Treatment Of Empyema Research Articles

Flap choice for closure of open window thoracotomy: a response to the author of the article entitled "the omentum flap for empyema treatment: indications and disadvantages".

The principle of empyema treatment includes cleansing the pleural cavity of bacterial infection and removing the empyema cavity. Open window thoracotomy (OWT) is the most invasive and radical treatment for severe empyema; the procedure itself, as well as its closure, is challenging.

Imaging guided streptokinase injected through small bore pigtail tail catheter in management of complicated empyema in pediatrics

PurposeThis study was done targeting the role of streptokinase injected through pigtail catheter in treatment of pleural empyema in pediatric. Subjects and methods15 patients were involved in this study of age ranged from 5months to 15years were subjected to STK injection once daily until the drainage don’t exceed 100ml/day and managed by ultrasound guided insertion of pigtail catheter. Broad spectrum antibiotics were given to all patients, after that the antibiotics were adapted according to result of microbial culture because of failed chest tube drainage intrapleural STK is recommended. Results13 cases show significant improvement, as the total amount of fluid before streptokinase injection was 5cc in average and significantly rose to 220cc after streptokinase instillation, while 2 cases do not response to this treatment. ConclusionImaging guided streptokinase injected through a pigtail catheter provides a powerful protocol for managing of complicated empyema in pediatrics.

The omentum flap for empyema treatment: indications and disadvantages.

Dear Sirs, We read with great interest the article of Shinohara et al . “Benefits of using omental pedicle flap over muscle flap for closure of open window thoracotomy “in which they compare the muscle and omentum flaps (1). The authors compare the omentum pedicle flap with the loco-regional muscle flaps for the treatment of empyema. They conclude that the omentum is superior in reducing local recurrence and shortening postoperative hospital stay after open-window thoracostomy (OWT) closure with mortality, morbidity and success rates remaining the same in both groups (1).

Surgical treatment of empyema after pulmonary resection using pedicle skeletal muscle plombage, thoracoplasty, and continuous cavity ablution procedures: a report on three cases.

We present three cases of postoperative empyema after pulmonary resection: case 1, acute empyema without fistula after lobectomy and chest wall resection; case 2, continuing empyema with fistula and total left residual lung abscess after upper divisionectomy; and case 3, chronic empyema with middle lobe bronchopleural fistula after lower lobectomy. Pedicle skeletal muscle plombage into the cavity, thoracoplasty, and continuous cavity ablution with 24-h instillation of minocycline and saline solution through drains were used for treatment. In case 2, a completion extrapleural left pneumonectomy was concurrently performed. In all three cases, the surgery was successful; however, case 2 developed a massive gastrointestinal hemorrhage, which led to blood aspiration pneumonitis, renal failure, and death. Muscle plombage effectively achieves the closure of empyema cavity and thoracoplasty complements this. When a residual space remains, cavity ablution is considered to be effective. However, concurrent completion lung parenchyma resection might be excessively aggressive.

Chest Wall Resection and Reconstruction

Since the first accounts of empyema treatment by Hippocrates of Kos, who pioneered surgical procedures of the chest wall and the emergence of thoracic surgery during the late 19th and early 20th century specifically to develop treatment strategies for tuberculosis, chest wall resection and reconstruction has become a mainstay of septic and oncologic thoracic surgery. Thanks to significant improvements in surgical technique, anesthesiological management, critical care therapy, the advent of antibiotics, and a continuously evolving array of grafts suitable for secondary repair, nowadays even extensive full thickness resection can be performed with acceptable overall morbidity and mortality. We present an overview of current indications for chest wall resection and list materials suitable for repair, ranging from synthetic meshes to tissue-engineered grafts.

