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A non-surgical option in large bronchopleural fistulas: Bronchoscopic conical stent application. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:480-487. [PMID: 32953211 DOI: 10.5606/tgkdc.dergisi.2020.18884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/02/2020] [Indexed: 11/21/2022]
Abstract
Background This study aims to compare the results of the open surgical approach versus endobronchial conical stent application in the treatment of extensive fistulas. Methods Between December 2004 and April 2016, a total of 36 patients (34 males, 2 females; mean age 59.6±8.1 years; range, 40 to 72 years) with a bronchopleural fistula of ≥8 mm in diameter and underwent either conventional open surgery with stump-supported intercostal muscle flap or endobronchial ultra-flex expandable stenting were retrospectively analyzed. The demographic and clinical characteristics of the patients, operative data including the length of hospital stay, thoracic drainage time, and early mortality, and survival data were recorded. Results The mean hospitalization time was 17.4±4.5 days for the bronchoscopic group and 22.5±6.7 days for the invasive surgery group (p=0.026). The median time to removal of thoracic drains was 15 (range, 10 to 30) days for the bronchoscopic group and 26 (range, 14 to 55) days for the surgical group (p=0.027). Early mortality rates of both approaches were in favor of the bronchoscopic approach (χ2=7.058; p=0.008). Two-year survival rate was 76.47% (n=13) in the bronchoscopic group and 70% (n=7) in the surgical group. There was no statistically significant difference in the survival rates between the two groups (χ2=0.132; p=0.716). Conclusion Our study results suggest that bronchoscopic approach can be the first choice in the treatment algorithm of fistulas with a diameter of ≥8 mm presenting with empyema in selected cases.
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Clark JM, Cooke DT, Brown LM. Management of Complications After Lung Resection: Prolonged Air Leak and Bronchopleural Fistula. Thorac Surg Clin 2020; 30:347-358. [PMID: 32593367 PMCID: PMC10846534 DOI: 10.1016/j.thorsurg.2020.04.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Prolonged air leak or alveolar-pleural fistula is common after lung resection and can usually be managed with continued pleural drainage until resolution. Further management options include blood patch administration, chemical pleurodesis, and 1-way endobronchial valve placement. Bronchopleural fistula is rare but is associated with high mortality, often caused by development of concomitant empyema. Bronchopleural fistula should be confirmed with bronchoscopy, which may allow bronchoscopic intervention; however, transthoracic stump revision or window thoracostomy may be required.
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Affiliation(s)
- James M Clark
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, 2335 Stockton Boulevard, 6th Floor North Addition Office Building, Sacramento, CA 95817, USA. https://twitter.com/JamesClarkMD
| | - David T Cooke
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, 2335 Stockton Boulevard, 6th Floor North Addition Office Building, Sacramento, CA 95817, USA. https://twitter.com/DavidCookeMD
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, 2335 Stockton Boulevard, 6th Floor North Addition Office Building, Sacramento, CA 95817, USA.
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Thori R, Desai GS, Pande P, Narkhede R, Vardhan A, Mehta H. “Video Assisted Thoracoscopic Surgery (VATS) for all Stages of Empyema Thoracis: a Single Centre Experience”. Indian J Surg 2020. [DOI: 10.1007/s12262-019-02042-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Jany B, Welte T. Pleural Effusion in Adults-Etiology, Diagnosis, and Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:377-386. [PMID: 31315808 DOI: 10.3238/arztebl.2019.0377] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/14/2019] [Accepted: 05/06/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pleural effusion is common in routine medical practice and can be due to many different underlying diseases. Precise differential diagnostic categorization is essential, as the treatment and prognosis of pleural effusion largely depend on its cause. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed and on the authors' personal experience. RESULTS The most common causes of pleural effusion are congestive heart failure, cancer, pneumonia, and pulmonary embolism. Pleural fluid puncture (pleural tap) enables the differentiation of a transudate from an exudate, which remains, at present, the foundation of the further diagnostic work-up. When a pleural effusion arises in the setting of pneumonia, the potential devel- opment of an empyema must not be overlooked. Lung cancer is the most common cause of malignant pleural effusion, followed by breast cancer. Alongside the treatment of the underlying disease, the specific treatment of pleural effusion ranges from pleurodesis, to thoracoscopy and video-assisted thoracoscopy (with early consultation of a thoracic surgeon), to the placement of a permanently indwelling pleural catheter. CONCLUSION The proper treatment of pleural effusion can be determined only after meticulous differential diagnosis. The range of therapeutic options has recently become much wider. More data can be expected in the near future concerning diagnostic test- ing for the etiology of the effusion, better pleurodetic agents, the development of interventional techniques, and the genetic background of the affected patients.
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Affiliation(s)
- Berthold Jany
- Julius-Maximilians-Universität Würzburg, Klinikum Würzburg Mitte, Missioklinik, Department of Pneumology; Department of Respiratory Medicine, Hannover Medical School
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van Middendorp LB, Franssen S, Gillissen S, Maessen JG, Hulsewé KWE, Vissers YLJ, de Loos ER. Uniportal video-assisted thoracoscopy is a safe approach in patients with empyema requiring surgery. J Thorac Dis 2020; 12:1460-1466. [PMID: 32395283 PMCID: PMC7212173 DOI: 10.21037/jtd.2020.02.29] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Empyema is a well-known complication of pneumonia, with high morbidity and mortality rates. This warrants direct treatment either with antibiotics and chest tube drainage or surgery. With less invasive surgical approaches such as uniportal video-assisted thoracoscopic surgery (uVATS), surgical intervention gets a more prominent role early on in the treatment of empyema. The aim of this study was to compare uVATS with the complete VATS (cVATS) approach in empyema, with respect to postoperative complications, hospital length of stay and mortality. Methods All cases of empyema that were treated surgically in our hospital between 2006 and 2019 were included in a retrospective database. The preferential surgical approach changed from cVATS from 2006 to 2015, towards uVATS from 2016 and on, based on the experience of the surgical team. The database included pre- and postoperative data, as well as peropartive characteristics. Results One hundred and thirty-seven patients were treated with cVATS and 49 with uVATS. Apart from a slightly reduced kidney function in the uVATS group (57.3±6.3 vs. 71.4±17.2 mL/min/1.73 m2, P≤0.001), there were no significant baseline differences in patient characteristics. The duration of uVATS was comparable to cVATS (70±17 vs. 56±23 min, P=0.240), and with low per- and postoperative complications. The postoperative hospital stay was equal in both groups (19±13 vs. 20±15 days, P=0.320). There were no statistically significant differences in postoperative complications or death. Conclusions Uniportal VATS is a feasible and safe technique for the use in patients with empyema requiring surgery. Even if decortication in stage III empyema is required this can be performed by uniportal VATS.
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Affiliation(s)
- Lars B van Middendorp
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.,Department of Cardiothoracic Surgery, Maastricht UMC+, Maastricht, The Netherlands
| | - Stijn Franssen
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Sanne Gillissen
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht UMC+, Maastricht, The Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Erik R de Loos
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
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Do H, Nguyen Q, Nguyen L, Nguyen L. Single Trocar Thoracoscopic Surgery for Pleural Empyema in Children. J Laparoendosc Adv Surg Tech A 2020. [PMID: 32326810 DOI: 10.1089/lap.2019.0637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aim: To present outcomes of single trocar thoracoscopic surgery in the treatment of pleural empyema (PE) in children. Patients and Methods: The thoracoscopic surgery was performed using a single trocar inserted through the fifth intercostal space. A conventional rigid scope with a working channel was used. Pleural fluid was aspirated, followed by debridement and ablation of all septa using one instrument through the working channel. Results: Sixty patients from 1 month to 14 years of age underwent surgery without any intraoperative complications or death. The mean operative time was 67 ± 21 minutes. There was no conversion to open thoracotomy. Postoperative complications occurred in 4 patients. Reoperation was required in 1 patient. Mean duration of postoperative hospitalization was 15 ± 9 days. Follow-up was obtained in 57 patients and resulted in normal clinical and chest X-ray findings in all patients. Conclusion: Single trocar thoracoscopic operation is safe, feasible, and effective in the treatment of PE in children. A future study with control group is required to draw accurate conclusions.
