Surgical Treatment of Pleural Empyema - Our Results.

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce morbidity, mortality and duration of hospital stay. Unfortunately, advanced stages of empyema need to use extensive surgery - decortications or thoracoplasty. Early recognition of the parapneumonic effusion and the adequate treatment with thoracentesis or pleural drainage, which is minimally invasive, is possible not to prograde the process and not to become empyema. AIM: To analyze the results of the surgical treatment in patients with empyema treated at Clinic for thoracic surgery. MATERIAL AND METHODS: In the retrospective study we analyzed 234 patients with empyema which were treated at the Clinic for Thoracic Surgery in 5 year period (2011-2015). The mean age of the patients was 51.94 years. They were treated with pleural drainage, decortications or thoracoplasty. RESULTS: With pleural drainage were treated 165/234 (70.51%) patients, of which successfully were finished 124/165 (75.15%), but 41/165 (24.85%) were indicated after the decortications. A total of 108/234 (46.15%) were treated with decortications from which, primary decortications were indicated in 67/234 (28.63%) patients. 5/234 (2.14%) patients were treated with thoracoplasty - 3 of the patients with decortications and 2 with primary indicated thoracoplasty according to the local findings, long term untreated empyema and bad general condition. The Mean hospitalization was 17.4 days, of which 13.4 days after surgery. In the group with primary drainage it was detected a lethal outcome in 7/124 (5.64%) patients, 5/105 (4.76%) in the group with decortications and 2/5 (40%) in the group with thoracoplasty. CONCLUSION: Early detection of the parapneumonic effusion and the adequate treatment will prevent the appearance of empyema. If the empyema is detected it is necessary as early as possible to start the treatment with minimally invasive pleural drainage. In earlier stages it is possible to use less invasive decortications, using VATS than the open thoracotomy decortication which is more extensive surgical intervention.

Muscle flaps and thoracomyoplasty: alternative solution for unresectable primary pulmonary abscesses.

BACKGROUND: The objective of this study is to perform a retrospective analysis of our experience in using muscle flaps and thoracomyoplasty for unresectable primary pulmonary abscesses. MATERIALS AND METHODS: Between January 1, 2003, and January 1, 2012, we have used different muscle flaps and thoracomyoplasty in 15 patients with unresectable primary pulmonary abscesses. Muscle transposition was used alone (3 cases) or during thoracomyoplasty procedures for lung abscesses complicated with empyema (12 cases). The objective of the procedure was complete obliteration of the diseased space, with additional limited thoracoplasty being required in 12 out of 15 patients (average resected ribs: 3.7); bronchial fistula were encountered in 9 patients and were closed-reinforced using muscle flaps. The following parameters were followed: mortality, morbidity, intensive care and overall postoperative hospitalization, recurrence, and late sequelae. RESULTS: We have encountered one postoperative death (6.7%) and an overall 46.7% morbidity. Intensive-care unit stay ranged between 1 and 5 days with a median of 2. Overall postoperative hospitalization ranged between 22 and 46 days, with a median of 32 days. At late 1-year follow-up, we encountered no recurrence and no major chest deformity with a moderate limitation of shoulder mobility in two patients. CONCLUSION: Space-filling procedures are a valuable solution for unresectable primary pulmonary abscesses, allowing the avoidance of open drainage and pleuropneumonectomy. The extensive mobilization of the flaps offers a good-quality biological material with considerable volume.

Modified thoraco-mediastinal plication (Andrews thoracoplasty) for post-pneumonectomy empyema: experience with 30 consecutive cases.

OBJECTIVES: The aim of our study is to evaluate the results of thoraco-mediastinal plication for the treatment of post-pneumonectomy empyema. METHODS: From 1 January 1985 to 1 January 2011, 30 patients underwent post-pneumonectomy empyema through a modified thoraco-mediastinal plication procedure (Andrews thoracoplasty). Indications for pneumonectomy included cancer (25 cases), tuberculosis (3 cases), and bronchiectasis (two cases). Rib resection was performed according to the topography of the cavity, ranging between 5 and 10. Neighbourhood muscle flaps were used in 22 cases but extensive mobilization was performed only in our last 4 cases, the aim of the procedure being the complete obliteration of the infected space. Bronchial fistula was present in 14 cases and was closed and reinforced with the use of flaps (intercostal 12 cases, serratus 1 case, and omentum 1 case). RESULTS: Overall mortality was 6.7% (2 cases); 2 patients (6.7%) presented with recurrence of the empyema requiring an open-window procedure and another patient (3.3%) presented with local tumoral recurrence. Intensive care unit hospitalization ranged between 1 and 14 days, with a median of 4 days, while overall postoperative hospitalization ranged between 23 and 52 days with a median of 32 days, the patients being discharged with healed wounds. Kaplan-Meier analysis of the oncologic patients showed a median survival of 41 months from thoraco-mediastinal plication. The presence of bronchial fistula had no statistically significant impact on the immediate outcome (mortality, need for postoperative prolonged mechanical ventilation, intensive care and overall postoperative hospitalization, P > 0.05 for all the parameters). CONCLUSIONS: Space-filling procedures are a valuable option for treating post-pneumonectomy empyema. The major advantages are the complete obliteration of the infected space and the quick healing from a single procedure; the major disadvantages are the magnitude of the procedure (with associated mortality and morbidity) and the permanent chest mutilation. Several technical details may improve the results and reduce the chest wall mutilation.