Management of empyema thoracis: Peshawar experience of 450 patients

Objective: To observe the various clinical presentations of empyema thoracis and evaluate its management and outcome. Study design: An observational descriptive study. Place and duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from June 2001 to June 2004. Materials and methods: Clinical record of 450 patients who underwent various surgical procedures during 3 years were retrospectively analyzed. Detailed scrutiny of record was carried out to analyze the clinical presentation; various surgical procedures and outcome. Results: There were 270 (60%) male and 180 (40%) female patients. Majority of the patients 310 (68.8%) were in the age range of 20 - 40 years. Common presentation was fever (62%); cough (26%) and chest pain (11%). The duration of symptoms was less than 8 weeks in 57 % and more than 8 weeks in 42% cases. Common etiologies were pneumonia (31%), post tuberculous (37.7%), traumatic (24%) and iatrogenic (6.6%). Tube thoracostomy was the initial l ine of management in 200 patients. Decortication was required in 200 patients while 50 patients needed thoracoplasty to obliterate persistent residual pleural space. The mortality was 4% (18/450). Thirty one (7%) had wound infection, air leak in 18 (4%), wound dehiscence in 9 (2%) and septicemia in 14 (3%) cases. Conclusion: Depending upon the stage, various surgical options exist for the treatment of thoracic empyema. Selection of the most appropriate procedure must be individualized but the basic principle is evacuation of pus from the pleural space, appropriate antibiotic therapy and obliteration of empyema cavity.

Outcomes of Stage-Adapted Surgical Treatment of Pleural Empyema

The surgical treatment of pleural empyema should be carried out depending on the stage of the disease and the patient's symptoms. The aim of this study was to evaluate the outcomes of surgical pleural empyema treatment. Retrospective analysis of all patients with pleural empyema treated surgically between January 2008 and December 2013. The primary endpoint of the study was inpatient lethality. Secondary endpoints included duration of inpatient stay, type of treatment (surgical/conservative), proof of pathogen and type, alteration and duration of antibiotic therapy. Of 359 patients, 0.8 % (n = 3) had stage I empyema, 50.4 % (n = 181) had stage II and 48.7 % (n = 175) had stage III. The most frequent causes (32.4 %) included acute pneumonia (parapneumonic pleural empyema), surgery (usually thoracic) in 18.0 % of cases and previous pneumonia (postpneumonic pleural empyema) in 15.4 %. Surgery was performed in 86 % of cases (operative procedures: open thoracotomy 85 %, VATS 15 %). The average duration of inpatient stay was 20 days for stages II and III. Recovery following VATS was significantly shorter in stage II compared to thoracotomy (p = 0.022). Hospital lethality amounted to 7.0 % (25 patients). The lethality rate was 5.5 % (10/185) in stage II and 8.6 % (15/175) in stage III. Patients with confirmed pathogens had a significantly worse mortality rate across all stages (9.8 %) than patients with no confirmed pathogens (4.0 %, p = 0.034). Age, malignant underlying disease, multiple comorbidities, immunosuppression, a change in antibiotic regimens and sepsis were significant risk factors. The inpatient lethality of patients with pleural empyema correlates with the stage of the condition. Positive confirmation of pathogens, sepsis, a higher age, multiple comorbidities, malignant tumour disease, immunosuppression and a change of antibiotics are negative prognostic factors.

Accelerated Treatment of Concomitant Empyema and Lung Cancer by Video-assisted Thoracoscopic Surgery

BackgroundThe most common cause of pleural empyema are parapneumonic effusions, and lung cancer is a rare cause of empyema. The aim of the present study is to analyse the results of the thoracoscopic treatment of empyema before definitive oncological treatment. MethodsRetrospective descriptive study of 332 patients including different clinical variables between 2002 and 2010. ResultsAmong 332 patients with empyema, the etiology of this disease was lung cancer in 11 patients. Ten of these patients were male and one was female (median age, 57.9 years; range, 46–76). The initial treatment was tube thoracostomy in 8 patients and video-assisted thoracoscopic surgery in 3 patients. Thoracoscopic debridement was performed in 4 patients whose tube thoracostomy underperformed because of insufficient drainage. The methods used for diagnosis of lung cancer were fiberoptic bronchoscopy and video-assisted thoracoscopic surgery. Surgical resection was performed on 7 suitable patients following infection control. Postoperative bronchopleural fístula and empyema occurred after pneumonectomy in one case. No operative mortality was observed. The mean survival time was 32.8 months for patients undergoing resection. ConclusionsEmpyema could be a rare presentation of lung cancer and those suitable for surgical treatment should undergo standard treatment with reasonable results.

