Acute empyema in children treated by open thoracotomy and decortication

Acute nontuberculous empyema treated conventionally by thoracentesis, thoracostomy drainage, and antibiotics has an unacceptably high rate of morbidity and mortality. Early open thoracotomy to eliminate the empyema with decortication of the fibrinous peel and reexpansion of the lung has proven safe and effective for 25 years. The goals of treatment of acute nontuberculous empyema are: (1) to save life, (2) to eliminate the empyema, (3) to reexpand the trapped lung, (4) to restore mobility of the chest wall and diaphragm, (5) to return respiratory function to normal, (6) to eliminate complications or chronicity, and (7) to reduce the duration of hospital stay. Our studies confirm the normal values to be expected in patients who have had complete recovery from the acute empyema, and we lay to rest any concern that decortication might, in time, limit pulmonary function. We present the cases of 21 children who had acute and mature empyemas that were treated by open thoracotomy and decortication, with an average follow-up of 18 years, among whom there were no deaths or complications.

Empyema following lung cancer resection: risk factors and prognostic value on survival

A retrospective evaluation of 199 consecutive patients undergoing resection for lung cancer revealed a significantly shorter long-term survival for those in whom empyema developed postoperatively. The overall five-year survival for the empyema group was 24% compared with 35% in the control group (patients without empyema), and the median survival was 15 months for the control group. These differences in survival were not found among patients with Stage I lung cancer. Pneumonectomy proved to be the main risk factor for the occurrence of empyema after operation, but a minor risk factor was the anatomical extent of disease. this correlation may be explained by major surgical contamination or manipulation as well as by lower immunological host reaction, all related to the extent of the tumor. A lower immunological defense could also explain the worse outcome for patients with Stage II or III lung cancer in whom empyema developed postoperatively.

Improved survival in management of empyema thoracis

Empyema thoracis following pneumonia, trauma, and surgical procedures continues to be a source of major morbidity and mortality. We retrospectively reviewed the hospital records of 100 patients treated for empyema thoracis at San Francisco General Hospital during the past 10 years. The causes of empyema in these patients were as follows: pneumonia 44%, trauma 24%, surgical and invasive procedures 15%, lung abscess 11%, and hematogenous spread 6%. Ten patients in this series died of sepsis from necrotizing pneumonia or overwhelming injuries caused by trauma. Streptococcus (31%), Staphylococcus (21%), and Bacteroides (15%) were the organisms most commonly isolated. Bacterial isolates were single in 55%, multiple 42%, and absent in 3%. The type of organism did not correlate with severity of disease or eventual requirement for thoracotomy, pleural débridement, or Eloesser procedure. Successful methods of treatment included aspiration in 9%, tube thoracostomy in 63%, pleural débridement and drainage in 7%, and an Eloesser procedure in 11%. Because our patients were often debilitated from chronic alcoholism, drug addiction, and major trauma, conservative management was initially tried. In most patients empyema resolved with tube thoracostomy. Pleural débridement should be reserved for patients with special problems such as multiple loculation or purulence inaccessible to percutaneous tube placement. the Eloesser procedure is indicated in patients who have an infected residual pleural space that persists despite adequate tube drainage.

Bronchogenic carcinoma and postoperative empyema: is survival really enhanced?

From 1959 to 1974, 542 patients underwent curative resection for bronchogenic carcinoma. Postoperative empyema occurred in 17 of these patients. The overall 5-year survival of these 17 patients was only 18%, compared with 27% in the 525 patients without empyema. We were unable to demonstrate by our study or by a review of the literature that postoperative empyema favorably influences survival in patients who have had pulmonary resection for bronchogenic carcinoma.

Postpneumonectomy empyema. The cloud with a silver lining?

I have reviewed the literature concerning the effect of postoperative sepsis on survival following resection for carcinoma of the bronchus and added to this my experience over a 12 year period. Surgeons agree that because of its morbidity and the morbidity of measures necessary for its treatment, postoperative empyema is to be avoided, but many still hope that some compensation might be afforded the unfortunate sufferer by improvement in long-term survival. I have not found this to be the case and I feel that statistical evidence favors this view.

The relationship between postoperative empyema and long-term survival after pneumonectomy. Results of surgical treatment of bronchogenic carcinoma

In order to present the possible influence of postoperative empyema on the survival rate of patients with bronchogenic carcinoma, who had been treated by pneumonectomy, a retrospective investigation was made upon 207 patients over a 10-year period. In patients with and without a complicating postoperative empyema, a cumulative survival rate of 0.04 and 0.26, respectively, was found. The difference was not significant. However, other retrospective investigations on the influence of postoperative empyema on long-term survival after surgical treatment for bronchogenic carcinoma have shown results that might stimulate prospective studies on the subject. Furthermore, this investigation showed that the probability of long-term survival was highest in patients under 60 years of age, when the bronchogenic carcinoma is a planocellular carcinoma located in the left lung without postoperative empyema. Among pneumonectomized lung cancer patients, the mortality was above expectancy, even 8-10 years after operation compared with the estimated survival rate in the average population.

