[Outcomes of Stage-Adapted Surgical Treatment of Pleural Empyema]. / Ergebnisse der stadienadaptierten chirurgischen Therapie von Pleuraempyemen.

BACKGROUND: 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. PATIENTS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.

[Para- and Postpneumonic Pleural Empyema: Current Treatment Strategies in Children and Adults]. / Para- und postpneumonisches Pleuraempyem: aktuelle Behandlungsstrategien bei Kindern und Erwachsenen.

INTRODUCTION: Parapneumonic pleural effusions arise from pneumonia and may develop into pleural empyema (PE). PE is defined as collection of pus in the pleural space with secondary inflammation of the visceral and parietal pleura. This review article describes the current treatment strategies for para- and postpneumonic PE both in children and adults. MATERIAL AND METHODS: Selective literature research via Medline (key words: pleural empyema, pleural empyema in children, thoracic empyema) and presentation of our own clinical experience with therapy recommendations. RESULTS: The incidence of postpneumonic PE is increasing in both children and adults. PE is associated with a high morbidity and mortality if it is not treated early and adequate. Progression of PE follows a characteristic morphological course, which is classified in three stages: the exsudative, fibrinopurulent, and organizing phase. Treatment should be adapted to these three phases including systemic antibiotic therapy and drainage of the pleural space. Intrapleural fibrinolysis can be performed with good success independent of age in the transition of stage 1 and 2. In persistent PE (stage 2), thoracoscopic decortication is recommended to avoid progression into the organizing phase (stage 3) with the need of an open decortication. In debilitated elderly patients the increasing use of intrathoracic vacuum therapy (Mini-VAC/Mini-VAC-instill) offers an effective and less invasive therapy option. CONCLUSION: Para- and postpneumonic PE requires an individualized and stage adapted therapy using a combination of medical and surgical treatment strategies with the aims of removing the source of infection and ensuring re-establishment of lung expansion.

Treatment of complicated parapneumonic pleural effusion and pleural parapneumonic empyema.

BACKGROUND: We performed this observational prospective study to evaluate the results of the application of a diagnostic and therapeutic algorithm for complicated parapneumonic pleural effusion (CPPE) and pleural parapneumonic empyema (PPE). MATERIAL/METHODS: From 2001 to 2007, 210 patients with CPPE and PPE were confirmed through thoracocentesis and treated with pleural drainage tubes (PD), fibrinolytic treatment or surgical intervention (videothoracoscopy and posterolateral thoracotomy). Patients were divided into 3 groups: I (PD); II (PD and fibrinolytic treatment); IIIa (surgery after PD and fibrinolysis), and IIIb (direct surgery). The statistical study was done by variance analysis (ANOVA), χ2 and Fisher exact test. RESULTS: The presence of alcohol or drug consumption, smoking and chronic obstructive pulmonary disease (COPD) were strongly associated with a great necessity for surgical treatment. The IIIa group was associated with increased drainage time, length of stay and complications. No mortality was observed. The selective use of PD and intrapleural fibrinolysis makes surgery unnecessary in more than 75% of cases. CONCLUSIONS: The selective use of PD and fibrinolysis avoids surgery in more than 75% of cases. However, patients who require surgery have more complications, longer hospital stay, and more days on PD and they are more likely to require admittance to the Intensive Care Unit.

[Modern tailored therapy for pleural empyema]. / Stadienadaptierte moderne Therapie des Pleuraempyems.

In spite of the development and widespread avail-ability of modern antibiotics, pleural empyema still represents a serious intrathoracic disease -associated with significant morbidity and mortality. Patients with complicated parapneumonic effusions and empyema have an increased morbidity and mortality due at least in part to inappropriate and delayed management of pleural space infections. Timely diagnosis of pleural empyema and rapid initiation of the appropriate surgical treatment modality represent keystone principles for efficient treatment of thoracic -empyema. Simple drainage, minimally invasive surgical treatment modalities (VATS) and image-guided small-bore catheters in combination with adjunctive fibrinolytic drugs have extended the potential therapeutic arsenal. Individual case management with a flexible selection of the most appropriate treatment modality by experienced thoracic surgeons may lead to improved outcomes. In this context a summary of the most recent opinions and results in thoracic empyema management is outlined in the present review.

[Treatment of pleural empyema]. / Behandlung des Pleuraempyems.