Thoracoscopy in the management of pediatric empyemas

IntroductionThoracoscopy is increasingly being used in the treatment of empyema. This study assesses feasibility, efficacy and safety in children. Material and methodsClinical files of patients who underwent primary thoracoscopy for empyema between 2006 and 2014 were reviewed. Demographic, clinical and surgical data were analyzed and a comparison between the period before (period1) and after (period2) the learning curve was performed. ResultsNinety-one patients (53 males, 58%) were submitted to thoracoscopy at a median age of 4 years. There were 19 conversions to thoracotomy with a steady decrease of conversion rate until 2009 (period1) and no conversions thereafter (period2). There was no difference in any of the analyzed parameters between patients submitted to thoracoscopy alone and those requiring conversion in period1. Six cases (6.6%) needed redo-operation (five in period2) and thoracotomy was the elected approach in four. Necrotizing pneumonia was present in 60% of the reoperated cases; in other words, in period2 3 out of 9 cases with necrotizing pneumonia required reintervention (p=0.07). Thoracotomy was avoided in sixty-eight (75%) patients (62% in period1 versus 92% in period2, p=0.001). Discussion and conclusionsThoracoscopic approach for empyema is feasible and safe avoiding a significant number of thoracotomies after a short learning curve. An increase of reintervention rate should be expected, but throracoscopy alone is effective in the great majority of the cases. Necrotizing pneumonia may be associated with a higher risk of reintervention, as it is a contra-indication to thoracoscopy and probably surgery.

Practical management of pleural empyema

Empyema is defined as pus in the thoracic cavity due to pleural space infection and has a multifactorial underlying cause, although the majority of cases are post-bacterial pneumonia. Despite treatment with antibiotics, patients with empyema have a considerable morbidity and mortality due at least in part to inappropriate management of the effusion. Timely diagnosis of pleural space infection and rapid initiation of effective pleural drainage represent fundamental principles for managing patients with empyema. Ultrasound is particularly useful to identify early fibrin membranes and septations in the pleural cavity conditioning treatment strategy. Empyema and large or loculated effusion with a pH < 7.20 need to be drained. Thoracoscopy has largely been used in pleural effusion due to lung infection. Whereas the efficacy of video-assisted thoracic surgery (VATS) in empyema management has been evaluated in several retrospective studies showing favourable results, less is known about the role of medical thoracoscopy (MT) in pleural infection. MT, appears to be safe and successful in multiloculated empyema treatment. It is also lower in cost and in frail patients is better tolerated than VATS which requires tracheal intubation.

Treatment of Tuberculous Empyema by Intrathoracic Transposition of a Latissimus Dorsi Muscle Flap.

Treatment of Tuberculous Empyema by Intrathoracic Transposition of a Latissimus Dorsi Muscle Flap.

Этиология, патогенез, клиника, диагностика и лечение эмпиемы плевры. Современные представления (Обзор литературы)

Этиология, патогенез, клиника, диагностика и лечение эмпиемы плевры. Современные представления (Обзор литературы)

Endobronchial Watanabe Spigotによる気管支充填術にて治療した有瘻性膿胸の一例

Endobronchial Watanabe Spigotによる気管支充填術にて治療した有瘻性膿胸の一例

Clinical characteristics and outcomes of patients with community-acquired, health-care-associated and hospital-acquired empyema.

