Management of patient with Fusobacterim nucletum related pleural empyema: intrapleural antibiotic therapy can be considered for salvage therapy.

Pleural empyema can lead to significant morbidity and mortality despite chest drainage and antibiotic treatment, necessitating novel and minimally invasive interventions. Fusobacterium nucleatum is an obligate anaerobe found in the human oral and gut microbiota. Advances in sequencing and puncture techniques have made it common to detect anaerobic bacteria in empyema cases. In this report, we describe the case of a 65-year-old man with hypertension who presented with a left-sided encapsulated pleural effusion. Initial fluid analysis using metagenomic next-generation sequencing (mNGS) revealed the presence of Fusobacterium nucleatum and Aspergillus chevalieri. Unfortunately, the patient experienced worsening pleural effusion despite drainage and antimicrobial therapy. Ultimately, successful treatment was achieved through intrapleural metronidazole therapy in conjunction with systemic antibiotics. The present case showed that intrapleural antibiotic therapy is a promising measure for pleural empyema.

Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial-MIST-3.

Rationale: Assessing the early use of video-assisted thoracoscopic surgery (VATS) or intrapleural enzyme therapy (IET) in pleural infection requires a phase III randomized controlled trial (RCT). Objectives: To establish the feasibility of randomization in a surgery-versus-nonsurgery trial as well as the key outcome measures that are important to identify relevant patient-centered outcomes in a subsequent RCT. Methods: The MIST-3 (third Multicenter Intrapleural Sepsis Trial) was a prospective multicenter RCT involving eight U.K. centers combining on-site and off-site surgical services. The study enrolled all patients with a confirmed diagnosis of pleural infection and randomized those with ongoing pleural sepsis after an initial period (as long as 24 h) of standard care to one of three treatment arms: continued standard care, early IET, or a surgical opinion with regard to early VATS. The primary outcome was feasibility based on >50% of eligible patients being successfully randomized, >95% of randomized participants retained to discharge, and >80% of randomized participants retained to 2 weeks of follow-up. The analysis was performed per intention to treat. Measurements and Main Results: Of 97 eligible patients, 60 (62%) were randomized, with 100% retained to discharge and 84% retained to 2 weeks. Baseline demographic, clinical, and microbiological characteristics of the patients were similar across groups. Median times to intervention were 1.0 and 3.5 days in the IET and surgery groups, respectively (P = 0.02). Despite the difference in time to intervention, length of stay (from randomization to discharge) was similar in both intervention arms (7 d) compared with standard care (10 d) (P = 0.70). There were no significant intergroup differences in 2-month readmission and further intervention, although the study was not adequately powered for this outcome. Compared with VATS, IET demonstrated a larger improvement in mean EuroQol five-dimension health utility index (five-level edition) from baseline (0.35) to 2 months (0.83) (P = 0.023). One serious adverse event was reported in the VATS arm. Conclusions: This is the first multicenter RCT of early IET versus early surgery in pleural infection. Despite the logistical challenges posed by the coronavirus disease (COVID-19) pandemic, the study met its predefined feasibility criteria, demonstrated potential shortening of length of stay with early surgery, and signals toward earlier resolution of pain and a shortened recovery with IET. The study findings suggest that a definitive phase III study is feasible but highlights important considerations and significant modifications to the design that would be required to adequately assess optimal initial management in pleural infection.The trial was registered on ISRCTN (number 18,192,121).

The role of the early video-assisted thoracoscopic surgery in children with pleural empyema.

PURPOSE: Pleural empyema (PE) is a collection of purulent material in the pleural space. PE's management in children is a challenge and an inappropriate diagnostic-therapeutic work up can lead to serious short and long-term complications. The aim of this study is to define the correct timing to approach a pediatric PE by video-assisted thoracoscopic surgery (VATS). METHODS: A retrospective observational study was conducted including pediatric patients who underwent video-assisted thoracoscopy for pleural empyema between May 2005 and September 2022. RESULTS: 62 patients were subjected to VATS for PE (32 in Group Early VATS, 30 in Group Late VATS). It emerged that the elapsed period between the onset of symptoms and surgery correlates in a statistically significant way with the post-operative stay in intensive care (z score 4.3 and p value < 0.0001) and the analysis between early VATS, late VATS and postoperative hospitalization showed a statistically significant reduction of the post-operative hospitalization in the early VATS groups (p value < 0.02). CONCLUSIONS: VATS resulted to be safe and effective for the treatment of PE in children, and an early minimally invasive thoracoscopic intervention (early VATS) correlates with better outcomes, specifically in terms of intensive care hospitalization and overall hospitalization.