Management of thoracic amebiasis

The thoracic complications of amebiasis frequently necessitate surgical intervention. Experience with 28 patients is presented. Involvement included the pleura in 19 patients, the lungs in 10, and the pericardium in five. In 25%, more than one site was involved. Treatment consisted of measures designed to obliterate the pleural space or widely drain the pericardial sac, as indicated. Concurrent drainage of the associated amebic liver abscess was done in half the cases. The mortality rate was 36%, generally related to the poor general condition of the patients and their delay in seeking hospitalization.

Influence of postoperative empyema on survival after pulmonary resection for bronchogenic carcinoma

Fifty patients who had developed empyema after pulmonary resection for primary carcinoma of the lung were individually paired with patients who had not suffered this complication. Pairs were matched as far as possible for age, sex, extent of operation, histology of tumour, extent of primary spread, extent of lymphatic spread, and use of postoperative radiotherapy. Analysis of survival times both for the matched pairs and for the two groups of patients showed no significant difference in long-term survival. The results suggest that any immunological suppression of carcinoma cells due to sepsis in the pleural space is ineffective in prolonging survival.

Empyema in children in tropics

Thirty-six cases of empyema were diagnosed in children over a two year period, giving an overall incidence of 0.11% of the total hospital admissions. Many of them had measles bronchopneumonia and most were malnourished. 16 children had penicillin resistant staphylococcal infection. 29 of them were treated with closed tube drainage. Thirteen died during the course of treatment, the majority within three days of admission. The rest were followed up over a period of up to six months and showed good recovery. Six of these patients developed pneumothorax during the course of treatment. Various combinations of Ampicillin, Cloxacillin, Gentamycin and Cotrimoxazole parenterally were used. Supportive treatment with blood transfusion was found to be beneficial.

Duration of hospitalization for acute bacterial empyema at Boston City Hospital during 12 selected years from 1935 to 1972

The duration of hospitalization for acute bacterial empyema of the pleura was determined for all cases at Boston City Hospital during 12 selected years between 1935 and 1972. Patients whose infection was acquired after admission stayed in the hospital longer than those in whom the empyema, or the infection of which the empyema was a complication, was present at the time of admission. The differences were mostly related to serious underlying disease in the hospital-acquired cases. However, the duration of hospitalization after the empyema was bacteriologically confirmed was not much different in the community-acquired and hospital-acquired cases. Hospital stay was further prolonged in patients whose empyema was superinfected with new bacterial species after the original infecting organisms were determined. Hospitalization was shorter in the 10 selected years between 1974 and 1972, when penicillin and other active antibiotics were used, than in two years before penicillin became available, 1935 and 1941.

Changing ecology of acute bacterial empyema: occurrence and mortality at Boston City Hospital during 12 selected years from 1935 to 1972

The occurrence, etiology, and demography of acute bacterial empyema are presented to reflect the widespread use of sulfonamides, penicillin, and other active antibiotics. In community-acquired (C-A) cases Streptococcus pneumoniae, hemolytic streptococci, and Staphylococcus aureus were the most frequent single organisms identified in initial positive cultures of pleural fluid during 1935. S. pneumoniae declined steadily until 1953 but continued to occur frequently in C-A cases. Hemolytic streptococci became infrequent. S. aureus increased and became the most frequent organism in 1955 and declined to original levels after 1965 while gram-negative rods increased. S. aureus, aerobic gram-negative rods, and enterococci were most frequent in originally mixed infections, hospital-acquired cases, and superinfections. Anaerobes with or without aerobes were mostly seen in C-A cases and did not vary in incidence. Mortality increased with age. Overall mortality was greater during the 10 antibiotic years, associated with a marked decrease in the proportion of patients younger than 50 years and increase in those over 60 years old, and was greater in patients with serious underlying diseases subjected to more complicated surgical procedures.

Computerized tomography and surgical treatment in intracranial suppuration. Report of 30 consecutive unselected cases of brain abscess and subdural empyema

The authors report their experience with 30 cases of intracranial suppuration: 23 with brain abscess and seven with subdural empyema. All of the cases were diagnosed by means of computerized tomography and enhancement with intravenous contrast material. Most of the patients were treated by single or repeated aspiration through burr holes.

Brain abscess and subdural empyema. Factors influencing mortality and results of various surgical techniques

The authors review the results of various surgical techniques in relation to mortality and morbidity in 100 consecutive cases of brain abscess and subdural empyema. The mortality rate is the same with total excision and fractional drainage of brain abscesses, although in acute and subacute cases slight differences between both techniques are seen. In terms of morbidity, fractional drainage appears to be more favourable than total excision. The authors believe that factors other than surgical procedure influence mortality in cases of brain abscess and subdural empyema. These factors are defined in detail.