Pleural empyema remains a frequently encountered clinical problem and is responsible for significant morbidity and mortality worldwide. Its diagnosis may be difficult; delays in diagnosis and treatment may contribute to morbidity, complications, and mortality. The management of parapneumonic effusion and empyema depends on timely, stage-dependent therapy and the underlying etiology. Thoracentesis and antibiotics remain the cornerstones of treatment in stage I disease. In the early fibrinopurulent phase (stage II) thoracoscopic methods should be considered. As treatment strategy for this stage, fibrinopurulent pleural empyema entails thorough debridement of multiloculated collections from the pleural cavity by video-assisted thoracic surgery. After evacuation of multilocular effusions and the removal of fibrin deposits with drainage by two intercostal chest tubes, irrigation treatment helps to achieve clarity of the pleural discharge. Open thoracotomy and decortication are reserved for organized, multiloculated empyema with lung entrapment (stage III disease). Early drain removal may lead to rapid symptomatic recovery and complete resolution.

[Pleural empyema in elderly patients].

We shall consider carefully for surgical management of pleural empyema in elderly patients over 80 years old for the reason that their preoperative conditions are frequently poor, due to such as several complications, low activity of dayly life and immunodeficiency on account of undernutrition. Sufficiently drainage and cleaning the abscess cavity by irrigation of saline with antibiotics through chest tube are required in acute period of empyema. In chronic period of empyema, prolonged hospitalization because of unsucusessful drainage, surgical management is necessary. Various surgical procedures reported by many authors were reviewd and suitable method should be selected respectively, taking individual states of elderly patients into consideration.

Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome.

OBJECTIVE: Despite modern diagnostic methods and appropriate treatment, pleural empyema remains a serious problem. Our purpose was to assess the feasibility and efficacy of the video-assisted thoracoscopic surgery in the management of nontuberculous fibrinopurulent pleural empyema after chest tube drainage treatment had failed to achieve the proper results. METHODS: We present a prospective selected single institution series including 45 patients with pleural empyema who underwent an operation between March 1993 and December 1996. Mean preoperative length of conservative management was 37 days (range, 8-82 days). All patients were assessed by chest computed tomography and ultrasonography and underwent video-assisted thoracoscopic debridement of the empyema and postoperative irrigation of the pleural cavity. RESULTS: In 37 patients (82%), video-assisted thoracoscopic debridement was successful. In 8 cases, decortication by standard thoracotomy was necessary. There were no complications during video-assisted thoracic operations. The mean duration of chest tube drainage was 7. 1 days (range, 4-140 days). At follow-up (n = 35) with pulmonary function tests, 86% of the patients treated by video-assisted thoracic operation showed normal values; 14% had a moderate obstruction and restriction without impairment of exercise capacity, and no relapse of empyema was observed. CONCLUSIONS: Video-assisted thoracoscopic debridement represents a suitable treatment for fibrinopurulent empyema when chest tube drainage and fibrinolytics have failed to achieve the proper results. In an early organizing phase, indication for video-assisted thoracic operation should be considered in due time to ensure a definitive therapy with a minimally invasive intervention. For pleural empyema in a later organizing phase, full thoracotomy with decortication remains the treatment of choice.

Video-assisted thoracoscopic surgery for children with stage II empyema.

Children with stage II empyema often fail traditional medical management, frequently succumbing to the effective albeit morbid clutches of thoracotomy. Video-assisted thoracoscopic surgery (VATS) has been recently introduced as a viable and potentially less morbid alternative to open thoracotomy. We review our VATS experience in children with empyema, assessing surgical outcome. Between August 1996 and March 1999, 13 patients at our institution with stage II empyema that did not respond to conventional medical management underwent a modified VATS with decortication. Data from retrospective chart review reflects intraoperative findings and postoperative course, including average time to defervescence, removal of thoracostomy tube, and hospital discharge. VATS was completed in all 13 patients. All intraoperative cultures of pleural fluid and fibrinopurulent debris obtained at VATS showed no growth. The average time to defervescence was 2.2 days (range, 0-4 days) and to removal of thoracostomy tube 3.6 days (range, 2-5 days). Average total chest tube days in patients with pre-VATS thoracostomy (n = 6) was 14.5 days (range, 8-37 days) versus 3.1 days (range, 2-5 days) in patients (n = 7) who underwent primary VATS (t test, p < 0.05). The average time to surgical discharge after VATS was 5.8 days (range, 3 to 19 days). All patients were well on follow-up clinic visits without delayed complications. VATS can be performed safely and effectively in children with stage II empyema, thus avoiding the morbidity of open thoracotomy and decortication. Importantly, early application of VATS significantly relieves patients of unnecessary days of thoracostomy drainage.

