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Tsukamoto Y, Odaka M, Nakada T, Yabe M, Harada E, Akiba T, Toya N, Ohtsuka T. Comparative study of local versus general anesthesia in video-assisted thoracoscopic surgery for empyema. Asian J Surg 2023; 46:4208-4214. [PMID: 36504150 DOI: 10.1016/j.asjsur.2022.11.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/17/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This study evaluated the feasibility of performing non-intubated video-assisted thoracoscopic surgery (VATS) with local anesthesia for parapneumonic effusion and empyema resistant to conservative treatment. METHODS We retrospectively reviewed 80 patients who underwent surgery for parapneumonic effusions and empyema between 2015 and 2021. Patients were divided into those who received non-intubated local anesthesia and general anesthesia during surgery. Patient demographics, characteristics, laboratory findings, treatment progress, and treatment outcomes were compared. The primary outcomes were duration of postoperative drainage, postoperative complication rate, and postoperative mortality rate within 30 days. RESULTS Among patients who received local (n = 21) and general anesthesia (n = 59), there was a significant difference in age (median 79.0 years [interquartile range (IQR) 77.0-80.0] vs. 68.0 years [IQR 54.5-77.5]; p < 0.001), preoperative performance status (3.0 [IQR 2.0-4.0] vs. 2.0 [IQR 1.0-3.0]; p < 0.001), and operative time (69 min [IQR 50-128] vs. 150 min [IQR 107-198]; p < 0.001) but not in preoperative white blood cell count (12,100/μL [IQR 8,400-18000] vs. 12,220/μL [IQR 8,950-16,724]; p = 0.840), C-reactive protein (15.2 mg/dL [8.8-21.3] vs. 17.9 mg/dL [IQR 9.5-23.6]; p = 0.623), postoperative drainage period (11 days [IQR 7-14] vs. 9 days [7-13]; p = 0.216), postoperative hospital stay (22 days [IQR 16-53] vs. 18 days [IQR 12-26]; p = 0.094), reoperation rate (9.5% vs. 15.3%; p = 0.775), postoperative complication rate (19.0% vs. 18.6%; p = 0.132), or postoperative 30-day mortality rate (4.8% vs. 0%; p = 0.587). CONCLUSIONS VATS using local anesthesia is feasible for patients with treatment-resistant parapneumonic effusion and empyema with poor general condition.
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Affiliation(s)
- Yo Tsukamoto
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan.
| | - Makoto Odaka
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Takeo Nakada
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Mitsuo Yabe
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Eriko Harada
- Department of Surgery, The Jikei University Hospital, Nishishinbashi 3-19-18, Minatoku, Tokyo, 105-8471, Japan
| | - Tadashi Akiba
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Naoki Toya
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita Kashiwashi, Chiba, 277-8567, Japan
| | - Takashi Ohtsuka
- Department of Surgery, The Jikei University Hospital, Nishishinbashi 3-19-18, Minatoku, Tokyo, 105-8471, Japan
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Issoufou I, Sani R, Amadou D, Alio K, Adamou-Nouhou K, Lakranbi M, Sani R, Ouadnouni Y, Abarchi H, Smahi M. Which Role for Muscle-Sparing Posterolateral Thoracotomy in the Treatment of Spontaneous Pneumothorax? Surg J (N Y) 2023; 9:e149-e155. [PMID: 38197090 PMCID: PMC10754642 DOI: 10.1055/s-0043-1770954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 05/26/2023] [Indexed: 01/11/2024] Open
Abstract
Objective This study aims to show the place of muscle-sparing posterolateral thoracotomy in the treatment of spontaneous pneumothorax. Methods It was a single-center study performed in the Department of Thoracic Surgery of Teaching hospital Hassan II of Fez for 8 years. We adopted the nosological definition, which classifies spontaneous pneumothorax into three categories. We included patients over 15 years of age with primary or secondary spontaneous pneumothorax operated by posterolateral thoracotomy without muscle section, and we analyzed the specific indications of this approach. It included 49 patients with primary or secondary spontaneous pneumothorax, operated by muscle-sparing posterolateral thoracotomy. Data were collected from regularly updated computer files of patients, entered by Excel 2013, and analyzed using SPSS.20 software. These data are: epidemiological, clinical, radiological, surgical exploration, surgical procedure, the result of the surgery and the evolution. Results The average age was 42 years. Smoking was found in 61% of cases and pulmonary tuberculosis in 10% of cases. Thoracic computed tomography (CT) showed bullae and blebs in 31% of cases, pleural adhesions and pachypleuritis in 50% of cases, and hydropneumothorax with pachypleuritis in 37% of cases. There is a statistical correlation between pleuropulmonary decortication and pachypleuritis ( p = 0.002) or hydropneumothorax ( p = 0.001) on CT. Bullae and blebs resection was performed in 53% of cases and pleuropulmonary decortication in 63% of cases. A right pleuropneumonectomy was performed in one case. The follow-up was uneventful in 82% of cases. Conclusion Muscle-sparing posterolateral thoracotomy remains the best approach and leads to good results.