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Affiliation(s)
- Hung Do
- Urological Department and General Surgical Department, National Children's Hospital, Hanoi, Vietnam
| | - Quang Nguyen
- Urological Department and General Surgical Department, National Children's Hospital, Hanoi, Vietnam
| | - Liem Nguyen
- Pediatric Surgical Department, Vinmec International Hospital, Hanoi, Vietnam
| | - Linh Nguyen
- Urological Department and General Surgical Department, National Children's Hospital, Hanoi, Vietnam
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Santanakrishnan R, Murali GS, Javaregowda D, Shankar G, Babu N, Jadhav V. Thoracoscopy in stage 3 empyema thoracis in children - A safe and feasible alternative to thoracotomy. J Pediatr Surg 2020; 55:756-760. [PMID: 31493886 DOI: 10.1016/j.jpedsurg.2019.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/08/2019] [Accepted: 08/07/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Even though the role of thoracoscopy is well defined in Stage 2 empyema thoracis and is very popular, its role in the management of advanced empyema is still unclear. The technical difficulties and the potential complications are the principal reasons for the hesitancy in attempting video assisted thoracoscopic surgery (VATS) in advanced stages. METHODS We prospectively studied the safety, feasibility and effectiveness of VATS for decortication in Stage 3 empyema. RESULTS In the 61 cases that we attempted VATS over the last 7 years, we could complete the procedure in 45 patients (73.77%). Four children among them required re-do procedure later for persistent problems. Conversion to thoracotomy was needed in 16 patients (26.23%). The post-operative hospital stay of patients who underwent primary VATS decortication was significantly less when compared to patients requiring conversion (p < 0.0001). CONCLUSION Thoracoscopy is a safe, feasible and effective option even in advanced empyema thoracis and should be offered in centers with adequate expertise and set up. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Ramesh Santanakrishnan
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
| | - Govindappa Saroja Murali
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India.
| | - Deepak Javaregowda
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
| | - Gowri Shankar
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
| | - Narendra Babu
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
| | - Vinay Jadhav
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
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Pleural Infection—a Growing Problem in the Elderly. CURRENT GERIATRICS REPORTS 2020. [DOI: 10.1007/s13670-020-00320-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Intrathoracic negative pressure therapy and/or endobronchial valve for pleural empyema minimal invasive management: case series of thirteen patients and review of the literature. Wideochir Inne Tech Maloinwazyjne 2020; 15:588-595. [PMID: 33294074 PMCID: PMC7687666 DOI: 10.5114/wiitm.2020.93210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/20/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction Intrathoracic negative pressure therapy is an adjunct to standard methods of complex empyema management in debilitated patients. Nevertheless, the use of endoscopic one-way endobronchial valves to successfully close large bronchopleural fistulas in patients with advanced pleural empyema has been described in only a few case reports. Aim To present our experience in managing complex pleural empyema using thoracostomy with intrathoracic negative pressure therapy and/or endobronchial valve implantation. Material and methods We retrospectively analyzed data from 13 consecutive patients (11 men, mean age: 56 years, range: 38–80 years) who were treated for pleural empyema using thoracostomy with intrathoracic negative pressure therapy and/or endobronchial valve implantation between October 2015 and November 2017. Results The control of empyema was satisfactory in 12 patients; however, 1 patient died from sepsis-related multiorgan failure despite complete cessation of air leak on day 9 after endobronchial valve implantation. The overall success rate for the final closure of the chest wall was 9/12 patients (75%): in 5 patients, the wall closed spontaneously, and in 4, the wall was closed using thoracomyoplasty. Conclusions Thoracostomy with intrathoracic negative pressure therapy, endobronchial valve implantation with tube drainage, and a combination of the two could adequately manage patients with pleural empyema with or without a persistent air leakage fistula.
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Abstract
Chest infection is a health care problem in many regions of the world, and pleural empyema is the most common type of surgical chest infection. In the past decennium, the introduction of nonintubated surgery and uniportal video-assisted thoracic surgery changed considerably surgical treatment of pleural empyema. Although the advantages seem evident, the need for randomized controlled trials is necessary to confirm the usefulness. Moreover, in the future, an education and training program for thoracic surgeons and anesthesiologists would allow increasing the number of awake surgical options in caring for patients with stages II to III empyema.
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Affiliation(s)
- Marcello Migliore
- Section of Thoracic Surgery, Department of Surgery and Medical Specialities, University of Catania, Policlinic University Hospital, Catania, Italy.
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Pilav I, Alihodzic-Pasalic A, Musanovic S, Kadic K, Dapcevic M, Custovic O. Efficacy of Video-Assisted Thoracoscopic Surgery (VATS) in the Treatment of Primary Pleural Empyema. Acta Inform Med 2020; 28:261-264. [PMID: 33627927 PMCID: PMC7879437 DOI: 10.5455/aim.2020.28.261-264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background Video-Assisted Thoracoscopic Surgery (VATS) has recently occupied a significant place in the surgical treatment of primary pleural empyema (PPE). Patients with anamnesis shorter than 4 weeks have a good chance of being cured only by VATS. As it is not easy to define precisely the beginning of the disease, it is difficult to say strictly to which period VATS method will be successful in PPE treatment. Objective The aim of this study was to determine the efficacy of the VATS method in the surgical treatment of primary pleural empyema. Methods The study included 50 patients with findings appropriate for PPE over a period of three years, in whom the VATS method was applied in the surgical treatment of pleural empyema. Results The established total length of treatment was 13.56 ± 7.98 days and the length of hospital treatment after surgery was 9.90 ± 3.315. The duration of thoracic drainage was 8.06 ± 3.005. Treatment was completed by the primary procedure without additional interventions in 94% of patients. Based on the final outcome, all patients from the clinic were discharged as cured. Conclusion The best time to indicate surgical treatment by using VATS method is history of disease in duration of four weeks Debridement or VATS decortication method is safe and efficient surgical procedure, especially in the first two stages. It is recommended to use this method as the first surgical option for patients in early stages of the disease.
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Affiliation(s)
- Ilijaz Pilav
- Clinic of Thoracic Surgery, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Alma Alihodzic-Pasalic
- Clinic of Thoracic Surgery, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Safet Musanovic
- Clinic of Thoracic Surgery, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Kenan Kadic
- Clinic of Thoracic Surgery, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Meho Dapcevic
- Clinic of Thoracic Surgery, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Orhan Custovic
- Clinic of Thoracic Surgery, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Yue F, Yang Z, Yang F, Liu Y, Zhao L, Chen Z, Gao F. Clinical observation of bronchoscopy alveolar lavage combined with thoracoscopy in the treatment of empyema in children. Medicine (Baltimore) 2019; 98:e18528. [PMID: 31876749 PMCID: PMC6946489 DOI: 10.1097/md.0000000000018528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to investigate the therapeutic effects of bronchoscopy alveolar lavage (BAL) combined with thoracoscopy in the treatment of empyema in children.Retrospectively analyzed 174 cases of pediatric empyema treated with thoracoscopy combined with BAL from January 2010 to December 2016 in our hospital. All the cases, according to admission order, were randomly divided into 2 groups, the control group (group A), which contained 89 cases, was treated with thoracoscopy; and the experimental group (group B), which contained 85 cases, was treated with BAL combined with thoracoscopy. The results of BAL treatment, the inflammatory indexes including body temperature, total leukocyte count in peripheral blood and CRP, and the therapeutic effect and prognosis including the days of antibiotic use, hospital stay, the incidence of thoracotomy and lobectomy were compared between the 2 groups.There was statistical difference in all the therapeutic indexes (P < .05).Bronchoscopy alveolar lavage combined with thoracoscopy has a higher success rate in the treatment of pediatric empyema, and is more comprehensive, safe and effective in controlling inflammation.
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Deterioration of chest wall depression causing congestive hepatopathy after an open thoracostomy window in a patient with pectus excavatum and tuberculosis empyema. Gen Thorac Cardiovasc Surg 2019; 68:1216-1219. [PMID: 31679134 DOI: 10.1007/s11748-019-01235-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
A 27-year-old man with severe pectus excavatum, dextrocardia and spinal scoliosis underwent thoracoscopic pleural decortication due to failure of 1-month medical treatment for tuberculous empyema. One month after the pleural decortication, he again underwent open thoracostomy window for repetitive pleuro-cutaneous fistula with tuberculosis empyema. He was subsequently referred to our clinic for progressive dyspnea and bilateral leg edema 4 months after the open thoracostomy window. Evaluations revealed deterioration of the chest wall depression and further compression of the inferior vena cava, which were considered an aggravation of the pectus excavatum after the open thoracostomy window. Herein, we present an extremely rare case of deterioration of chest wall depression causing congestive hepatopathy after an open thoracostomy window in a patient with pectus excavatum and tuberculosis empyema.