[The intracavitary administration of contrast medium in the aftercare of complicated thoracic empyema with long-term drainage: x-ray fluoroscopy compared to computed tomography]. / Die intrakavitäre Kontrastmittelgabe bei der Nachsorge des komplizierten langzeitdrainierten Thoraxempyems: Röntgendurchleuchtung im Vergleich zur Computertomographie.

PURPOSE: To define the value of conventional radiography compared with CT in the follow-up of complicated, long-term tube drained pleural empyema after intracavitary application of contrast medium. METHODS: 28 patients with complicated pleural empyema (stage III) and long-term tube drainage were submitted to fluoroscopy of the pleural cavity and a CT of the thorax after contrast medium had been instilled into the pleural space. Both examinations were judged by the following criteria: number and morphology of pleural cavities, quality of drainage and accompanying thoracic disease. RESULTS: 49 pleural cavities were diagnosed. Judgement of drainage corresponded in 79% of cases and differed in 21% with proof of further not drained cavities only on CT. 4 bronchopleural fistulas were diagnosed by fluoroscopy, of which only 2 were evident on CT. Accompanying thoracic disease was reliably detected by CT only. CONCLUSIONS: Diagnosis of bronchopleural fistulas and judgement of the pleural drainage is best possible using fluoroscopy after application of contrast medium into the pleural space. CT is most accurate to detect further cavities that have not been drained, to look for concomitant thoracic disease, and to judge the morphology of the pleural cavity. Conventional radiography of the pleural space is effective and recommended to be used as a first line investigation for the follow-up of stage III empyemas. Patients in poor general condition (fever, elevated blood markers indicating inflammation) should be examined by both fluoroscopy and CT.

[Pyothorax in pneumonectomy cavity. Apropos of 24 cases]. / Les pyothorax sur cavité de pneumonectomie. A propos de 24 cas.

AIM OF THE STUDY: Describe as series of post-pneumonectomy empyema episodes, with or without bronchial fistula treated at the department of Thoracic Surgery, University of Ibn Sina, Rabat, Morocco. PATIENTS, METHOD AND RESULTS: Twenty-four patients with post-pneumonectomy pyothorax cared for between 1991 and 2000 were reviewed retrospectively. There were 15 men and 9 women, mean age 34 years. Pneumonectomy was indicated for tuberculous pyothorax and destroyed lung (n = 8), 8 destroyed lung (n = 8), pulmonary aspergilloma (n = 2), pulmonary hydatidosis (n = 2), bronchial dilatation (n = 2), lung cancer (n = 1), and bullet wound (n = 1). The patients were divided into two groups according to presence or absence of bronchial fistula: group 1, 19 patients with without bronchial fistula, and group 2 5 with bronchial fistula. Fourteen patients in group 1 (73.7%) achieved definitive cure, 12 after drainage and washout (63%) at mean delay of 45 days and 2 after drainage and washout with thoracoplasty. Five patients did not respond to hospital drainage and washout and remained under definitive ambulatory drainage as they declined further surgical treatment. One death occurred in this group. Two patients in group 2 (40%) achieved definitive cure, one after daily aspiration, and the other after thoracoplasty. Two fistulae in one patient were treated with nitratage. For this patient, we also attempted revision of the bronchial stube via posterior throacotomy, the closure of the bronchial fistula using an intercostal muscle flap associated with thoracoplasty. All these methods failed. There were two deaths in this group. CONCLUSION: Sixteen patients were definitively cured (66.6%). Eight patients (33.3%) remain in a chronic condition. Patients with pyothorax on a pneumonectomy cavity should be managed in specialized centers before reaching the chronic stage. Thoracomyoplasty with preparation of the cavity by thoracostomy should be proposed.

Surgical treatment of pleural empyema according to disease stage.