Patients with pneumonia, a common cause of empyema, are stratified based on their risk factors, and the treatment of empyema might benefit from this risk stratification. The etiology, bacteriologic profile and outcome of patients diagnosed with empyema in Shinko Hospital between May 2005 and October 2013 were retrospectively studied. The patients were stratified according to whether they had community-acquired empyema (CAE), health-care-associated empyema (HCAE) or hospital-acquired empyema (HAE). The study included 81 patients, 25 CAE, 40 HCAE and 16 HAE. The comorbidity rate was highest among HAE patients (100%), followed by 95% of HCAE and 72% of CAE patients (P = 0.005). The rates of cancer and central nervous system (CNS) disease were higher in patients with HCAE and HAE than in patients with CAE (P = 0.030, P = 0.018, respectively). Pleural fluid cultures were positive in 58/81 patients. Streptococcus species were the most common organisms cultured from CAE (12/15) and HCAE patients (17/30), but not from HAE patients (3/13). Anaerobic organisms were cultured from 3 CAE, 5 HCAE and 3 HAE patients. Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa were only cultured from HCAE and HAE patients. The mortality rates were higher in HCAE (18%) and HAE (50%) than in CAE (4%) patients (log-rank test: P = 0.0012). Half of patients with empyema were HCAE patients, who had comorbidities, bacteriological profile and outcome different from CAE patients. The patient with HCAE should be differentiated from CAE patient, and the stratification of patients based on risk factors may be useful for treatment strategy.

Early and Persistent Hemothorax and Pneumothorax

The incidence of traumatic injury to the thorax is estimated at up to 40 % of patients that require hospitalization. The vast majority of these injuries can be managed with observation. However, the presence of pneumothorax or hemothorax has traditionally mandated tube thoracostomy placement and the inherent morbidities that may arise. Persistent pneumothorax is typically defined as the presence of pneumothorax and/or air leak for 5–7 days after tube placement. This morbidity may be managed expectantly or with video-assisted thoracoscopic surgery (VATS). The most feared complication after hemothorax is the presence of retained blood and the risk of infection that follows. Most authorities support the early use of VATS to resolve retained hemothoraces with the hopes of avoiding more invasive procedures aimed at the treatment of fibrothorax and empyema.

Video-assisted thoracoscopic surgical decortication in the elderly with thoracic empyema: Five years' experience

BackgroundVideo-assisted thoracoscopic surgery (VATS) with decortication is a major treatment for thoracic empyema in the fibropurulent stage. Compared to open thoracotomy, VATS decortication has similar efficacy but fewer postoperative complications in the treatment of thoracic empyema. The role of VATS decortication in the elderly had rarely been investigated. MethodsFrom January 2006 to August 2011, we retrospectively enrolled 33 patients older than 65 years diagnosed as thoracic empyema and treated with VATS decortication. We analyzed the outcomes of this geriatric population, including surgical effectiveness, postoperative morbidity, and mortality. ResultsA total of 33 patients with mean age of 73.6 ± 7.1 years received VATS decortication for their empyema. Twenty-one (63.6%) patients were male. Only one patient died of progressive sepsis, due to pulmonary infection 9 days after VATS decortication. The 30-day mortality was 3% after the surgery. The major etiology (87.9%) of thoracic empyema was pneumonia. The main causes of postoperation morbidity included respiratory failure requiring mechanical ventilation for >7 days (15.2%) and septic shock (15.2%), followed by persistent air leakage for >7 days (9.1%). Twenty-four (75%) of 32 patients had good re-expansion of the affected lung 3 months after VATS decortication. ConclusionWe concluded that VATS decortication in the treatment of thoracic empyema is effective in elderly patients. The major concerns of postoperative complications are respiratory failure and sepsis.

Differential Treatment Strategy of Pleural Empyema in a Post-Pneumonectomy Cavity