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Altmann ES, Crossingham I, Wilson S, Davies HR. Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst Rev 2019; 2019:CD002312. [PMID: 31684683 PMCID: PMC6819355 DOI: 10.1002/14651858.cd002312.pub4] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pleural infection, including parapneumonic effusions and thoracic empyema, may complicate lower respiratory tract infections. Standard treatment of these collections in adults involves antibiotic therapy, effective drainage of infected fluid and surgical intervention if conservative management fails. Intrapleural fibrinolytic agents such as streptokinase and alteplase have been hypothesised to improve fluid drainage in complicated parapneumonic effusions and empyema and therefore improve treatment outcomes and prevent the need for thoracic surgical intervention. Intrapleural fibrinolytic agents have been used in combination with DNase, but this is beyond the scope of this review. OBJECTIVES To assess the benefits and harms of adding intrapleural fibrinolytic therapy to standard conservative therapy (intercostal catheter drainage and antibiotic therapy) in the treatment of complicated parapneumonic effusions and empyema. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase, ClinicalTrials.gov and the World Health Organization (WHO) trials portal. We contacted trial authors for further information and requested details regarding the possibility of unpublished trials. The most recent search was conducted on 28 August 2019. SELECTION CRITERIA Parallel-group randomised controlled trials (RCTs) in adult patients with post-pneumonic empyema or complicated parapneumonic effusions (excluding tuberculous effusions) who had not had prior surgical intervention or trauma comparing an intrapleural fibrinolytic agent (streptokinase, alteplase or urokinase) versus placebo or a comparison of two fibrinolytic agents. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We contacted study authors for further information. We used odds ratios (OR) for dichotomous data and reported 95% confidence intervals (CIs). We used Cochrane's standard methodological procedures of meta-analysis. We applied the GRADE approach to summarise results and to assess the overall certainty of evidence. MAIN RESULTS We included in this review a total of 12 RCTs. Ten studies assessed fibrinolytic agents versus placebo (993 participants); one study compared streptokinase with urokinase (50 participants); and one compared alteplase versus urokinase (99 participants). The primary outcomes were death, requirement for surgical intervention, overall treatment failure and serious adverse effects. All studies were in the inpatient setting. Outcomes were measured at varying time points from hospital discharge to three months. Seven trials were at low or unclear risk of bias and two at high risk of bias due to inadequate randomisation and inappropriate study design respectively. We found no evidence of difference in overall mortality with fibrinolytic versus placebo (OR 1.16, 95% CI 0.71 to 1.91; 8 studies, 867 participants; I² = 0%; moderate certainty of evidence). We found evidence of a reduction in surgical intervention with fibrinolysis in the same studies (OR 0.37, 95% CI 0.21 to 0.68; 8 studies, 897 participants; I² = 51%; low certainty of evidence); and overall treatment failure (OR 0.16, 95% CI 0.05 to 0.58; 7 studies, 769 participants; I² = 88%; very low certainty of evidence, with evidence of significant heterogeneity). We found no clear evidence of an increase in adverse effects with intrapleural fibrinolysis, although this cannot be excluded (OR 1.28, 95% CI 0.36 to 4.57; low certainty of evidence). In a sensitivity analysis, the reduction in referrals for surgery and overall treatment failure with fibrinolysis disappeared when the analysis was confined to studies at low or unclear risk of bias. In a moderate-risk population (baseline 14% risk of death, 20% risk of surgery, 27% risk of treatment failure), intra-pleural fibrinolysis leads to 19 more deaths (36 fewer to 59 more), 115 fewer surgical interventions (150 fewer to 55 fewer) and 214 fewer overall treatment failures (252 fewer to 93 fewer) per 1000 people. A single study of streptokinase versus urokinase found no clear difference between the treatments for requirement for surgery (OR 1.00, 95% CI 0.13 to 7.72; 50 participants; low-certainty evidence). A single study of alteplase versus urokinase showed no clear difference in requirement for surgery (OR alteplase versus urokinase 0.46, 95% CI 0.04 to 5.24) but an increased rate of adverse effects, primarily bleeding, with alteplase (OR 5.61, 95% CI 1.16 to 27.11; 99 participants; low-certainty evidence). This translated into 154 (6 to 499 more) serious adverse events with alteplase compared with urokinase per 1000 people treated. AUTHORS' CONCLUSIONS In patients with complicated infective pleural effusion or empyema, intrapleural fibrinolytic therapy was associated with a reduction in the requirement for surgical intervention and overall treatment failure but with no evidence of change in mortality. Discordance between the negative largest trial of this therapy and other studies is of concern, however, as is an absence of significant effect when analysing low risk of bias trials only. The reasons for this difference are uncertain but may include publication bias. Intrapleural fibrinolytics may increase the rate of serious adverse events, but the evidence is insufficient to confirm or exclude this possibility.
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Affiliation(s)
- Emile S Altmann
- John Hunter HospitalDepartment of General MedicineNew Lambton HeightsNew South WalesAustralia
| | | | - Stephen Wilson
- East Lancashire Hospitals NHS TrustBlackburnLancashireUK
| | - Huw R Davies
- Southern Adelaide Local Health Network (SALHN)Respiratory and Sleep ServicesBedford ParkSouth AustraliaAustralia5041
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Tsai YM, Gamper N, Huang TW, Lee SC, Chang H. Predictors and Clinical Outcomes in Empyema Thoracis Patients Presenting to the Emergency Department Undergoing Video-Assisted Thoracoscopic Surgery. J Clin Med 2019; 8:jcm8101612. [PMID: 31623408 PMCID: PMC6832114 DOI: 10.3390/jcm8101612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/23/2019] [Accepted: 09/25/2019] [Indexed: 01/27/2023] Open
Abstract
Background: Video-assisted thoracoscopic surgery (VATS) is widely used for the treatment of empyema. We evaluated clinical symptoms, laboratory examinations, and thoracentesis to assess patients in the emergency department (ED) with empyema thoracis, undergoing VATS to identify predictors of adverse outcomes. Methods: This retrospective study was conducted by reviewing records of ED patients with pleural empyema admitted for VATS from January 2007 to June 2014. Demographic data, clinical symptoms, and laboratory examinations were compared for survivors (Group I) and non-survivors (Group II). Logistic regression analysis was used to identify parameters related to postoperative mortality. Results: From 380 patients, 7.6% (n = 29) died postoperatively. Survivors and non-survivors exhibited differences in age, gender, presence of cough, dyspnea, chest pain, empyema stage, cerebrovascular disease, malignancy, the glucose level of pleural fluid, serum hemoglobin, platelet count, blood urea nitrogen, and potassium levels. The logistic analysis demonstrated that the most significant factor related to the postoperative morbidity is chest pain (p = 0.018). Conclusions: VATS could be a safe option for pediatric and geriatric patients. Age does not appear to affect postoperative mortality. A high degree of awareness is essential for perioperative management and early surgical treatment when ED patients present with the clinical symptom of chest pain.
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Affiliation(s)
- Yuan-Ming Tsai
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Taipei 114, Taiwan; (Y.-M.T.)
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS2 9JT, UK;
| | - Nikita Gamper
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS2 9JT, UK;
| | - Tsai-Wang Huang
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Taipei 114, Taiwan; (Y.-M.T.)
| | - Shih-Chun Lee
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Taipei 114, Taiwan; (Y.-M.T.)
| | - Hung Chang
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Taipei 114, Taiwan; (Y.-M.T.)
- Correspondence:
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Ohki T, Shigematsu Y, Hatooka S. Group B streptococcal empyema necessitatis with pleural fistula after blunt trauma: A case report. Int J Surg Case Rep 2019; 63:44-47. [PMID: 31563057 PMCID: PMC6796706 DOI: 10.1016/j.ijscr.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 09/04/2019] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION We report the first case of empyema necessitatis (EN) with pleural fistula and septic arthritis caused by Streptococcus agalactiae following blunt trauma. PRESENTATION OF THE CASE A 46-year-old man with diabetes mellitus and a history of recent right rib fracture and right knee bruising presented with dyspnea and right knee pain. He was diagnosed with EN and underwent chest drainage, followed by open-window thoracotomy. Septic arthritis occurred on day 8 after thoracotomy. The chest wall wound healed after 3 months. DISCUSSION EN is a rare complication of empyema. In this patient, infection was invasive, causing necrotizing pneumonia with a pleural fistula. To our knowledge, there are no reports of group B streptococcal EN with a pleural fistula resulting from blunt chest trauma. CONCLUSION Group B streptococcal infection might become invasive in immunocompromised patients, so careful follow-up for those patients is important.