Modern view on the problem of acute pleural empyema surgical treatment.

OBJECTIVE: Aim: data study on the results of treatment of acute non-specific purulent-destructive pleura diseases with the purpose of further improvement of its results on the basis of improvement of diagnostics, identification of factors of disease prognosis and by implementing differential tactics of surgical treatment with the use of minimally invasive interventions. PATIENTS AND METHODS: Materials and Methods: We have studied modern literary sources on the topic of current trends in the treatment of acute pleural empyema and its complications. The studied material is summarized and presented in the form of a literature review in this article. CONCLUSION: Conclusions: These issues cannot be considered to be completely solved and require further study. Everything mentioned above dictates the search of new effective methods of the treatment of the mentioned pathology and proves the relevance of the theme. The outlined information highlights the necessity of improvement of surgical tactics in patients with pleural empyema.

Medical Thoracoscopy and Intrapleural Fibrinolytic Therapy for the Management of Pleural Empyema: A Cohort Study.

BACKGROUND: Pleural empyema is associated with relevant morbidity and mortality, and it may be classified, according to evolution and ultrasound, into three stages: stage I (free-flowing effusion), stage II (viscous effusion with the tendency to loculate), and stage III (organizing phase). According to guidelines, antibiotic therapy and pleural drainage are recommended, with surgery being performed when patients fail and/or in case of organized empyema. OBJECTIVES: The aim of the study was to report the efficacy and safety of medical thoracoscopy in patients with pleural empyema stratified by chest ultrasound. METHOD: Observational retrospective cohort study analyzing patients with pleural empyema treated with medical thoracoscopy. Procedure success and mortality were evaluated at 30 days and 90 days after the procedure; complications were also reported. RESULTS: 131 patients were included. Intrapleural fibrinolytic therapy was performed thereafter in the majority of cases. Medical thoracoscopy was considered successful without subsequent intervention in 99 patients (76%); 19 patients (15%) underwent a second procedure (drainage, thoracoscopy, video-assisted thoracic surgery, or thoracotomy); and 6 patients (5%) died of the evolution of empyema. Patients treated in stages I and II showed significantly better post-procedure results compared with patients treated in stage III (100%, 83.3%, and 58.1%, respectively). Thoracoscopy complications were observed in 18 patients and were reversible in all cases. CONCLUSIONS: Patients with pleural empyema treated in earlier stages (free-flowing or multiloculated effusion) with medical thoracoscopy show significantly better results than patients treated in later stages (organized empyema). This approach is safe, minimally invasive, and efficient in these patients with disease having relevant mortality; however, patient selection remains essential.

Risk Factors for Postoperative Pulmonary Complications Leading to Increased Morbidity and Mortality in Patients Undergoing Thoracic Surgery for Pleural Empyema.