UNLABELLED: Para pneumonic effusions are often complications of bacterial pneumonia, occurring in 5-50% patients and in 15% cases it can progress into pleural empyema. Pleural empyema treatment includes drainage of pus, re-expansion of lung by using appropriate antibiotics. Surgical treatment covers implementation of certain thoracic drainage modifications, use of VATS techniques and thoracotomy with pleura decortications. PATIENTS: Research has involved 100 patients with diagnosis and treatment of para pneumonic and meta pneumonic pleural empyema. RESULTS: Based on previously defined phase of pleural empyema it was determined which surgical procedures have been used in definitive treatment of pleural empyema. In case of 31,17% (24/77) patients it has been found that pre-clinical treatment lasted 31 days and longer, and 49,35% (38/77) patients have been admitted at Clinic after 11 to 30 days of pre-clinic treatment. Only in 19.48% (15/77) patients pre-clinic treatment lasted up to 10 days. 79% (79/100) patients were in third phase of disease, 19% (19/100) patients were in second phase and 2% (2/100) patients were in first stage of disease. Among patients with first stage of disease 1 patient was subject to pleural drainage and 1 was subject to decortications. Among patients with second phase of disease 10 patients were subject to pleural drainage and 9 to decortications. Among patients with third phase of disease 20 patients were subject to pleural drainage and 49 to decortications, 4 patients were subject to pleural drainage with rib resection, and 2 were subject to combination of thoracoscopy and drainage, while in case of 4 patients it was necessary to perform additional drainage. CONCLUSIONS: Pleural drainage is first procedure in surgical treatment of pleural empyema, but very often it is not definitive measure of treatment of patients with third phase of disease. Definitive treatment of empyema in third phase is decortications of pleura carried out on 62% patients with this phase of disease. Efficiency of treatment determined on basis of mortality level is satisfactory.

[Video-assisted thoracoscopic surgery (VATS) for the management of parapneumonic pleural empyema]. / Videoassistierte thorakoskopische Chirurgie (VATS) zur Behandlung des parapneumonischen Pleuraempyem.

Parapneumonic pleural empyema has been classified by international societies and by pleural diseases experts into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, Light has classified pleural empyema according to radiological, physical and biochemical characteristics, and the American College of Chest Physicians (ACCP) has categorised patients with pleural empyema according to the risk of a poor outcome. According to these classifications, the management of the pleural empyema is based on the stage of the disease. The recommended treatment options in (ATS) stage I disease (Light classes I-III, ACCP categories I and II) are therapeutic thoracentesis or tube thoracostomy and antibiotics when necessary. In (ATS) stage II disease (Light classes IV-VI, ACCP category III), thoracoscopy (VATS) is the treatment of choice because it has a higher efficacy than treatment strategies that utilise tube thoracostomy or catheter-directed fibrinolytic therapy alone, whereas in (ATS) stage III disease (Light class VII, ACCP category IV), decortication via thoracoscopy or thoracotomy is the treatment of choice.

VATS decortication in patients with stage 3 empyema.

We present here a technique for VATS decortication in patients with stage 3 empyema. It was undertaken with satisfactory outcomes in a limited number of patients. In our technique, the fibrous peel at the surface of the lung is completely removed via two or three incisions without parietal decortication. We believe that our technique will be improved with increased experience and may be an alternative to open thoracotomy and decortication in a selected group of stage 3 empyema patients.

[The treatment of parapneumonic effusions and pleural empyemas]. / Die Behandlung des parapneumonischen Ergusses und des Pleuraempyems.

Pleural effusions of infectious origin usually present as a complication of pneumonia, or, more rarely, of thoracic surgical procedures. Treatment is based upon the clinical picture, the appearance of the pleural fluid, on certain laboratory parameters, and upon the success of therapeutic interventions. The initial antibiotic regimen should cover the causative organisms that may empirically be expected in the individual setting of the patient. Similar to the situation in pneumonias, the spectrum of organisms in community-acquired effusions or empyemas differs substantially from that in hospital-acquired pleural infections. The management of pleural empyemas should follow an interdisciplinary strategy which involves the pulmonologist and the thoracic surgeon. The single most important intervention is the early and effective drainage of the pleural cavity. Loculated effusions that do not promptly improve after drainage can additionally be treated by a trial of intrapleural fibrinolysis for a period of approximately three days. However, the precise role of fibrinolytics in the setting of complicated pleural effusions and empyemas remains to be better defined. Early definitive surgical treatment, preferentially by video-assisted thoracoscopic surgery (VATS), should be the goal in all patients who do not promptly respond to drainage and/or intrapleural fibrinolytic therapy and who qualify for a surgical intervention.