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Affiliation(s)
- Takashi Ohki
- Department of Respiratory Surgery, Ichinomiya-Nishi Hospital, 1 Kaimei Hira, Ichinomiya-shi, Aichi, Japan.
| | - Yoshiki Shigematsu
- Department of Respiratory Surgery, Ichinomiya-Nishi Hospital, 1 Kaimei Hira, Ichinomiya-shi, Aichi, Japan.
| | - Shunzo Hatooka
- Department of Respiratory Surgery, Ichinomiya-Nishi Hospital, 1 Kaimei Hira, Ichinomiya-shi, Aichi, Japan.
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67
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Yeung C, Dawson J, Gilbert S. Uniportal video-assisted thoracoscopy approach to the management of non-pulmonary diseases of the chest. J Thorac Dis 2019; 11:S2062-S2068. [PMID: 31637039 DOI: 10.21037/jtd.2019.03.21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The use of uniportal video-assisted thoracoscopy (u-VATS) is becoming a commonly used surgical technique and can be an effective approach for the surgical treatment of many pulmonary and non-pulmonary conditions. This review article summarizes current medical evidence informing the practice of u-VATS for treating non-pulmonary conditions including hyperhidrosis, hemothorax, pleural effusion, and thymic disease.
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Affiliation(s)
- Ching Yeung
- The Ottawa Hospital Research Institute, University of Ottawa, The Ottawa Hospital - General Campus, Ottawa, ON, Canada.,Faculty of Medicine, Department of Surgery, University of Ottawa, The Ottawa Hospital - General Campus, Ottawa, ON, Canada
| | - Jennifer Dawson
- The Ottawa Hospital Research Institute, University of Ottawa, The Ottawa Hospital - General Campus, Ottawa, ON, Canada
| | - Sebastien Gilbert
- The Ottawa Hospital Research Institute, University of Ottawa, The Ottawa Hospital - General Campus, Ottawa, ON, Canada.,Faculty of Medicine, Department of Surgery, University of Ottawa, The Ottawa Hospital - General Campus, Ottawa, ON, Canada
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68
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Yeap E, Nataraja RM, Roseby R, McCullagh A, Pacilli M. Factors Affecting Outcome Following Video-Assisted Thoracoscopic Surgery for Empyema in Children: Experience from a Large Tertiary Referring Centre. J Laparoendosc Adv Surg Tech A 2019; 29:1276-1280. [PMID: 31381468 DOI: 10.1089/lap.2019.0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: We report the results of video-assisted thoracoscopic surgery (VATS) in a large population of children with empyema, focusing on the factors affecting the postoperative length of stay (LOS). Materials and Methods: After ethical approval (RES-18-0000-071Q), a retrospective review was performed (2013-2018). Results are reported as number of cases (%) and median (range) and analyzed by Mann-Whitney U and Kruskal-Wallis tests. Correlation analysis was conducted. Results: We identified 159 children with empyema; 75 [42 (56%) males] underwent VATS. Median age was 3.6 (0.4-14.5) years. Presentation was: autumn 15 (20%), winter 26 (35%), spring 18 (24%), summer 16 (21%) with no difference in LOS (P = .6). Preoperative symptoms duration was 7 (2-28) days. Postoperatively, chest drain was on suction in 30 (40%) patients, in situ for 3 (2-13) days. Six (8%) children required further procedures. LOS was 8 (3-47) days. Pleural fluid revealed: Streptococcus species. 41 (55%), other species 8 (11%), no bacteria 26 (34%); LOS was longer with positive pleural fluid: 9 (4-47) versus 6.5 (3-16) days (P = .02). There was no correlation between the LOS and preoperative symptoms duration (r = -0.03 [95% CI -0.3 to 0.2]; P = .7), empyema size (r = 0.2 [95% CI -0.07 to 0.5]; P = .1) and chest drain size (r = 0.09 [95% CI -0.14 to 0.3]; P = .4). Discussion: In our experience, >90% of children with empyema will be treated with a single VATS with an average LOS of 8 days. Positive microbiology culture significantly affects the LOS.
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Affiliation(s)
- Evie Yeap
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Ramesh Mark Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, School of Clinical Sciences at Monash Health, Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Robert Roseby
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Angela McCullagh
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, School of Clinical Sciences at Monash Health, Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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69
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Sokouti M, Sadeghi R, Pashazadeh S, Abadi SEH, Sokouti M, Ghojazadeh M, Sokouti B. Treating empyema thoracis using video-assisted thoracoscopic surgery and open decortication procedures: a systematic review and meta-analysis by meta-mums tool. Arch Med Sci 2019; 15:912-935. [PMID: 31360187 PMCID: PMC6657246 DOI: 10.5114/aoms.2018.77723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/11/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The optimal treatment of empyema thoracis is still debatable between academics and surgeons. This study reviews advantages and disadvantages of video-assisted thoracoscopic surgery (VATS) and open thoracotomy decortication (OTD) considering outcomes of empyema thoracis. MATERIALS AND METHODS A descriptive Boolean query was used for searching three databases to extract the published studies up to 27 March 2017. The outcomes of VATS and OTD were extracted and assessed by random-effects model of meta-analysis. The Egger's test and trim-and-fill method were used for analyzing publication bias, and, meta-regression and subgroup analyses were done for determining heterogeneity. RESULTS A total of 2219 patients, from 13 studies, meeting the inclusion criteria were selected and subjected to further analyses. Of 2219 patients, 1120 were treated by VATS and the remaining were subjected to OTD. During VATS, 252 patients were converted to OTD. Forest plots showed that VATS was far superior in terms of incidence of duration of hospital stay and operative time (SMDs = 1.189, 1.565; p < 0.001, < 0.001) compared to OTD. Mortality, prolonged air leakage, wound infection, and recurrence rates (ORs = 1.234, 2.564, 1.363, 1.962; p = 0.576, 0.077, 0.0692, 0.4) had no advantages for both procedures while failure or conversion rate (OR = 0.198, p < 0.001) of VATS was more than those of OTD. CONCLUSIONS The results of the current research suggest no trends of superior outcomes with VATS in the treatment of empyema thoracis. Hence, VATS and OTD could be recommended as treatments for empyema thoracis.
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Affiliation(s)
- Massoud Sokouti
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ramin Sadeghi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeid Pashazadeh
- Department of Computer and Electrical Engineering, University of Tabriz, Tabriz, Iran
| | - Saeed Eslami Hasan Abadi
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Sokouti
- Department of Cardiothoracic Surgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Ghojazadeh
- Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Sokouti
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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70
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Abstract
Pleural effusions are a common clinical problem for the primary care physician. Over the past 10 years, there has been a paradigm shift in the field due to emergence of new evidence, which includes the ubiquitous use of thoracic ultrasound, the reemergence of pleuroscopy as a diagnostic and therapeutic modality, the widespread use of indwelling pleural catheters for malignant pleural effusions, and the evidence-based approach to management of complex parapneumonic effusions. This review focuses on these advancements with an emphasis on practical clinical application.
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Affiliation(s)
- Matthew Aboudara
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, The Vanderbilt Clinic, 1301 Medical Center Drive, B-817 The Vanderbilt Clinic, Nashville, TN 37232-5735, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, The Vanderbilt Clinic, 1301 Medical Center Drive, B-817 The Vanderbilt Clinic, Nashville, TN 37232-5735, USA.