Pleural empyema in a post-pneumonectomy cavity (PEC) occurs with a frequency of 2% -15% and a mortality of more than 10%. It can occur with or without bronchopleural fistula (BPF). The treatment of empyema in the PEC requires a strict algorithm: drainage, bronchoscopy, closure of the fistula, thorough cleaning of the PEC, filling the cavity, thoracoplasty. 39 cases with an empyema in the PEC were analysed retrospectively (men: n = 38; women: n = 1; mean age: 60.3 ± 7.6 years). In 32 (82.1%) of the patients, a BPF was detected (right: n = 26, left: n = 6). The average length of stay in hospital was 125 days (22 - 293 days). Cleaning of the PEC was achieved in all surviving patients (n = 23, 65.1%). All patients (n = 39) underwent bronchoscopy with placement of a chest tube for drainage. The BPF was closed in three cases (7.7%) with a stent while in 12 cases (30.8%) a vascularized flap was used. In 14 patients (35.9%) the bronchial stump was either reclosed with sutures or resected. In three cases (7.7%) a re-anastomosis was performed. The PEC became sterile by regular flushing with antibiotic solution in three patients (7.7%). In 35.9% of the patients (n = 14), aggressive surgical debridement (Weder procedure) was necessary. A thoracic window was applied in 22 patients (56.4%), followed by negative pressure wound therapy (NPWT) and change of dressing every three to four days or a tamponade of the thoracic cavity with simple dressings. In 19 patients (48.7%) the thoracic cavity was sealed with an antibiotic solution. In 5 cases an Alexander thoracoplasty took place. Pleural empyema after pneumonectomy still poses a serious postoperative complication. A bronchopleural fistula is often detected. Thus, two problems arise at the same time – fistula and infection in the pleural cavity. Through a strict algorithm, both problems can be dealt with in stages. After sealing the fistula, the thoracic cavity is thoroughly cleaned and finally the thorax is closed. Only in a small number of patients (1.3%) in whom these measures remain ineffective (persistent MRSA, aspergillus colonization) should the cavity be obliterated by thoracoplasty.

EACTS expert consensus statement for surgical management of pleural empyema.

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preference.

Subdural empyema of odontogenic origin due to Streptococcus constellatus

A 9-year-old boy with multiple decayed teeth developed right eye preseptal cellulitis and left subdural empyema due to Streptococcus constellatus. He recovered after neurosurgical evacuation of the empyema and antibiotic treatment with high- dose intravenous ampicillin for three weeks. Poor oral hygiene predisposes to hematogenous and possibly fatal dissemination of rare oral commensals to the subdural space.

Intrathoracic Vacuum-Assisted Closure in the Treatment of Pleural Empyema and Lung Abscess

Complex pleural empyema or lung abscesses are either characterised by long-standing treatment (including treatment failure) or by a bad general condition of the patient (multiple morbidity, sepsis). The operative rectification is often associated with increased morbidity and mortality rates in these cases. Traditionally, the therapeutic tendency for such patients was towards primary creation of a thoracic window including open wound treatment, but this was always also associated with a long sickness and restrictions in the quality of life. The intrathoracic vacuum treatment (VAC) offers here entirely new options in the treatment of complicated pleural empyema and lung abscesses. We present an illustration of our own clinical experience associated with a selective literature research via Medline (keywords: VAC, vacuum-assisted closure, thoracic empyema). After the initial successes of the extrathoracic application of the VAC treatment, the procedure was also analysed for its intrathoracic/pleural use to treat pleural empyema and lung abscesses with and without bronchus stump insufficiency. Initially, the use of the intrathoracic VAC treatment was carried out via a thoracic window (with rib resection), later we developed a minimally invasive procedure (Mini-VAC) while relieving the osseous thorax. An additional intrapleural rinsing with antiseptics (Mini-VAC-Instill) is very practical in cases of proven germ populations. The benefits of the Mini-Vac/Mini-VAC-Instill are: immediate secretion suction with quick local cleaning, rapid germ eradication with a small risk of a fresh population, improvement of the expansion behaviour of the lung as well as short treatment times with quick reclosure of the thorax. In addition to many retrospective examinations, there has so far only been one cohort study in which the classic thoracic window was compared with the VAC treatment. The duration of the stomatic situation as well as the long-term survival in the VAC group were better here than those in the non-VAC group. The intrathoracic VAC treatment (Mini-Vac/Mini-VAC-Instill) is an innovative procedure that promotes wound cleaning and wound healing in complicated pleural empyema and lung abscesses. Due to the benefits of this procedure, including the improvement of the patient's comfort and the quality of life, the procedure has seen a rapid and broad clinical acceptance.