Scoring system for empyema thoracis and help in management.

OBJECTIVE: To evaluate the implications of a newly defined severity scoring of empyema in children for the prediction of surgical management and to compare the length of hospitalization as an outcome measure of patients treated using medical therapy, salvage video-assisted thoracoscopic surgery (VATS) vs early elective VATS. METHODS: A retrospective chart review of parapneumonic empyema of patients below 18 years of age admitted to a tertiary children's hospital in northern Taiwan from April 1993 to December 2002 was performed. Patients were categorized into a medical group who received antibiotic therapy, needle aspirations with/without tube thoracostomy; a salvage VATS group when the patients required surgery for the relief of persistent fever > 38 degrees C, chest pains or dyspneic respirations despite initial medical therapy; an early VATS group when the patients received elective surgery early after admission. The demographic data, clinical features, laboratory findings, and duration of hospitalization were compared using a severity score of empyema (SSE). RESULTS: Streptococcus pneumoniae was the most common infecting organism, followed by Staphylococcus aureus, Pseudomonas aeruginosa. No organisms were recovered in 39% of patients. A pleural pH < 7.1 increases the odds of requiring surgical intervention by 6 times among this cohort. Children who required decortication of empyema had a higher severity score (mean 4.8 vs 3.0, p < 0.005). The duration of hospitalization for patients having early VATS showed a shortening stay (mean 18 vs 28 days) as compared to salvage VATS. CONCLUSION: A pleural pH < 7.1 and a newly designed clinical severity score of empyema 4 are two predictors of surgical intervention for fibrinopurulent empyema in the present study. Early elective VATS may be adopted not later than 7 days after failure of appropriate antibiotic therapy and adequate drainage of empyema to decrease the length of stay and minimize morbidity.

[Pleural empyema: surgical treatment]. / Pleuraempyem: Operative Therapie.

Pleural empyema runs in three stages, if untreated. Because it produces uncharacteristic signs, specific diagnosis and adequate treatment is often delayed. The treatment should be early, according to the stage and adapted to the given situation. Expenditure and morbidity of treatment are the higher the longer it is delayed. In the exudative stage 1, drainage--if necessary combined with antibiotic administration--is likely to be successful. In the fibrinous-purulent stage 3, often not clearly demarked from the other stages, video-assisted thoracoscopy (VATS) in its various forms provides the best therapeutic prerequisite. It makes it possible to open all cavities and free pleural layers from the, usually fibrinous or fibrosing, contents. Furthermore, VATS allows targeted drainage placement as essential precondition of effective irrigation. The definitive stage 3 of organization requires the technically demanding empyema excision or decortication.

Parapneumonic and post-traumatic pleural space infections.

Thoracic empyema, an accumulation of pus in the pleural space, was first described by Hippocrates. Today, parapneumonic and post-traumatic empyemas account for two thirds of all pleural space infections. Although modern antibiotic therapy has significantly reduced the incidence of thoracic empyemas, it remains a problem that thoracic surgeons will encounter and should feel comfortable about recognizing and treating. The successful management of thoracic empyemas centers on adequate and timely drainage, the use of appropriate antibiotics, the selective use of decortication, and the proper treatment of underlying pulmonary parenchymal disease.

[Parapneumonic effusion and pleural empyema - topical aspects of classification, diagnosis and treatment]. / Parapneumonischer Erguss und Pleuraempyem - aktuelle Aspekte zu Einteilung, Diagnose und Therapie.

Parapneumonic effusions can be diagnosed in about 40 - 50 % of patients with bacterial pneumonia, and therefore should be considered as a frequent condition. Despite their prevalence, there is limited consensus about diagnostic pathways and therapeutic procedures due to the lack of evidence-based data available. The classification of parapneumonic effusions is based on morphological, chemical and bacteriological criteria. Dependent on the complexity of the effusion, available management approaches include observation without intervention, thoracentesis, chest tube drainage with or without local fibrinolysis and the surgical options VATS and thoracotomy. This overview summarizes the actual aspects of classification, diagnosis and treatment of the parapneumonic effusion and draws conclusions for the daily management of this condition.