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71
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Froudarakis ME. Thematic series: Novel insights in pleural diseases: Pleural disease: A continuously improved information. THE CLINICAL RESPIRATORY JOURNAL 2019; 13:269-271. [PMID: 30953578 DOI: 10.1111/crj.13029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Marios E Froudarakis
- Department of Pneumonology and Thoracic Oncology, North Hospital, University Hospital of Saint-Etienne, Saint-Etienne, France
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72
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Management of paediatric empyema by video-assisted thoracoscopic surgery (VATS) versus chest drain with fibrinolysis: Systematic review and meta-analysis. Paediatr Respir Rev 2019; 30:42-48. [PMID: 31130425 DOI: 10.1016/j.prrv.2018.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/05/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The ideal surgical approach for empyema in children (≤18 years) remains controversial. Video assisted thoracoscopic surgery (VATS) and chest drain with fibrinolysis (CDF) are both accepted methods. The aim of this study was to clarify which of these two techniques provides the best clinical outcome. METHODS A systematic review and meta-analysis (1997-2018) was conducted. We used the random-effect model to produce risk ratio (RR) for categorical variables, and standard difference in means (SDM) for continuous variables, along with 95% confidence intervals [CI]. I2 value was used to assess heterogeneity. P values <0.05 were considered significant. RESULTS We identified 707 studies: 10 studies were included in the final analysis. The incidence of total peri-operative complications was not different between the two groups (RR 0.6 [CI: 0.3-1.2], p = 0.2; I2 = 0.0%; p = 0.6). Need for re-intervention was significantly lower in the VATS group (RR 0.55 [CI: 0.34-0.88], p = 0.01; I2 = 14.4%; p = 0.3). Post-operative length of hospital stay was significantly shorter in the VATS group (SDM -0.45 [CI: -0.78 to -0.12], p = 0.007; I2 = 88%; p = 0.001). CONCLUSIONS Current evidence suggests that VATS and CDF for empyema in children have a similar incidence of peri-operative complications. However, VATS seems associated with reduced need for re-intervention and shorter post-operative hospital stay.
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73
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Towe CW, Carr SR, Donahue JM, Burrows WM, Perry Y, Kim S, Kosinski A, Linden PA. Morbidity and 30-day mortality after decortication for parapneumonic empyema and pleural effusion among patients in the Society of Thoracic Surgeons' General Thoracic Surgery Database. J Thorac Cardiovasc Surg 2019; 157:1288-1297.e4. [DOI: 10.1016/j.jtcvs.2018.10.157] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/03/2018] [Accepted: 10/12/2018] [Indexed: 10/27/2022]
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Affiliation(s)
- Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Giessen, Germany
| | - Johannes Bodner
- Department of Thoracic Surgery, Klinikum Bogenhausen, Munich, Germany.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Innsbruck, Austria
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75
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Bedawi EO, Hassan M, Rahman NM. Recent developments in the management of pleural infection: A comprehensive review. CLINICAL RESPIRATORY JOURNAL 2018; 12:2309-2320. [PMID: 30005142 DOI: 10.1111/crj.12941] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data regarding the epidemiology, microbiology, and the management of pleural infection. DATA SOURCE Medline was searched for articles related to pleural infection using the terms "pleural infection," "empyema," and "parapneumonic." The search was limited to the years 1997-2017. Only human studies and reports in English were included. RESULTS A rise in the incidence of pleural infection is seen worldwide. Despite the improvement in healthcare practices, the mortality from pleural infection remains high. The role of oral microflora in the etiology of pleural infection is firmly established. A concise review of the recent insights on the pathogenesis of pleural infections is presented. A particular focus is made on the role of tPA, DNAse and similar substances and their interaction with inflammatory cells and how this affects the pathogenesis and treatment of pleural infection. CONCLUSION Pleural infection is a common disease with significant morbidity and mortality, as well as a considerable economic burden. The role of medical management is expanding thanks to the widespread use of newer treatments.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom.,Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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76
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Abstract
The widely accepted and still increasing use of video-assisted thoracic surgery (VATS) in pleuro-pulmonary pathology imposes the need to deal with two major pitfalls: the first is to avoid its unselective use, while the second relates to inappropriate rejection of VATS on the basis of "insufficient radicality". Unlike a quite established role of VATS in lung cancer patients, in patients with pleural empyema, the role of VATS is less clearly defined. The current evidence about VATS in patients with pleural empyema could be summarised as follows: VATS is accepted as a useful treatment option for fibrinopurulent empyema, but the treatment failure rate increases with the increasing proportion of stage III empyema, necessitating further surgical options like thoracotomy and decortication. As both pulmonologists and surgeons deal with diagnosis and treatment of pleural empyema, this article is an attempt to highlight the existing evidence in a more user-friendly way in order to help practising physicians to optimise the use of VATS in these patients. In other words, in the absence of randomised studies comparing VATS and thoracotomy, the key question to be answered is: are there any pre-operative findings that can be used to select patients for initial VATS versus proceeding directly to a thoracotomy?
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Affiliation(s)
- Dragan Subotic
- Clinic for Thoracic Surgery, University Hospital Basel, Basel, Switzerland
| | - Didier Lardinois
- Clinic for Thoracic Surgery, University Hospital Basel, Basel, Switzerland
| | - Aljaz Hojski
- Clinic for Thoracic Surgery, University Hospital Basel, Basel, Switzerland
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77
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Saha SP, Rodgers-Fischl P. Editorial on "current state of empyema management". J Thorac Dis 2018; 10:S3271-S3273. [PMID: 30430030 DOI: 10.21037/jtd.2018.08.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sibu P Saha
- Division of Cardiothoracic Surgery, University of Kentucky, Lexington, KY, USA
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Ismail M, Nachira D, Meacci E, Ferretti GM, Swierzy M, Englisch JP, Ossami Saidy RR, Faber S, Congedo MT, Chiappetta M, Petracca Ciavarella L, Margaritora S, Rueckert JC. Uniportal video-assisted thoracic surgery in the treatment of pleural empyema. J Thorac Dis 2018; 10:S3696-S3703. [PMID: 30505554 DOI: 10.21037/jtd.2018.05.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The efficacy of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has recently been proven. Till today, very few works evaluated the role of uniportal-VATS (U-VATS) approach in the treatment of pleural empyema even if it currently represents the most innovative and less invasive thoracoscopic approach. We report our experience with U-VATS in the treatment of pleural empyema. Methods A retrospective bicentric analysis of 35 consecutive patients who underwent surgical treatment of stage II and stage III pleural empyema was performed, from January 2015 to May 2017. Results The mean age of patients was 57.26±18.29 years and 54.3% of them were males. In 85.7% of the cases, empyema was related to a complicated parapneumonic effusion; in only 5 cases it was a post-surgical consequence. All patients were treated with broad-spectrum antibiotics and subsequent target therapy for 14.62±21.76 days prior to operation and 23 patients needed the placement of a chest tube. Twenty patients (57.1%) presented with stage III, 11 patients (31.4%) stage II and 4 patients (11.4%) stage I empyema. Complete debridement and decortication were obtained in all patients through U-VATS approach and no conversion or further access was needed for any reason. No major complication was recorded. Only 2 cases of trapped lung were not responsive to surgical treatment. At a mean follow-up of 247.42±306.29 days, 33 patients (94.3%) were alive with no recurrence, 2 patients died for causes unrelated to the operation. Conclusions According to our experience, we consider U-VATS as an adequate procedure in the treatment of "stages II and III" empyemas when the necessary surgical expertise has been achieved. Indeed, U-VATS permits an easier performance and complete debridement and decortication, with a very low risk for conversion and excellent postoperative outcomes in terms of less pain, fast recovery and cosmetic results.
