EMPYEMA THORACIS

Postoperative empyema following lung cancer surgery

Postoperative empyema following lung cancer surgery is a serious complication. Occurrence rate of postoperative empyema following lung cancer surgery, patient background, surgical procedures, date of empyema onset, treatment, and prognosis of 4772 patients who underwent lung cancer surgery between 2008 and 2012 were investigated. Postoperative empyema following lung cancer surgery was found in 43 patients (0.9%). The occurrence rate of postoperative empyema was significantly higher in patients with the following factors: male gender, extended surgery such as pneumonectomy, bi-lobectomy and thoracotomy, squamous cell carcinoma, and an advanced pathologic stage of II and above. Chest drainage, video-assisted thoracic surgery debridement, fenestration, and thoracoplasy were performed, where 29 patients were cured (67.5%) and 5 patients (11.6%) died from thoracic empyema-related complications. Nine patients were not cured and died due to cancer or other diseases during treatment. When comparing cured and non-cured patients, it is indicated that squamous cell carcinoma, administration of steroids, history of interstitial pneumonia, presence of bronchial stump fistula, exacerbation of interstitial pneumonia and presence of non-fermenting Gram-negative bacilli led to a significantly low prognosis. The five-year overall survival rate was 34.9%.

Fever in Cancer Treatment: Coley's Therapy and Epidemiologic Observations

In the fall of 1890, an athletic, self-possessed, and thoughtful 17-year-old girl, who had just returned from an adventurous trip to Alaska where she had hurt her hand in a trivial accident, went to see a young, innovative surgeon in his new practice in New York City. Barely out of Harvard Medical School, he was a rising star in New York surgical circles, and the young woman asked him for help with her poorly healing, swollen, and naggingly painful injury. This visit had a far-reaching effect on cancer research, American philanthropy, and the career of the young man, William Coley, MD (1862-1936, Figure 1). The patient, Elisabeth Dashiell, confidant and close friend of John D. Rockefeller, Jr, was diagnosed by Coley with a highly aggressive round cell sarcoma, and despite radical surgery and in spite of Coley's undoubtedly fine surgical skills and intensive care, a rapid progression of the cancer, immense suffering, and Elisabeth's death a few months later could not be prevented.

Intra-abdominal sepsis and survival after surgery for colorectal cancer

Of 361 patients who survived curative left colonic or sphincter-saving rectal resection for cancer, 44 developed significant postoperative intra-abdominal sepsis and 317 did not. The two groups were well matched for age, sex, site of tumour, Dukes stage, tumour differentiation and timing of operation. There was no significant difference in the 5-year overall actuarial survival rate (P = 0.25) or in the 5-year disease-free survival rate (P = 0.23). Stepwise regression analysis of prognostic variables including age, sex, site of tumour, Dukes stage, tumour differentiation, timing of operation, grade of surgeon and postoperative intra-abdominal sepsis identified Dukes stage, age at operation and tumour differentiation as predictors of survival. These results suggest that postoperative intra-abdominal sepsis is not a prognostic factor for long-term survival in colorectal cancer as has been previously reported.

Infected hepatic Echinococcus cyst presenting as recurrent Escherichia coli empyema

An 81-year-old man, previously a shepherd in Italy, presented with recurrent Escherichia coli empyema over an 8-month period. His empyema was caused by an infected, nonviable hepatic Echinococcus cyst that eroded the diaphragm and led to intermittent spillage and pleural seeding. This case demonstrates that when dealing with Escherichia coli empyema, a subdiaphragmatic source ought to be suspected, and among immigrants from areas with prevalent hydatid disease, infected hepatic Echinococcus cyst might rarely be the cause.

Treatment of postpneumonectomy empyema and associated bronchopleural fistula. Experience of 100 consecutive postpneumonectomy patients

Experience in the management of 100 consecutive patients with postpneumonectomy empyema is presented. Open-window thoracostomy was used for treatment of the empyema in all cases. The patients were grouped according to surgical procedure after this treatment. In group 1 the thoracostomy window was left permanently open. In group 2 it was closed, and in group 3 the open pleural cavity was covered with skin, using a pedicle of muscle and skin and free skin transplants. The pectoralis skin pedicle was used to close large bronchopleural fistulas. The results in each group are presented and a staged method, which can be used in all cases of postpneumonectomy empyema, with or without bronchopleural fistula, is described.

Management of Empyema thoracis in children--a study of 65 cases

Sixty-five cases of pleural empyema (50 boys and 15 girls) were seen between January 1983 and June 1986. Fifty-three of these 65 children were below 10 years of age. Pulmonary infection was the commonest underlying cause. Cough with or without expectoration (98%) and fever (95%) were the commonest symptoms followed by breathlessness (85%) and chest pain (83%). Staphylococcus aureus was isolated from pus and blood in 61% and 18% of cases, respectively, while pseudomonas was grown in 8% and 3%. Most of the children (88%) were treated with antibiotics and tube thoracostomy drainage. Decortication was needed in 12% of cases. There were four deaths in this study. The overall success rate was 94%.

