šio gydymo kurso pleurostomos tūris sumažėjo nuo 600 ml iki 100 ml. Pacientas išrašytas gydytis ambulatoriškai. Po dviejų mėnesių ertmė buvo sumažėjusi iki 10 ml, visiškai epitelizavosi ir buvo tinkama torakoplastinei operacijai. Gydant pleuros empiemą, kuri komplikavosi piopneumotoraksu, galima sėkmingai naudoti vakuuminę žaizdų gydymo sistemą. Šis gydymo metodas sutrumpina liekamosios pleuros ertmės egzistavimą ir leidžia greičiau atkurti krūtinės sienos vientisumą.

The treatment of chronic pleural empyema with laparoscopic omentoplasty. Initial report.

IntroductionPleural empyema is the most serious, life-threatening postoperative complication of pneumonectomy, observed after 1–12% of all pneumonectomies, with bronchopleural fistula being its main cause.AimThe aim of this publication is to present early outcomes of minimally invasive surgical management of pleural empyema. Patients were subjected to a single, complex procedure, consisting of the laparoscopic mobilization of the greater omentum and its transposition via the diaphragm into the pleural cavity to fill in the empyema cavity with the consecutive pleuro-cutaneous fistuloplasty (thoracoplasty).Material and methodsBetween May 2011 and April 2013, 8 patients were qualified to undergo the procedure. The mean age was 61 years (range: 46–77 years). Presence of bronchopleural fistula was confirmed in 3 cases. The median time of treatment with thoracostomy was 14.5 months.ResultsThe mean operative time was 125 min. The mean duration of post-operative hospital stay was 13.5 days (range: 7–31 days). In 6 patients (75%) the objective of permanent resolution of pleural empyema was achieved. In total, 4 patients had complications: pleural empyema recurrence (2 patients), splenic injury, hiatal hernia, gastrointestinal bleed. Two patients with empyema recurrence had Staphylococcus aureus infections prior to surgery. They were successfully managed both with prolonged thoracic drainage and antibiotics.ConclusionsUse of the greater omentum that was laparoscopically mobilized and transpositioned into the pleural cavity allows simultaneous management of the pleural empyema cavity and thoracostomy. The procedure is safe, with few direct complications. It is well tolerated and has at least a satisfactory cosmetic effect. The minimally invasive approach allows faster recovery and return to daily activities in comparison to the fully open technique.

Management of Intrathoracic Defects

Intrathoracic defects continue to provide one of the most challenging problems faced by the reconstructive surgeon, particularly in the presence of bronchopleural fistula. We review the principles of management of bronchopleural fistulae and empyema, with an emphasis on the Clagett principle, pedicled and free muscle flaps, and the concept of a "designed air fistula" in bronchopleural fistula management. Although the importance of muscle flap closure in intrathoracic defects is undisputed, the timing and relative superiority of muscle flap closure versus conventional thoracic-surgical techniques remains an unanswered question.

Intrapleural Enzymatic Debridement With Tryptar

SUMMARY AND CONCLUSIONS The cases presented illustrate some of the situations in which the pancreatic enzyme trypsin can be used for the purpose of selective intrapleural proteolytic debridement. These included tuberculous empyema, tuberculous infection of the extrapleural space, mixed tuberculous empyema, non-tuberculous empyema following resection for tuberculosis, non-tuberculous postoperative empyema, and non-specific bilateral pleural effusion of an indeterminant nature. Complete cure was obtained in the two cases of tuberculous empyema and the two cases of postoperative empyema, and almost complete relief obtained in the case of bilateral effusion of unknown origin. Improvement as manifested by decrease in viscosity and sterilization of the fluid was noted in the other three cases and contributed to eventual good surgical results in this manner. Following these initial encouraging experiences, tryptic debridement has subsequently been employed in an additional 22 patients with comparable results. In addition to the above mentioned indications, this method has been successfully used in the treatment of postoperative and traumatic hemothorax. It is concluded that tryptic debridement is a valuable adjunct in the treatment of intrapleural infections and hemothorax and is deserving of more widespread usage. Side effects are few and inconsequential. Its use is not necessarily contraindicated in the presence of bronchopleural fistula.

The Use of Trypsin in Chest Disease

The use of tryptic debridement in fibrinopurulent empyema is definitely indicated. It quickly removes the pyogenic membrane, decreases the viscosity of the fluid, and in a high percentage of cases sterilizes the space. It thus prepares patients ideally for surgical decortication or resection. In cases of less than six months' duration, tryptic debridement alone may be expected to expand the lung in 65 per cent. It is effective in both tuberculous and non-tuberculous empyema. The incidence of side effects in the nature of histamine-like reaction are few and of minor importance. Complete protection is offered by concomitant anti-histamine therapy. There have been no harmful results, and only one case of 17 is classed as a complete failure. Trypsin can be conveniently packaged, easily handled, and used with a minimum amount of waste. The use of tryptic debridement in post-traumatic clotted chest will supplant surgical decortication. It can be used in postoperative empyema without fear of damaging the process of tissue repair. Its use in the presence of bronchopleural fistula is not contraindicated. Results thus far obtained warrant a continued investigation of the use of aerosol trypsin in cases associated with copious, tenacious and purulent sputum.