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Affiliation(s)
- Mahmoud Ismail
- Competence Center of Thoracic Surgery, Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dania Nachira
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy
| | - Elisa Meacci
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy
| | - Gian Maria Ferretti
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy
| | - Marc Swierzy
- Competence Center of Thoracic Surgery, Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julianna Paulina Englisch
- Competence Center of Thoracic Surgery, Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ramin Raul Ossami Saidy
- Competence Center of Thoracic Surgery, Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Svea Faber
- Competence Center of Thoracic Surgery, Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maria Teresa Congedo
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy
| | - Marco Chiappetta
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy
| | | | - Stefano Margaritora
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario "A. Gemelli", Rome, Italy
| | - Jens C Rueckert
- Competence Center of Thoracic Surgery, Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Bedawi EO, Yarmus L, Rahman NM. The ongoing struggle with empyema management: is surgery really the answer? J Thorac Dis 2018; 10:S4122-S4125. [PMID: 30631571 DOI: 10.21037/jtd.2018.10.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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80
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Makdisi T, Makdisi G. Contemporary surgical management of thoracic empyema. J Thorac Dis 2018; 10:S3069-S3070. [PMID: 30370082 DOI: 10.21037/jtd.2018.08.55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tony Makdisi
- Internal Medicine Department, Berkshire Medical Center, University of Massachusetts Medical School, Pittsfield, Massachusetts, USA
| | - George Makdisi
- Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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81
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Reichert M, Pösentrup B, Hecker A, Padberg W, Bodner J. Lung decortication in phase III pleural empyema by video-assisted thoracoscopic surgery (VATS)-results of a learning curve study. J Thorac Dis 2018; 10:4311-4320. [PMID: 30174878 DOI: 10.21037/jtd.2018.06.72] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Pleural empyema (PE) is a devastating disease with a high morbidity and mortality. According to the American Thoracic Society it is graduated into three phases and surgery is indicated in intermediate phase II and organized phase III. In the latter, open decortication of the lung via thoracotomy is the gold standard whereas the evidence for feasibility and safety of a minimally-invasive video-assisted thoracoscopic approach is still poor. Methods Retrospective single-center analysis of patients undergoing surgery for phase III PE from 02/2011 to 03/2015 [n=138, including n=130 VATS approach (n=3 of them with bilateral disease) and n=8 open approach]. The learning curve was assessed by grouping those 127 patients with unilateral disease who underwent a video-assisted thoracoscopic approach into two groups: VATS-1 (03/2011 to 06/2012, n=43) and VATS-2 (06/2012 to 03/2015, n=84). Results ASA-scores (P=0.0279) and rate of pre-operative drainage therapy (P=0.0534) were higher in VATS-2 patients. Operating times were longer in VATS-1 (P=0.0308), intra-operative complication as well as conversion to open surgery rates did both not differ. Rates of post-operative vasoconstrictive therapy (P=0.0191) and prolonged mechanical ventilation (P=0.0560) were both higher in VATS-2, however, post-operative length of stay (LOS) at intensive care unit, overall post-operative LOS and post-operative complication rate were similar in both groups. Conclusions Video-assisted thoracoscopic surgery is feasible for evacuation and decortication in late phase III PE. A learning curve of approximately 40 cases is sufficient to gain procedure-specific surgical skills and thus reduce the operating times sufficiently.
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Affiliation(s)
- Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Giessen, Germany
| | - Bernd Pösentrup
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Giessen, Germany
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Giessen, Germany
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Giessen, Germany
| | - Johannes Bodner
- Department of Thoracic Surgery, Klinikum Bogenhausen, Munich, Germany.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Innsbruck, Austria
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82
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Mariani AW, Lisboa JBRM, Rodrigues GDA, Avila EM, Terra RM, Pêgo-Fernandes PM. Mini-thoracostomy with vacuum-assisted closure: a minimally invasive alternative to open-window thoracostomy. J Bras Pneumol 2018; 44:S1806-37132018005002103. [PMID: 29947716 PMCID: PMC6188697 DOI: 10.1590/s1806-37562017000000167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 10/30/2017] [Indexed: 11/22/2022] Open
Abstract
Thoracostomy is a common treatment option for patients with stage III pleural empyema who do not tolerate pulmonary decortication. However, thoracostomy is considered mutilating because it involves a thoracic stoma, the closure of which can take years or require further surgery. A new, minimally invasive technique that uses the vacuum-assisted closure has been proposed as an alternative to thoracostomy. This study aims to analyze the safety and effectiveness of mini-thoracostomy with vacuum-assisted closure in an initial sample of patients.
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Affiliation(s)
- Alessandro Wasum Mariani
- . Disciplina de Cirurgia Torácica, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | | | - Ester Moraes Avila
- . Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Ricardo Mingarini Terra
- . Disciplina de Cirurgia Torácica, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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83
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Price K, Hall J, Nicou N, Hardavella G. An interesting case of recurrent shortness of breath and pleuritic chest pain. Breathe (Sheff) 2018; 14:123-130. [PMID: 29875831 PMCID: PMC5980474 DOI: 10.1183/20734735.012118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 58-year-old male presented to the emergency department in August 2015 with sudden-onset shortness of breath associated with sharp right-sided pleuritic chest pain. His only past medical history was of hypertension. Prior to this presentation he had been clinically well and was fully independent. He was a smoker with a 40 pack-year history. He did not drink alcohol and had no recent travel history. Can you diagnose this case of a 58-year-old male with sudden-onset shortness of breath associated with sharp right-sided pleuritic chest pain?http://ow.ly/HLmk30j4DEH
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Affiliation(s)
- Kathryn Price
- Dept of Respiratory Medicine, King's College Hospital, London, UK
| | - Jocelin Hall
- Dept of Respiratory Medicine, King's College Hospital, London, UK
| | - Niki Nicou
- Dept of Thoracic Surgery, King's College Hospital, London, UK
| | - Georgia Hardavella
- Dept of Respiratory Medicine, King's College Hospital, London, UK.,Dept of Respiratory Medicine and Allergy, King's College London, London, UK
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84
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Knebel R, Fraga JC, Amantea SL, Isolan PBS. Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion. J Pediatr (Rio J) 2018; 94:140-145. [PMID: 28837796 DOI: 10.1016/j.jped.2017.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/11/2017] [Accepted: 03/06/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To evaluate the effectiveness of videothoracoscopic surgery in the treatment of complicated parapneumonic pleural effusion and to determine whether there is a difference in the videothoracoscopic surgery outcome before or after the chest tube drainage. METHODS The medical records of 79 children (mean age 35 months) undergoing videothoracoscopic surgery from January 2000 to December 2011 were retrospectively reviewed. The same treatment algorithm was used in the management of all patients. Patients were divided into two groups: in group 1, videothoracoscopic surgery was performed as the initial procedure; in group 2, videothoracoscopic surgery was performed after previous chest tube drainage. RESULTS Videothoracoscopic surgery was effective in 73 children (92.4%); the other six (7.6%) needed another procedure. Sixty patients (75.9%) were submitted directly to videothoracoscopic surgery (group 1) and 19 (24%) primarily underwent chest tube drainage (group 2). Primary videothoracoscopic surgery was associated with a decrease of hospital stay (p=0.05), time to resolution (p=0.024), and time with a chest tube (p<0.001). However, there was no difference between the groups regarding the time until fever resolution, time with a chest tube, and the hospital stay after videothoracoscopic surgery. No differences were observed between groups regarding the need for further surgery and the presence of complications. CONCLUSIONS Videothoracoscopic surgery is a highly effective procedure for treating children with complicated parapneumonic pleural effusion. When videothoracoscopic surgery is indicated in the presence of loculations (stage II or fibrinopurulent), no difference were observed in time of clinical improvement and hospital stay among the patients with or without chest tube drainage before videothoracoscopic surgery.
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Affiliation(s)
- Rogerio Knebel
- Universidade Federal de Santa Maria (UFSM), Hospital Universitário de Santa Maria (HUSM), Santa Maria, RS, Brazil.
| | - Jose Carlos Fraga
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Departamento de Cirurgia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Sergio Luis Amantea
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil; Hospital Santo Antônio de Porto Alegre, Porto Alegre, RS, Brazil
| | - Paola Brolin Santis Isolan
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Departamento de Cirurgia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
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85
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Knebel R, Fraga JC, Amantéa SL, Isolan PBS. Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2018. [DOI: 10.1016/j.jpedp.2017.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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86
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Affiliation(s)
- David Feller-Kopman
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Johns Hopkins University, Baltimore (D.F.-K.); and the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville (R.L.)
| | - Richard Light
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Johns Hopkins University, Baltimore (D.F.-K.); and the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville (R.L.)
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87
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Reichert M, Pösentrup B, Hecker A, Schneck E, Pons-Kühnemann J, Augustin F, Padberg W, Öfner D, Bodner J. Thoracotomy versus video-assisted thoracoscopic surgery (VATS) in stage III empyema-an analysis of 217 consecutive patients. Surg Endosc 2017; 32:2664-2675. [PMID: 29218675 DOI: 10.1007/s00464-017-5961-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 10/23/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pleural empyema is an infectious disease of the chest cavity, with a high morbidity and mortality. According to the American Thoracic Society, pleural empyema gets graduated into three stages, with surgery being indicated in intermediate stage II and chronic stage III. Evidence for the feasibility of a minimally-invasive video-assisted thoracoscopic approach in stage III empyema for pulmonary decortication is still little. METHODS Retrospective single-center analysis of patients conducted to surgery for chronic stage III pleural empyema from 05/2002 to 04/2014 either by video-assisted thoracoscopic surgery (VATS, n = 110) or conventional open surgery by thoracotomy (n = 107). Multiple regression analysis and propensity score matching was used to evaluate the influence of operation technique (thoracotomy versus VATS) on the length of post-operative hospitalization. RESULTS Operation time was longer in the thoracotomy-group (p = 0.0207). Conversion rate from VATS to open surgery by thoracotomy was 4.5%. Post-operative complication- (61 patients in thoracotomy- and 55 patients in VATS-group), recurrence- (3 patients in thoracotomy- and 5 in VATS-group) and mortality-rates (6.5% in thoracotomy- and 9.5% in VATS-group) did not differ between both groups; the length of (post-operative) stay at intensive care unit was longer in the VATS-group (p = 0.0023). Duration of chest tube drainage and prolonged air leak rate were similar among both groups, leading to a similar overall and post-operative length of hospital stay in both groups. Adjusted to clinically and statistically relevant confounders, multiple regression analysis showed an influence of the surgical technique on length of post-operative stay after pair matching of the patients (n = 84 in each group) by propensity score (B = - 0.179 for thoracotomy = 0 and VATS = 1, p = 0.032) leading to a reduction of 0.836 days after a VATS-approach compared to thoracotomy. CONCLUSIONS VATS in late stage (III) pleural empyema is feasible and safe. The decrease in post-operative hospitalization demonstrated by adjusted multiple regression analysis may indicate the minimally-invasive approach being safe, more tolerable for patients, and more effective.