OBJECTIVES: Surgery for pleural empyema carries a high burden of morbidity and mortality. The authors investigated the incidence of postoperative pulmonary complications (PPCs) and their effects on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs were analyzed. DESIGN: Retrospective observational study. SETTING: A single, large university hospital. PARTICIPANTS: A total of 250 adult patients were included who underwent thoracic surgery for pleural empyema between January 2017 and December 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 250 patients with pleural empyema underwent thoracic surgery by video-assisted thoracoscopic surgery (49%; n = 122) or open thoracotomy (51%; n = 128). A proportion (42% [105]) of patients had ≥1 PPCs; 28% (n = 70) had to undergo resurgery; and 10% (n = 25) were re-admitted unexpectedly to the ICU. Preoperative respiratory failure (odds ratio [OR]: 5.8, 95% CI: 2.4-13.1), general anesthesia without regional analgesia techniques (OR: 2.9, 95% CI: 1.4-5.8), open thoracotomy and subsequent resurgery (OR: 3.9, 95% CI 1.5-9.9), surgery outside the regular working hours (OR: 3.1, 95% CI 1.2-8.2), and postoperative sepsis (OR: 2.6, 95% CI 1.1-6.8) were identified as independent risk factors for PPCs. Postoperative pulmonary complications were independent factors for unplanned intensive care unit admission (OR: 10.5, 95% CI 2.1-51 for >1 PPC), death within 360 days (OR: 4.5, 95% CI 2.2-12.3 for ≥2 PPCs), and death within 30 days for ≥1 PPCs (OR: 1.2, 95% CI 1.1-1.3). CONCLUSIONS: The incidence of PPCs is a significant risk factor for morbidity and mortality after surgery for pleural empyema. Targeting the risk factors identified in this study could improve patient outcomes.

[Staged reconstructive surgery for bronchopleural fistula]. / Etapnaya rekonstruktivno-vosstanovitel'naya khirurgiya pri bronkhoplevral'nom svishche.

Treatment of bronchopleural fistula after pneumonectomy is still an urgent problem for thoracic surgeons. Transsternal bronchial stump occlusion should be preferable if possible. However, this is not enough for curing in some cases. We present a patient with concomitant cancer and tuberculosis of lungs whose postoperative period was complicated by bronchial stump failure. Preoperative diagnostic data are presented. We describe the indications for surgeries and main surgical stages. Some interventions including reconstructive surgery using a muscle flap led to recovery. Latissimus dorsi muscle flap on thoracodorsal artery is the best option for reconstructive surgical treatment in patients with extensive chest wall defects and thoracostomy.

A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection: results from the ACTion trial.

BACKGROUND: Pleural infection is a complex condition with a considerable healthcare burden. The average hospital stay for pleural infection is 14 days. Current standard of care defaults to chest tube insertion and intravenous antibiotics. There have been no randomised trials on the use of therapeutic thoracentesis (TT) for pleural fluid drainage in pleural infection. AIMS AND OBJECTIVES: To assess the feasibility of a full-scale trial of chest tube vs TT for pleural infection in a single UK centre. The primary outcome was defined as the acceptability of randomisation to patients. METHODS: Adult patients admitted with a pleural effusion felt to be related to infection and meeting criteria for drainage (based on international guidelines) were eligible for randomisation. Participants were randomised (1:1) to chest tube insertion or TT with daily review assessing need for further drainages or other therapies. Neither participant nor clinician were blinded to treatment allocation. Patients were followed up at 90 days post-randomisation. RESULTS: From September 2019 to June 2021, 51 patients were diagnosed with pleural infection (complex parapneumonic effusion/empyema). Eleven patients met the inclusion criteria for trial and 10 patients were randomised (91%). The COVID-19 pandemic had a substantial impact on recruitment. Data completeness was high in both groups with no protocol deviations. Patients randomised to TT had a significantly shorter overall mean hospital stay (5.4 days, SD 5.1) compared to the chest tube control group (13 days, SD 6.0), p = 0.04. Total number of pleural procedures required per patient were similar, 1.2 in chest tube group and 1.4 in TT group. No patient required a surgical referral. Adverse events were similar between the groups with no readmissions related to pleural infection. CONCLUSIONS: The ACTion trial met its pre-specified feasibility criteria for patient acceptability but other issues around feasibility of a full-scale trial remain. From the results available the hypothesis that TT can reduce length of stay in pleural infection should be explored further. TRIAL REGISTRATION: ISRCTN: 84674413.

Interventional closure of a bronchopleural fistula in a 2 year old child with detachable coils.