Postpneumonic pleural suppuration in children

Postpneumonic pleural suppuration is a common condition seen in paediatric practice in Nigeria. One hundred and twenty cases seen at the University of Nigeria Teaching Hospital, Enugu, over a 4-year period were reviewed. The patients were aged between 1 1/2 months and 16 years. History of antecedent measles was elicited in 27 of the children, and 70% of the patients presented to the hospital later than 7 days after the onset of symptoms of pleura suppuration. From the pleural aspirates of 106 cases (88.3%) Staphylococcus aureus was cultured in 31.2%, but there were no organisms cultured in 39.4%. Twenty-nine children were treated by chemotherapy only; 11 of them (37.9%) died. Sixty-eight cases had tube drainage of the pleural collections, with 6 deaths (8.8%). Twenty-three patients had thoracotomy, evacuation of the suppurative lesion and decortication of the lung, with no mortality. There was overall hospital mortality of 14.2%, the highest mortality being in children who had associated measles, gastroenteritis, anaemia or malnutrition. Early surgical drainage by tube thoracostomy or by thoracotomy and decortication in addition to appropriate and adequate antibiotic therapy is the treatment of choice.

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

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

Recent trends in empyema thoracis

One hundred and twenty-three patients with empyema thoracis presenting between 1968 and 1978 were studied. The predominant cause was pneumonia, with thoracic and gastrooesophageal surgery as the other important predisposing factors. 99 patients had received antibiotics before hospital admission and organisms were isolated from the empyema of 62 of these (63%). Of the 62 patients with organisms 39 (63%) had previously received an antibiotic appropriate to the sensitivity of the pathogen. Staph. aureus, Str. pneumoniae and anaerobes were the organisms most frequently found in empyemata following pneumonia, whilst Gram-negative enteric bacilli, the most frequently isolated organisms, were the predominant pathogens in postoperative cases. Following treatment with antibiotics alone or with closed chest drainage 29% of empyemata resolved but another 64% required subsequent surgery. The former group had a mean duration of symptoms of 2.8 (SE +/- 0.8) weeks before hospital treatment whereas the surgically treated group had symptoms for a mean period of 8.3 (SE +/- 1.5) weeks. 83% of patients who required thoracotomy had a history of more than four weeks at the time of admission. Thirty-six deaths were recorded, 11 of which were attributable to the empyema, giving an empyema mortality-rate of 9%. We conclude that with widespread use of antibiotics the nature of empyemata has changed and that those now seen are more often refractory to closed chest drainage, particularly if the history prior to hospital admission is longer than four weeks.

Comparison between irrigation and conventional treatment for empyema and pneumonectomy space infection

A new method of treating pleural empyema or pneumonectomy space infection by irrigation was evaluated in 11 patients. The infected cavities were filled with an antibiotic or antiseptic solution for three hours, and allowed to drain for one hour. This cycle was repeated every four hours for seven to 10 days. When cultures of the infected cavity became sterile the irrigation tube was removed and the wound sealed. Using this method, infection was eradicated after an average of 11 days in five of six patients with pleural empyema and in all five patients treated for an infected pneumonectomy space, including one with a bronchopleural fistula. The results of treating 58 similar cases of intrapleural sepsis over a 10-year period by the standard methods of aspiration, open drainage, decortication, or thoracoplasty were compared with the results of irrigation. In general, cyclical irrigation resulted in a shorter hospital stay and a shorter period of wound drainage than other methods.

Management of pleural sepsis in Nigerian children

Pleural sepsis in children is common in most developing countries. It may present as total pyothorax, pyopneumothorax, or localised thoracic empyema. In most cases, it follows an attack of bronchopneumonia, but other debilitating conditions such as measles, malnutrition, and sickle cell anaemia form part of the clinical syndrome. In a review of 60 cases of pleural sepsis in children aged between 1.5 months and 16 years, there were 40 cases of pyothorax, 15 of pyopneumothorax, and five of localised empyema. Treatment with chemotherapy only was given in 22 cases of whom eight died. Twenty-three patients had chemotherapy and tube drainage of the pleural contents; five died. Fifteen children had excision of the pleural disease, and decortication of the lung; none died. In view of the chronicity of the pleural sepsis by the time the child is seen in the hospital, and also the low mortality and shorter period in hospital, thoracotomy and decortication is recommended as the treatment of choice.

Bronchogenic carcinoma and postoperative empyema: is survival really enhanced?

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

Prophylaxis of postpneumonectomy empyema

Systemic antibiotics started before operation have been found to give inadequate prophylaxis against postpneumonectomy empyema in our practice. Experimental work by others has suggested that combining this treatment with topical irrigation and intrapleural antibiotics would give improved results. We have adopted this suggestion and found it to give better prophylaxis where pneumonectomy is associated with high risk factors. The difficulty of anticipating these high risk cases, and fringe benefits of this combined technique, make this brief addition to operating routine reasonable in all cases.

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

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

Pleural empyema in association with renal sepsis

Five cases of pleural empyema in association with perinephric abscess or renal infection are presented. This represents 4 per cent of a series of 122 pleural empyemas, or 30 per cent of empyemas with subdiaphragmatic aetiology. It is suggested that the renal tract should be investigated in all cases of recurrent or non-resolving pleural empyema of uncertain aetiology.

Pleuro-pulmonary amoebiasis

Experience with amoebic infestation of the pleural space and the lung in an area where amoebiasis is endemic is described. The manifestations of pleuro-pulmonary amoebiasis are outlined, and, for completeness, a note is added on pericardial amoebiasis and the technique of pericardiocentesis.

Empyema due to Klebsiella pneumoniae

Three cases of post-pneumonic empyema due to infection with Klebsiella pneumoniae are reported. All were men considerably debilitated by complicating factors. The presence of persistent fistulae and of lung necrosis makes eradication of this infection very difficult and tedious, and in the management of these cases the objective is to secure adequate removal of necrotic tissue, effective drainage, and finally a satisfactory deroofing procedure to obliterate the empyema cavity.