Is thoracoscopic decortication sufficient for the treatment of empyema?

Before thoracoscopy became popular in the 1990s, thoracotomy and decortication was the treatment of choice for empyema thoracis not responding to tube thoracostomy. An Institutional Review Board-approved, retrospective review of all patients treated for empyema between September 1, 2006, and August 31, 2009, at Kern Medical Center was conducted. A total of 37 patients (male=33; female=4) with a mean age of 43.7 years were treated. Empyema developed after community-acquired pneumonia (CAP) in 27, traumatic hemothorax (TH) in nine, and other cause in one. For 34 of 36 patients (91%), a thoracoscopic approach was successful. Two of 36 patients required conversion to thoracotomy, whereas one patient required an initial thoracotomy in each case as a result of tenacious adhesions. Mean duration of the chest tube was 4.1 days in patients with CAP and 4.6 days in patients with TH. Mean length of stay after surgery was 6 days for patients with CAP and 9.1 days for patients with TH. Five of 37(13.5%) had complications and one patient died (2.7%). Follow-up was complete for 81.1 per cent of patients, none of whom required a subsequent intervention. Compared with the literature, it appears that the conversion rate to thoracotomy, length of chest tube duration, and postoperative length of stay have decreased as experience has increased.

Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.

STUDY OBJECTIVE: To demonstrate the efficacy, safety, and appropriate mode of instillation of talc for sclerosis in treatment of malignant pleural effusions (MPEs). DESIGN: A prospective, randomized trial was designed to compare thoracoscopy with talc insufflation (TTI) to thoracostomy and talc slurry (TS) for patients with documented MPE. MEASUREMENTS: The primary end point was 30-day freedom from radiographic MPE recurrence among surviving patients whose lungs initially re-expanded > 90%. Morbidity, mortality, and quality of life were also assessed. RESULTS: Of 501 patients registered, those eligible were randomized to TTI (n = 242) or TS (n = 240). Patient demographics and primary malignancies were similar between study arms. Overall, there was no difference between study arms in the percentage of patients with successful 30-day outcomes (TTI, 78%; TS, 71%). However, the subgroup of patients with primary lung or breast cancer had higher success with TTI than with TS (82% vs 67%). Common morbidity included fever, dyspnea, and pain. Treatment-related mortality occurred in nine TTI patients and seven TS patients. Respiratory complications were more common following TTI than TS (14% vs 6%). Respiratory failure was observed in 4% of TS patients and 8% of TTI patients, accounting for five toxic deaths and six toxic deaths, respectively. Quality-of-life measurement demonstrated less fatigue with TTI than TS. Patient ratings of comfort and safety were also higher for TTI, but there were no differences on perceived value or convenience of the procedures. CONCLUSIONS: Both methods of talc delivery are similar in efficacy; TTI may be better for patients with either a lung or breast primary. The etiology and incidence of respiratory complications from talc need further exploration.

Prevalence of methicillin-resistant Staphylococcus aureus in elective surgical patients at a public teaching hospital: an analysis of 1039 patients.

Methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly common cause of postoperative surgical site infections (SSIs). It is unclear, however, whether asymptomatic colonization or nosocomial acquisition of MRSA results in postoperative SSI. We conducted a retrospective review of patients screened for MRSA between May 2008 and October 2010 at our institution. End points included rates of MRSA infection, SSI, and the cost of routine MRSA screening of patients undergoing elective surgery. Of the 1039 patients screened preoperatively, 48 (4.6%) tested positive for MRSA by nasal or oral swab, whereas 991 (95.4%) tested negative. Forty-five (93.8%) MRSA-positive patients received vancomycin or linezolid and three (6.25%) received cefazolin perioperatively. Three (6.25%) MRSA-positive patients developed postoperative SSIs. Two required rehospitalization for intravenous antimicrobials, whereas a third patient required removal of infected abdominal mesh. Twenty (2.02%) MRSA-negative patients and four (5.26%) unscreened patients developed non-MRSA SSIs. Regardless of MRSA status, none of 609 patients who had a laparoscopic procedure or inguinal hernia repair developed SSI. Twenty-two patients needed to be screened to obtain one positive test. The role of MRSA screening and longer perioperative coverage for MRSA-positive patients undergoing complex elective procedures remains to be determined.

Preoperative exercise Vo2 measurement for lung resection candidates: results of Cancer and Leukemia Group B Protocol 9238.

INTRODUCTION: A stepwise approach to the functional assessment of lung resection candidates is widely accepted, and this approach incorporates the measurement of exercise peak Vo2 when spirometry and radionuclear studies suggest medical inoperability. A new functional operability (FO) algorithm incorporates peak exercise Vo2 earlier in the preoperative assessment to determine which patients require preoperative radionuclear studies. This algorithm has not been studied in a multicenter study. METHODS: The CALGB (Cancer and Leukemia Group B) performed a prospective multi-institutional study to investigate the use of primary exercise Vo2 measurement for the prediction of surgical risk. Patients with known or suspected resectable non-small cell lung cancer (NSCLC) were eligible. Exercise testing including measurement of peak oxygen uptake (Vo2), spirometry, and single breath diffusion capacity (DLCO) was performed on each patient. Nuclear perfusion scans were obtained on selected high-risk patients. After surgery, morbidity and mortality data were collected and correlated with preoperative data. Mortality and morbidity were retrospectively compared by algorithm-based risk groups. RESULTS: Three hundred forty-six patients with suspected lung cancer from nine institutions underwent thoracotomy with or without resection; 57 study patients did not undergo thoracotomy. Patients who underwent surgery had a median survival time of 30.9 months, whereas patients who did not undergo surgery had a median survival time of 15.6 months. Among the 346 patients who underwent thoracotomy, 15 patients died postoperatively (4%), and 138 patients (39%) exhibited at least one cardiorespiratory complication postoperatively. We found that patients who had a peak exercise Vo2 of <65% of predicted (or a peak Vo2/kg <16 ml/min/kg) were more likely to suffer complications (p = 0.0001) and were also more likely to have a poor outcome (respiratory failure or death) if the peak Vo2 was <15 ml/min/kg (p = 0.0356). We also found a subset of 58 patients who did not meet FO algorithm criteria for operability, but who still tolerated lung resection with a 2% mortality rate. CONCLUSIONS: Our data provide multicenter validation for the use of exercise Vo2 for preoperative assessment of lung cancer patients, and we encourage an aggressive approach when evaluating these patients for surgery.