BACKGROUND: Bronchopleural fistula (BPF) is a severe complication following pneumonia or pulmonary surgery, resulting in persistent air leakage (PAL) and pneumothorax. Surgical options include resection, coverage of the fistula by video-assisted thoracoscopic surgery (VATS), or pleurodesis. Interventional bronchoscopy is preferred in complex cases and involves the use of sclerosants, sealants and occlusive valve devices. CASE PRESENTATION: A 2.5-year-old girl was admitted to our hospital with persistent fever, cough and dyspnoea. Clinical and radiological examination revealed right-sided pneumonia and pleural effusion. The child was started on antibiotics, and the effusion was drained by pleural drainage. Following removal of the chest tube, the child developed tension pneumothorax. Despite insertion of a new drain, the air leak persisted. Thoracoscopic debridement with placement of another new drain was performed after 4 weeks, without abolishment of the air leak. Bronchoscopy with bronchography revealed a BPF in right lung segment 3 (right upper-lobe anterior bronchus). We opted for an interventional approach that was performed under general anaesthesia during repeat bronchoscopy. Following bronchographic visualisation of the fistula, a 2.7 French microcatheter was placed in right lung segment 3 (upper lobe), allowing occlusion of the fistula by successive implantation of 4 detachable high-density packing volume coils, which were placed into the fistula. Subsequent bronchography revealed no evidence of residual leakage, and the chest tube was removed 2 days later. The chest X-ray findings normalized, and follow-up over 4 years was uneventful. CONCLUSIONS: Bronchoscopic superselective occlusion of BPF using detachable high-density packing large-volume coils was a successful minimally invasive therapeutic intervention performed with minimal trauma in this child and has not been reported thus far. In our small patient, the short interventional time, localized intervention and minimal damage in the lung seemed superior to the corresponding outcomes of surgical lobectomy or pleurodesis in a young growing lung, enabling normal development of the surrounding tissue. Follow-up over 4 years did not show any side effects and was uneventful, with normal lung-function test results to date.

[Laparoscopic transchiatal access in Boerhaave syndrome]. / Laparoskopicheskii transkhiatal'nyi dostup pri sindrome Burkhave.

Diagnosis of spontaneous rupture of the esophagus (Boerhaave syndrome) followed by purulent mediastinitis and pleural empyema has now been greatly simplified due to CT. The main thing is to suspect this syndrome in a timely manner. Methods of surgical treatment of this disease are still being discussed. We present successful laparoscopic treatment of spontaneous rupture of the esophagus.

Intrapleural Foreign Body: Case Report.

The detection of foreign bodies in the pleural cavity is rare and mostly consequent to iatrogenic or traumatic events. The migration of an inhaled foreign body from the airways to the pleural space through a bronchopleural fistula is an exceptional event. We report a case of a pleural empyema consequent to an inhaled wooden skewer. CT scan and bronchoscopy were unable to identify the foreign body, due to its migration in the peripheral airways. The thin and pointed foreign body perforated the visceral pleural surface emerging in the pleural cavity.

Video-assisted thoracoscopic surgery versus open thoracotomy in the management of empyema: A comparative study.

INTRODUCTION: With a rise in the incidence of thoracic empyema, surgical interventions also have evolved from the traditional open decortication to the current minimally invasive video-assisted thoracoscopic surgery (VATS). In this study, we determine the feasibility of VATS and also put the superiority of VATS over open thoracotomy (OT) to test. SUBJECTS AND METHODS: Prospective single-centre comparative analysis of clinical outcome in 60 patients undergoing either VATS or OT for thoracic empyema was done between 1st September, 2014, and 1st November, 2018. Furthermore, another group of patients, who were converted intraoperatively from VATS to OT, was studied descriptively. RESULTS: Nearly 75% of the patients were male with a mean age of 45.16 years. Every second patient had associated tuberculosis (TB), attributed to the endemicity of TB in India. When compared with OT, VATS had a shorter duration of surgery (268.15 vs. 178.33 min), chest tube drainage (11.70 vs. 6.13 days), post-operative hospital stay (13.56 vs. 7.42 days) and time to return to work (26.96 vs. 12.57 days). Post-operative pain and analgesic requirement were also significantly reduced in the VATS group (P < 0.0001). Conversion rate observed was 14.2%, the most common reason being the presence of dense adhesions. CONCLUSION: We conclude that VATS, a minimally invasive procedure with its substantial advantages over thoracotomy and better functional outcome, should be preferred whenever feasible to do so. Also if needed, conversion of VATS to the conventional open procedure, rather than a failure, is a wise surgical judgement.