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Affiliation(s)
- Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35392, Giessen, Germany.
| | - Bernd Pösentrup
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35392, Giessen, Germany
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35392, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35392, Giessen, Germany
| | - Jörn Pons-Kühnemann
- Medical Statistics, Institute of Medical Informatics, Justus-Liebig-University of Giessen, Rudolf-Buchheim Strasse 6, 35392, Giessen, Germany
| | - Florian Augustin
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35392, Giessen, Germany
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Johannes Bodner
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35392, Giessen, Germany.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Anichstrasse 35, Innsbruck, 6020, Austria.,Department of Thoracic Surgery, Klinikum Bogenhausen, Englschalkinger Strasse 77, 81925, Munich, Germany
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88
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Khan JA, Lehtomäki AI, Toikkanen VJ, Ukkonen MT, Nevalainen RM, Laurikka JO. Long-Term Prognosis and Causes of Death After Pleural Infections. Scand J Surg 2017; 107:145-151. [PMID: 29121816 DOI: 10.1177/1457496917738868] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS The development of pleural infection may imply a worse state of health and prognosis. The objective of this study was to ascertain the long-term survival and causes of death after pleural infections and to compare them to those of matched controls. MATERIAL AND METHODS Altogether 191 patients treated for pleural infections at a single University Hospital between January 2000 and December 2008 and 1910 age- and gender-matched controls were included. Survival data and the causes of death for non-survivors were obtained from national databases and compared between the groups. RESULTS The etiology of pleural infection was pulmonary infection in 70%, procedural complication in 9%, trauma in 5%, malignancy in 4%, other in 7%, and unknown in 5% of patients. The course of treatment was surgical in 82%, drainage only in 12%, and conservative in 5% of included patients. The median follow-up time was 11 years. Mortality rates were 8.4% versus 0.8% during the first 90 days, p < 0.001, and 46.6% versus 24.5% overall, p < 0.001, in patients and controls, respectively. Mortality was significantly higher in patients with pulmonary infection, procedural complication, or malignancy as the etiology of pleural infection. In multivariable analysis, advanced age, previous malignancies, institutional care, alcoholism, and malignant etiology for the infection were associated with inferior survival. Deaths caused by malignancies, respiratory diseases, and digestive diseases were significantly more common in patients than in controls. CONCLUSION Long-term survival in patients with pleural infections is significantly inferior to that of age and gender-matched controls.
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Affiliation(s)
- J A Khan
- 1 Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - A I Lehtomäki
- 1 Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - V J Toikkanen
- 1 Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - M T Ukkonen
- 2 Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - R M Nevalainen
- 3 Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - J O Laurikka
- 1 Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland.,4 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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89
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Sokouti M, Ghojazadeh M, Sokouti M, Sokouti B. Surgical and nonsurgical outcomes for treating a cohort of empyema thoracis patients: A monocenteric retrospective cohort study. Ann Med Surg (Lond) 2017; 24:19-24. [PMID: 29062481 PMCID: PMC5647471 DOI: 10.1016/j.amsu.2017.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/06/2017] [Accepted: 10/06/2017] [Indexed: 12/14/2022] Open
Abstract
Background There are several studies reporting high success rates for surgical and nonsurgical treatments of empyema separately. The aim of current retrospective cohort study is to find the best treatment in low socio-economic areas. Material and methods A total of 149 patients were treated in the referring hospital from January 2002 to December 2008. The current retrospective cohort study was carried out by nonsurgical (medically & thoracenthesis & chest tube drainage with or without fibrinolytic agents) and surgical (VATS &open thoracotomy decortication methods) procedures in single center performed in thoracic and respiratory medicine wards. The independent t-test on demographic data was the statistical test tool. Results The complete cure and mortality rates for 130 patients were 27% (35 out of 130 patients) and 0.3% (1 out of 130 patients), respectively. Thirteen out of 149 patients that were estimated to be at stage II underwent VATS decortication. The results showed zero success rates for this procedure which was then converted to open thoracotomy decortication. And, 113 patients who underwent thoracotomy decortication had a cure rate of 96.4% (109 patients) and mortality rate of 1.8% (2 patients). Four (3.5%) patients needed thoracoplasty, 2 died and 2 (1.8%) needed open window thoracostomy resulted in empyema necessitans that remained uncured. Total hospitalization lengths for the patients treated by tube thoracostomy and thoracotomy decortication were (15.4 ± 2.1) and (6.2 ± 1.8) days (P < 0.001), respectively. The success rates between surgical and nonsurgical treatments were 98.2% and 27.1%. And, the difference between them was significant (P < 0.001). Conclusion Because of the advanced stages of empyema in our patients, thoracotomy decortication procedure is often the first rank choice with success rates higher than nonsurgical techniques. However, nowadays, the success rates of nonsurgical and VATS management of empyema thoracis are mostly reported in the literature. Outcomes of surgical and nonsurgical management for treating empyema thoracis patients were presented based on STROCSS criteria. Due to advanced stages of empyema in low socioendemic areas, thoracotomy decortication procedure proposed higher success rates. Success and cure rates, and hospitalization time showed significant differences between surgical and nonsurgical procedures.
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Affiliation(s)
- Mohsen Sokouti
- Department of Cardiothoracic Surgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Ghojazadeh
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Massoud Sokouti
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Babak Sokouti
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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90
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Bongiolatti S, Voltolini L, Borgianni S, Borrelli R, Tancredi G, Viggiano D, Gonfiotti A. Uniportal thoracoscopic decortication for pleural empyema and the role of ultrasonographic preoperative staging. Interact Cardiovasc Thorac Surg 2017; 24:560-566. [PMID: 28108575 DOI: 10.1093/icvts/ivw423] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 11/29/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives The surgical approach to chronic pleural empyema is still controversial. Video-assisted thoracic surgery (VATS) debridement and decortication has shown favourable outcomes, while the uniportal VATS (U-VATS) approach is still anecdotal. We report our experience with ultrasonographic (US) preoperative staging followed by U-VATS decortication for pleural empyema. Methods We performed a retrospective analysis of patients who underwent surgical treatment of stage II and stage III pleural empyema from 2012 to 2015. Pre-, intra- and postoperative data were investigated to evaluate outcomes including postoperative complications and disease recurrence. Results were analysed according to preoperative US appearance of pleural space (stages A-E) and surgical approach (thoracotomy vs U-VATS). Results We performed 30 (47%) uniportal thoracoscopic pleural decortication and 34 (53%) open decortication for empyema in stage II (40%) or III (60%) obtaining a complete debridement and decortication in all patients. In-hospital mortality was zero and overall morbidity was 29%. U-VATS was associated with lower blood loss (118 ± 80 ml vs 247 ± 140 ml P < 0.001), lower chest tubes duration (5.6 ± 1.4 vs 10.6 ± 4.4 days P < 0.001), shorter hospital stay (6.7 ± 1.9 vs 12.2 ± 4.7 days, P < 0.001) and lower complications (10% vs 16%, P < 0.001). Elevated US patterns (D-E) are associated with thoracotomy, higher blood loss, operative time and a significant incidence of complications. Conclusions Uniportal thoracoscopic decortication for pleural empyema is a safe and effective approach for selected patients based on a combination of clinical and imaging staging. US patterns well corresponded with intraoperative pleural findings and showed a prognostic value.