Surgical treatment for pulmonary aspergilloma: a 35-year experience in the Chinese population.

The surgical treatment of pulmonary aspergilloma is challenging and controversial. This study was designed to evaluate the clinical profile, indications and surgical outcomes of pulmonary aspergilloma operated on in our institute. A total of 256 patients with pulmonary aspergilloma underwent surgical treatment from 1975 to 2010. The patients were divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160). The principal underlying lung disease was tuberculosis (71.1%). The surgical procedures consisted of 212 lobectomies in both groups; eight cavernoplasties, 10 bilobectomies, 16 pneumonectomies and six thoracoplasties in Group B; four segmentectomies and six wedge resections in Group A. Postoperative complications occurred in 40 patients (15.6%). The major complications were residual pleural space (3.9%), prolonged air leak (3.1%), bronchopleural fistula (1.6%), excessive bleeding (1.6%), respiratory insufficiency (1.9%) and empyema (1.2%). No intraoperative deaths occurred. The overall mortality within 30 days post-operation was 1.2%, occurring only in Group B. There was no statistically significant difference in the postoperative morbidity between Groups A and B (P = 0.27). With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.

[Computerized modelling of operation (CMO) before thoracoplasty]. / Thoraco-myoplastica mutéteink számítógépes modellezése és tervezése.

INTRODUCTION: Thoraco-myoplasty (TMP) has proven to be the only successful method of treatment for severe cases of chronic pyothorax (CPT). Great loss of muscle tissue and permanent bone-structure defects with severe functional damage can be caused by this method. The aim of the applied CMO was to prevent additional loss of muscle function. Preoperative evaluation of spiral CT scan 3-dimensional imaging provided a significant aid in decreasing adverse effects of the TMP. MATERIALS AND METHOD: Between 1990 and 2010, TMP was applied in 85 patients, whose CPT came from several different origins. CLINICAL DATA: average age: 62.7; mortality: 4.8%. Tissue and function preserving TMP was achieved following open treatment after thoracic fenestration in 76 cases, and drainage with continuous suction was performed in 9 patients prior to this. In our department TMP with computerized modeling was introduced as the definitive treatment of CPT in 2006, since then it has been applied in 8 patients. RESULTS: The number and length of the ribs to be resected can be anticipated applying spiral CT imaging. Furthermore, accurate volume measurement of the empyema cavity and rotatable muscles (pectoral major and latissimus dorsal) faciliatates elimination of the primary defect during surgery. CONCLUSION: Therefore, we believe that CMO can provide significant aid for surgeons to reduce the negative effects caused by muscle trauma and the structural changes in the thoracic wall.

[Osteoplastic thoracoplasty with concomitant pulmonectomy in the surgery of generalized destructive pulmonary tuberculosis]. / Osteoplasticheskaia torakoplastika s odnomomentnoi rezektsiei legkogo v khirurgii rasprostranennogo destruktivnogo tuberkuleza legkikh.

The paper analyzes the results of surgical treatment in 155 patients with generalized destructive pulmonary tuberculosis who underwent pulmonectomy concomitantly with different types of thoracoplasties in 1986 to 1999. According to the type of thoracoplasty, all the patients were divided in 3 groups: 1) 38 patients undergone pulmonectomy with concomitant osteoplastic thoracoplasty; 2) 41 patients had pulmonectomy with concomitant extrapleural thoracoplasty; and 3) 76 had pulmonectomy with concomitant intrapleural thoracoplasty. On discharge, the full clinical effect was achieved in 92.2% of the patients from Group 1 with their mortality rates of 2.6, whereas in the control groups (Groups 2 and 3), the efficiency of treatment was less and the mortality rates were higher (82.9 and 4.9% in Group 2 and 76.3% and 3.9% in Group 3, respectively). Long-term results in 132 patients were followed up for 2-15 years. Clinical recovery was stated in 91.2, 77.8, and 83.3% in Groups 1, 2, and 3, respectively.

Thoracoplasty: an obsolete procedure?

After the advent of chemotherapy for pulmonary tuberculosis, the operation of thoracoplasty became rare in the developed countries. However, this was not the case in developing countries like India. Between July 1992 and June 1997, we performed thoracoplasty in 139 patients. Indications of surgery were tubercular empyema (84 patients), pyogenic empyema (33 patients), post-operative empyema with bronchopleural fistula (8 patients), drug resistant pulmonary tuberculosis (2 patients) and recurrent haemoptysis (2 patients). Successful outcome in the form of control of sepsis, closure of bronchopleural fistula, sputum conversion and control of haemoptysis was achieved in most cases. There were four deaths in the entire series. We conclude that with the persisting problem of pulmonary tuberculosis in the developing countries, thoracoplasty is still an operation of continued relevance.