Multiplex bacterial polymerase chain reaction in a cohort of patients with pleural effusion.

BACKGROUND: The identification of the pathogens in pleural effusion has mainly relied on conventional bacterial culture or single species polymerase chain reaction (PCR), both with relatively low sensitivity. We investigated the efficacy of a commercially available multiplex bacterial PCR assay developed for pneumonia to identify the pathogens involved in pleural infection, particularly empyema. METHODS: A prospective, monocentric, observational study including 194 patients with pleural effusion. Patients were evaluated based on imaging, laboratory values, pleura ultrasound and results of thoracentesis including conventional microbiology studies during hospitalisation. Multiplex bacterial PCR (Curetis Unyvero p55) was performed in batch and had no influence on therapeutic decisions. RESULTS: Overall, there were 51/197 cases with transudate and 146/197 with exudate. In 42% (n = 90/214) there was a clinical suspicion of parapneumonic effusion and the final clinical diagnosis of empyema was made in 29% (n = 61/214) of all cases. The most common microorganisms identified in the cases diagnosed with empyema were anaerobes [31] followed by gram-positive cocci [10] and gram-negative rods [4]. The multiplex PCR assay identified more of the pathogens on the panel than the conventional methods (23.3% (7/30) vs. 6.7% (2/30), p = 0.008). CONCLUSION: The multiplex PCR-based assay had a higher sensitivity and specificity than conventional microbiology when only the pathogens on the pneumonia panel were taken into account. A dedicated pleural empyema multiplex PCR panel including anaerobes would be needed to cover most common pathogens involved in pleural infection.

Cryotherapy in Semirigid Thoracoscopy for Debridement of Multiloculated Empyema.

Surgical intervention is occasionally required for the treatment of pleural empyema. Semirigid thoracoscopy is a safe and successful surgical approach utilized by interventional pulmonologists, conventionally utilizing flexible forceps and suction as the main tools, but they can sometimes be inefficient for more complicated cases. In debriding a case of multiloculated empyema with semirigid thoracoscopy, we report the novel use of cryotherapy in clearing adhesions from the pleural cavity. We found using the cryoprobe to be more efficient than using forceps and suggest further investigation into its use in medical thoracoscopy.

[Transsternal occlusion of main bronchi fistulae after pneumonectomy]. / Transsternal'naya okklyuziya svishcha glavnogo bronkha posle pnevmonektomii.

OBJECTIVE: To summarize our experience in transsternal occlusion of main bronchus fistula. MATERIAL AND METHODS: We have performed 146 transsternal occlusions of the main bronchi for the period from 1979 to 2018. There were 123 (84.2%) men and 23 (15.7%) women. Mean age of patients was 63 years. Lung tuberculosis was diagnosed in 36 (24.7%) patients, lung cancer - 91 (62.3%) patients, non-specific suppurative lung diseases - 14 (9.6%) patients, trauma - 5 (3.4%) patients. All patients underwent transsternal occlusion of the main bronchi fistulae with or without pericardial cavity dissection. Wedge-shaped bronchial resection or tracheal bifurcation resection were carried out for a short stump fistula. RESULTS: Perioperative complications occurred in 28 (19.2%) out of 146 patients. Intraoperative complications developed in 4 (2.6%) patients. Postoperative complications were observed in 25 (17.1%) patients. Intraoperative mortality rate was 1.4% (n=2), postoperative mortality - 6.2% (n=9). Thus, overall mortality rate was 7.6% (n=11 It should be noted that intraoperative complications were absent if dissection of the pericardium and pulmonary artery stump ligation were not performed. CONCLUSION: Transsternal occlusion of the main bronchi fistulae was successful in 80.8% of patients. In these cases, healing of fistulae was not associated with any complications. Thus, we believe that transsternal occlusion of the main bronchial stump fistula should be considered as preferable surgical strategy.

Evaluation of clinical risk factors for developing pleural empyema secondary to liver abscess.