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Affiliation(s)
| | - Luca Voltolini
- Thoracic Surgery Unit, University Hospital Careggi, Florence, Italy
| | - Sara Borgianni
- Thoracic Surgery Unit, University Hospital Careggi, Florence, Italy
| | - Roberto Borrelli
- Thoracic Surgery Unit, University Hospital Careggi, Florence, Italy
| | - Giorgia Tancredi
- Thoracic Surgery Unit, University Hospital Careggi, Florence, Italy
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91
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Krantz AM, Ratnaraj F, Velagapudi M, Krishnan M, Gujjula NR, Foral PA, Preheim L. Streptococcus Gordonii Empyema: A Case Report and Review of Empyema. Cureus 2017; 9:e1159. [PMID: 28507831 PMCID: PMC5429153 DOI: 10.7759/cureus.1159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Streptococcus gordonii (S. gordonii) is a pioneer oral bacteria that is recognized as an agent of bacterial endocarditis. However, an extensive review of the literature revealed no reported case of S. gordonii causing empyema. We present a case of a 65-year-old male who presented with respiratory distress. Physical examination revealed several dental caries with decreased breath sounds in the bibasilar regions. A computed tomography (CT) scan of the chest and abdomen demonstrated left-sided pleural effusion and a 4.3 cm x 2.8 cm splenic abscess. He received intravenous (IV) antibiotics, and his blood cultures remained negative. Drainage of the splenic abscess grew S. gordonii. A CT-guided thoracentesis yielded 450 ml of exudative fluid. Pleural fluid cultures grew S. gordonii. A CT scan of the head and neck ruled out an intra-oral abscess. He received six weeks of IV penicillin with a follow-up CT scan showing resolution of both the splenic abscess and the left parapneumonic effusion.
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Affiliation(s)
| | | | | | | | | | - Pamela A Foral
- Internal Medicine, Creighton University School of Pharmacy and Health Professions
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92
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Urso B, Michaels S. Differentiation of Lung Cancer, Empyema, and Abscess Through the Investigation of a Dry Cough. Cureus 2016; 8:e896. [PMID: 28018766 PMCID: PMC5178986 DOI: 10.7759/cureus.896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An acute dry cough results commonly from bronchitis or pneumonia. When a patient presents with signs of infection, respiratory crackles, and a positive chest radiograph, the diagnosis of pneumonia is more common. Antibiotic failure in a patient being treated for community-acquired pneumonia requires further investigation through chest computed tomography. If a lung mass is found on chest computed tomography, lung empyema, abscess, and cancer need to be included on the differential and managed aggressively. This report describes a 55-year-old Caucasian male, with a history of obesity, recovered alcoholism, hypercholesterolemia, and hypertension, presenting with an acute dry cough in the primary care setting. The patient developed signs of infection and was found to have a lung mass on chest computed tomography. Treatment with piperacillin-tazobactam and chest tube placement did not resolve the mass, so treatment with thoracotomy and lobectomy was required. It was determined through surgical investigation that the patient, despite having no risk factors, developed a lung abscess. Lung abscesses rarely form in healthy middle-aged individuals making it an unlikely cause of the patient's presenting symptom, dry cough. The patient cleared his infection with proper management and only suffered minor complications of mild pneumoperitoneum and pneumothorax during his hospitalization.
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Affiliation(s)
| | - Scott Michaels
- College of Medicine, University of Central Florida ; FM Medical, Inc
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93
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Reichert M, Hecker M, Witte B, Bodner J, Padberg W, Weigand MA, Hecker A. Stage-directed therapy of pleural empyema. Langenbecks Arch Surg 2016; 402:15-26. [DOI: 10.1007/s00423-016-1498-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 08/10/2016] [Indexed: 11/29/2022]
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94
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Chang CC, Chen TP, Yeh CH, Huang PF, Wang YC, Yin SY. A simple weighted scoring system to guide surgical decision-making in patients with parapneumonic pleural effusion. J Thorac Dis 2016; 8:3168-3174. [PMID: 28066596 DOI: 10.21037/jtd.2016.11.93] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The selection of ideal candidates for surgical intervention among patients with parapneumonic pleural effusion remains challenging. In this retrospective study, we sought to identify the main predictors of surgical treatment and devise a simple scoring system to guide surgical decision-making. METHOD Between 2005 and 2014, we identified 276 patients with parapneumonic pleural effusion. Patients in the training set (n=201) were divided into two groups according to their treatment modality (non-surgery vs. surgery). Using multivariable logistic regression analysis, we devised a scoring system to guide surgical decision-making. The score was subsequently validated in an independent set of 75 patients. RESULTS A white blood cell count >13,500/µL, pleuritic pain, loculations, and split pleura sign were identified as independent predictors of surgical treatment. A weighted score based on these factors was devised, as follows: white blood cell count >13,500/µL (one point), pleuritic pain (one point), loculations (two points), and split pleura sign (three points). A score >4 was associated with a surgical approach with a sensitivity of 93.4%, a specificity of 82.4%, and an area under curve (AUC) of 0.879 (95% confidence interval: 0.828-0.930). In the validation set, a sensitivity of 94.3% and a specificity of 79.6% were found (AUC=0.869). CONCLUSIONS The proposed scoring system reliably identifies patients with parapneumonic pleural effusion who are candidates for surgery. Pending independent external validation, our score may inform the appropriate use of surgical interventions in this clinical setting.
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Affiliation(s)
- Che-Chia Chang
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan;; Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Tzu-Ping Chen
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chi-Hsiao Yeh
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Pin-Fu Huang
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yao-Chang Wang
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shun-Ying Yin
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
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95
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Migliore M, Borrata F, Nardini M, Criscione A, Calvo D, Gangemi M, Scalieri F. Awake uniportal video-assisted thoracic surgery for complications after pneumonectomy. Future Oncol 2016; 12:51-54. [PMID: 27744718 DOI: 10.2217/fon-2016-0362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Since 1998, we started a clinical program for awake video-assisted thoracic surgery in our unit using four-step local anesthesia and sedation. Throughout the years, we experienced several difficult cases, three of them had complications postpneumonectomy. The aim of this paper is to report these three cases.
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Affiliation(s)
- Marcello Migliore
- Section of Thoracic Surgery, Department of General Surgery & Medical Specialities, University of Catania, Catania, Italy
| | - Francesco Borrata
- Section of Thoracic Surgery, Department of General Surgery & Medical Specialities, University of Catania, Catania, Italy
| | - Marco Nardini
- Section of Thoracic Surgery, Department of General Surgery & Medical Specialities, University of Catania, Catania, Italy
| | - Alessandra Criscione
- Section of Thoracic Surgery, Department of General Surgery & Medical Specialities, University of Catania, Catania, Italy
| | - Damiano Calvo
- Section of Thoracic Surgery, Department of General Surgery & Medical Specialities, University of Catania, Catania, Italy
| | - Mariapia Gangemi
- Section of Thoracic Surgery, Department of General Surgery & Medical Specialities, University of Catania, Catania, Italy
| | - Francesco Scalieri
- Section of Thoracic Surgery, Department of General Surgery & Medical Specialities, University of Catania, Catania, Italy
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96
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Lagunes L, Encina B, Ramirez-Estrada S. Current understanding in source control management in septic shock patients: a review. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:330. [PMID: 27713888 DOI: 10.21037/atm.2016.09.02] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sepsis and septic shock is one of the leading causes of death worldwide. Antibiotics, fluid resuscitation support of vital organ function and source control are the cornerstones for the treatment of these patients. Source control measures include all those actions taken in the process of care to control the foci of infection and to restore optimal function of the site of infection. Source control represents the multidisciplinary team required in order to optimize critical care for septic shock patients. In the last decade an increase interest on fluids, vasopressors, antibiotics, and organ support techniques in all aspects whether time, dose and type of any of those have been described. However information of source control measures involving minimal invasion and new techniques, time of action and outcome without it, is scarce. In this review the authors resumes new information, recommendations and future directions on this matter when facing the more common types of infections.
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Affiliation(s)
- Leonel Lagunes
- Critical Care Department, Hospital Especialidades Médicas de la Salud, San Luis Potosi, Mexico;; Medicine Department, Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Belen Encina
- Critical Care Department, Vall d'Hebron University Hospital, Barcelona, Spain
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Mathisen DJ. Searching for answers! Eur J Cardiothorac Surg 2015; 48:653-4. [PMID: 26345983 DOI: 10.1093/ejcts/ezv290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Douglas J Mathisen
- Department of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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