Long term non-invasive domiciliary assisted ventilation for respiratory failure following thoracoplasty.

BACKGROUND: Ventilatory failure is a well recognised complication of patients who have had a thoracoplasty for tuberculosis, but there are few data regarding the value of long term non-invasive assisted ventilation in this situation. METHODS: Thirty two patients who had had a thoracoplasty 20-46 years previously and who had developed respiratory failure were treated with nocturnal cuirass assisted ventilation or nasal positive pressure ventilation. Their survival and changes in arterial blood gases, nocturnal oximetry, and pulmonary function tests were assessed. RESULTS: The actuarial survival rates at one, three, five, and seven years after starting treatment were 91%, 74%, 64%, and 55%, respectively. Only seven of the 13 deaths were directly attributable to chronic respiratory or cardiac failure. The arterial PO2, PCO2, mean nocturnal oxygen saturation, vital capacity, and maximal inspiratory and expiratory pressures had all improved at the time of the initial post-treatment assessment (mean 12 days after starting treatment), but no subsequent improvements were seen after up to 48 months of follow up. Neither survival nor physiological improvements were correlated with the patients' age, the interval since thoracoplasty, or the pretreatment arterial blood gas tensions or results of pulmonary function tests. CONCLUSIONS: These results show that, even when ventilatory failure has developed, the prognosis with non-invasive assisted ventilation is good and the physiological abnormalities can be partially reversed. Patients who develop respiratory failure after a thoracoplasty should be considered for this type of long term domiciliary treatment.

The effects of five years of nocturnal cuirass-assisted ventilation in chest wall disease.

We investigated the long-term effectiveness of cuirass-assisted ventilation, and examined whether mortality and morbidity could have been predicted at the time of admittance. Twenty five patients were commenced on nocturnal cuirass-assisted ventilation between 1983 and 1985, 10 with scoliosis or kyphosis, 8 with a thoracoplasty and 7 with neuromuscular disease. Mean pretreatment vital capacity was 30% of predicted, and arterial carbon dioxide tension (Paco2) was 8.2 kPa (62 mmHg). Fifteen patients were alive 5 yrs later. Two had discontinued assisted ventilation, both dying soon afterwards, and three had been changed to intermittent positive pressure ventilation. Survival could not have been predicted from age, severity of disease, lung volumes or arterial blood gases at presentation. Paco2 in the survivors had risen from a mean of 6.1 kPa (46 mmHg) after one year to 6.8 kPa (52 mmHg) after 5 yrs (p < 0.05), but remained significantly less than at presentation. There were no significant change in arterial oxygen tension (Pao2), lung volumes, respiratory muscle strength, haemoglobin, right heart failure, exercise tolerance, mental function and symptom scores after 5 yrs, compared to after 1 yr. The median amount of time spent in hospital declined from 15 days per patient in the first year after initial discharge with cuirass-assisted ventilation, to between 3-5.5 days per patient in subsequent years. We conclude that nocturnal cuirass-assisted ventilation has a role in long-term management of patients with neuromuscular and skeletal chest wall disorders. A randomized comparison with nasal intermittent positive pressure ventilation is now indicated.

Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment.

From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.

The modern use of thoracoplasty.

Thoracoplasty is a time-honored but, at present, rarely indicated procedure for reducing thoracic cavity volume. This study reviews a series of 30 patients treated with thoracoplasty over a 14-year period (1970 through 1983). Indications were to close a persistent pleural space in 28 patients and to tailor the thoracic cavity to accept diminished lung volume concomitant with a pulmonary resection in 2 patients. Persistent pleural space, often associated with a bronchopleural fistula (24 patients), occurred after operation in 19 patients: following pulmonary resection in 17 patients, resection of mesothelioma in 1 patient, and following decortication without resection in 1. In the remaining 9 patients with a persistent pleural space, problems developed from primary lung destruction due to tuberculosis (4 patients), postpneumonic empyema (1 patient), or as late infection of a residual pleural space many years after therapeutic pneumothorax and collapse therapy for tuberculosis (4 patients). The overall success rate of thoracoplasty in eliminating intrathoracic space problems was 73%. There were 3 deaths (10%) and 5 failures to heal, representing a 33% failure in the first half of the series (to 1976) and a 17% failure rate thereafter (1 death and 1 nonhealing patient). The primary underlying disease was tuberculosis in 23 patients, 8 of whom had concomitant aspergilloma and 1, atypical tuberculosis. The failures were analyzed and reviewed to clarify the principles for the successful use of thoracoplasty. It is concluded that thoracoplasty is a rarely required salvage-type procedure applicable to moderately debilitated patients in whom it is considered desirable to eliminate open drainage.(ABSTRACT TRUNCATED AT 250 WORDS)