BACKGROUND: The aim of this study was to investigate the clinical manifestation and predictive risk factors of pleural empyema developing during treatment of the pyogenic liver abscess. METHODS: Medical records of patients with the liver abscess in our institution were reviewed retrospectively. Enrolled patients were classified into four groups; Group 1: patients without pleural effusion, Group 2: patients with pleural effusion and who were treated noninvasively, Group 3: patient with pleural effusion and who were treated with thoracentesis, and Group 4: patients with pleural effusion that developed into empyema. Patient characteristics, clinical manifestation, and possible risk factors in development of empyema were analyzed. RESULTS: A total of 234 patients was enrolled in this study. The incidence rate of empyema was 4.27% (10 patients). The mean interval for developing pleural effusion was 5.6 ± 6.35 days. In multivariate analysis, risk factors for developing pleural effusion included the location of the liver abscess near the right diaphragm (segment 7 and 8, OR = 2.30, p = 0.048), and larger diameter of the liver abscess (OR = 1.02, p = 0.042). Among patients who developed pleural effusions, presences of mixed microorganisms from culture of liver aspirates (OR = 10.62, p = 0.044), bilateral pleural effusion (OR = 46.72, p = 0.012) and combined biliary tract inflammation (OR = 21.05, p = 0.040) were significantly associated with the need for invasive intervention including surgery on effusion. CONCLUSION: The location of the liver abscess as well as pleural effusion, elevated inflammatory markers, and combined biliary tract inflammation may be important markers of developing pleural complication in patients with pyogenic liver abscess.

International survey of paediatric infectious diseases consultants on the management of community-acquired pneumonia complicated by pleural empyema.

AIM: Community-acquired pneumonia (CAP) complicated by pleural empyema is an important paediatric problem. Antibiotic management decisions are made on the basis of little available data and without strong specific recommendations in guidelines. METHODS: This was an online survey of paediatric infectious diseases (PID) physicians disseminated by major international professional organisations, examining empiric and targeted antibiotic choice, switch to oral antibiotics and duration of treatment for two hypothetical cases of contrasting severity. RESULTS: This study included 183 responses, mostly from North America, Western Europe and Australia/New Zealand. Increased disease severity was significantly associated with broader-spectrum and combination empiric and targeted antibiotic treatment, empiric methicillin-resistant Staphylococcus aureus (MRSA) coverage and both longer intravenous (IV) and total duration of antibiotic treatment. Empirical MRSA coverage was also associated with local prevalence. Clinical progress was most important for determining the timing of the switch from IV to oral antibiotics. Few respondents chose antibiotics with activity against organisms associated with atypical pneumonia (e.g. Mycoplasma, Chlamydia), and most did not choose agents that inhibit protein synthesis (e.g. clindamycin), even in the case of a severe invasive group A streptococcal infection. Some variation in targeted treatment choices reflected areas of uncertainty, such as Streptococcus pneumoniae susceptibility breakpoints, comparative effectiveness of anti-staphylococcal penicillins and first-generation cephalosporins for serious S. aureus infections and linezolid and vancomycin for MRSA pneumonia. CONCLUSIONS: This international survey of PID physicians highlights the priority targets for clinical research to improve antibiotic treatment of CAP complicated by empyema. Interventions that might be studied include empirical antibiotic guidelines stratified by case severity, adjunctive empirical use of agents that inhibit protein synthesis (e.g. clindamycin) and approaches to encourage rapid IV-to-oral switch and shorter total antibiotic treatment.

[Surgical treatment of tuberculous empyema in children]. / Khirurgicheskoe lechenie tuberkuleznoi émpiemy plevry u detei.

OBJECTIVE: To analyze surgical treatment of tuberculous pleural empyema in children depending on the stage of the process. MATERIAL AND METHODS: There were 82 patients aged 4-17 years with tuberculous pleural empyema. Clinical and X-ray features of different stages of disease are described. Certain types of surgical interventions at each stage of the process are analyzed. RESULTS: In 72 children with empyema stage III 76 surgeries were performed. Postoperative complications occurred in 2 (2.6%) cases (delayed lung inflation) that required thoracocentesis with pleural drainage. There was no postoperative mortality. CONCLUSION: Complex treatment of tuberculous pleural empyema in children and adolescents with the use of modern surgical methods is followed by satisfactory outcomes in all patients. However, surgical technique, postoperative morbidity and hospital-stay depend on the stage of the process. Unfortunately, almost 90% of patients had empyema stage III. Therefore, minimally invasive surgery was not advisable and extensive, traumatic surgeries were required.

[Transsternal occlusion of the main bronchus stump in bronchopleural fistula and non-specific pleural empyema]. / Transsternal'naia okkliuziia kul'ti glavnogo bronkha pri bronkhoplevral'nom svishche i nespetsificheskoi émpieme plevry.

OBJECTIVE: To present our experience in the treatment of patients with bronchopleural fistula and chronic non-specific pleural empyema after pneumonectomy. MATERIAL AND METHODS: There were 25 patients with chronic pleural empyema following bronchopleural fistula after pneumonectomy. All patients were examined in standard fashion and divided into two groups depending on length of bronchial stump: more or equal to 20 mm and less than 20 mm. Transsternal occlusion of bronchial stump was performed in the 1st group. Pedicled muscle or omental flap was applied for bronchial stump repair in the 2nd group. RESULTS: Follow-up period ranged from 18 to 110 months (median 48 (19; 52) months). Complications were grade daccording to Clavien-Dindo classification. Infectious complications not associated with bronchial stump insufficiency and required antibiotic therapy and/or topical treatment were registered in 6 (24%) out of 25 patients (95% CI 11.5-43.4): suppurative tracheobronchitis, pneumonia, postoperative wound suppuration in 1 (4%), 2 (8%) and 3 (12%) patients, respectively. Overall mortality rate was 2 (8%) out of 25 patients. There were no recurrences after transsternal occlusion of bronchial stump. In the control group, recurrent bronchopleural fistula was noted in 2 (12.5%) out of 16 patients (95% CI 3.5-36). Mean hospital-stay was 13 (13; 16) and 20 (11; 35) days in both groups, respectively (p<0.05). A good and satisfactory result after transsternal occlusion of bronchial stump was achieved in 23 (92%) out of 25 patients (95% CI 75-97.8). CONCLUSION: Transsternal occlusion of bronchial stump is more advisable than tissue flap transposition in patients with chronic pleural empyema followed by BPF and bronchial stump length over 20 mm due to less trauma and good reproducibility.

Trends in Hospital Treatment of Empyema in Children in the United States.

OBJECTIVE: To evaluate trends in procedures used to treat children hospitalized in the US with empyema during a period that included the release of guidelines endorsing chest tube placement as an acceptable first-line alternative to video-assisted thoracoscopic surgery. STUDY DESIGN: We used National Inpatient Samples to describe empyema-related discharges of children ages 0-17 years during 2008-2014. We evaluated trends using inverse variance weighted linear regression and characterized treatment failure using multivariable logistic regression to identify factors associated with having more than 1 procedure. RESULTS: Empyema-related discharges declined from 3 in 100 000 children to 2 in 100 000 during 2008-2014 (P = .04, linear trend). There was no significant change in the proportion of discharges having 1 procedure (66.1% to 64.1%) or in the proportion having 2 or more procedures (22.1% to 21.6%). The proportion coded for video-assisted thoracoscopic surgery as the only procedure declined (41.4% to 36.2%; P = .03), and the proportions coded for 1 chest tube (14.6% to 20.9%; P = .04) and 2 chest tube procedures (0.9% to 3.5%; P < .01) both increased. The median length of stay for empyema-related discharges remained unchanged (9.3 days to 9.8 days; P = .053). Having more than 1 procedure was associated with continuous mechanical ventilation (adjusted OR, 2.7; 95% CI, 1.8-4.1) but not with age, sex, payer, chronic conditions, transfer admission, hospital size, or census region. CONCLUSIONS: The use of video-assisted thoracoscopic surgery to treat children in the US hospitalized with empyema seems to be decreasing without associated increases in length of stay or need for additional drainage procedures.