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Affiliation(s)
- Ibrahim Issoufou
- Department of Thoracic Surgery, Teaching Hospital Hassan II, Fez, Morocco
| | - Rabiou Sani
- Department of Thoracic Surgery, Teaching Hospital Hassan II, Fez, Morocco
| | - Daouda Amadou
- Department of Cardiovascular Surgery, Teaching Hospital Hassan II, Fez, Morocco
| | - Kadre Alio
- Department of Stomatology and Maxillofacial Surgery, Hôpital Général de Référence, Niamey, Niger
- Department of Surgery and Surgical Specialities, Faculty of Health Sciences, Abdou Moumouni University, Niamey, Niger
| | - Kaled Adamou-Nouhou
- Department of Cardiovascular Surgery, Teaching Hospital Hassan II, Fez, Morocco
| | - Marouane Lakranbi
- Department of Thoracic Surgery, Teaching Hospital Hassan II, Fez, Morocco
- Department of Surgery, Faculty of Medicine and Pharmacy, University Sidi Mohamed Ben Adellah, Fez, Morocco
| | - Rachid Sani
- Department of Surgery and Surgical Specialities, Faculty of Health Sciences, Abdou Moumouni University, Niamey, Niger
- Department of General Surgery, National Hospital of Niamey, Niamey, Niger
| | - Yassine Ouadnouni
- Department of Thoracic Surgery, Teaching Hospital Hassan II, Fez, Morocco
- Department of Surgery, Faculty of Medicine and Pharmacy, University Sidi Mohamed Ben Adellah, Fez, Morocco
| | - Habibou Abarchi
- Department of Surgery and Surgical Specialities, Faculty of Health Sciences, Abdou Moumouni University, Niamey, Niger
- Department of Pediatric Surgery, Hospital Amirou Boubacar Diallo, Niamey, Niger
| | - Mohamed Smahi
- Department of Thoracic Surgery, Teaching Hospital Hassan II, Fez, Morocco
- Department of Surgery, Faculty of Medicine and Pharmacy, University Sidi Mohamed Ben Adellah, Fez, Morocco
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Pathak V, Adhikari L, Zhou C. Effects of Concurrent Dosing on the Efficacy of Tissue Plasminogen Activator and Deoxyribonuclease in the Treatment of Pleural Infection. Cureus 2023; 15:e46683. [PMID: 37942362 PMCID: PMC10629377 DOI: 10.7759/cureus.46683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND The goal of this study was to evaluate how the administration of concurrent tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) therapy with variable dosing for complicated parapneumonic effusions and empyema affects patient outcomes in an inner-city community hospital. METHODS This retrospective analysis was performed at an inner-city hospital located in Raleigh, North Carolina. A list of all patients treated with tPA and DNase between July 1, 2015, and December 31, 2017, was generated and screened. Data were collected through a review of past medical records, including demographics, past medical history, and details about their hospital course. RESULTS A total of 38 patients were found to have been treated with concurrent tPA and DNase for complicated parapneumonic effusion or empyema. Twenty (52.6%) patients received the full six doses of combined concurrent tPA/DNase. Of the 18 (47.4%) patients who did not receive the full six doses, 11 did not require the full six doses for effusion resolution, and seven had to discontinue therapy due to tube blockage or pain. Only seven (18.4%) patients had complications related to tPA/DNase administration, most commonly pain. Nineteen (50%) patients had complete radiological clearance of effusion, with 13 (34.2%) having partial clearance, and six (15.8%) having no change or worsening of their effusion. Eight (21.1%) patients needed further surgical management of their effusion. CONCLUSIONS The current most common dosing pattern for combined tPA and DNase therapy of twice daily for three days may not be optimal for all patients. The dosing regimen should be individualized depending on clinical response. Concurrent dosing is safe.
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Affiliation(s)
- Vikas Pathak
- Pulmonary and Critical Care, Virginia Institute of Lung Diseases, Richmond, USA
| | - Lukash Adhikari
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, NPL
| | - Christine Zhou
- Pulmonary and Critical Care Medicine, University of Cincinnati Medical Center, Cincinnati, USA
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Shiroshita A, Kimura Y, Yamada A, Shirakawa C, Yue C, Suzuki H, Anan K, Sato K, Nakashima K, Takeshita M, Okuno T, Nitawaki T, Igei H, Suzuki J, Tomii K, Ohgiya M, Kataoka Y. Effectiveness of Immediate Video-Assisted Thoracoscopic Surgery for Empyema: A Multicentre, Retrospective Cohort Study. Respiration 2023; 102:821-832. [PMID: 37634506 DOI: 10.1159/000533439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Because of limitations in previous randomised controlled trials and observational studies, the effectiveness of immediate video-assisted thoracoscopic surgery (VATS) for patients with empyema in real-world settings remains unclear. OBJECTIVE This study aimed to evaluate whether immediate VATS improves clinical outcomes in patients with empyema. METHODS This multicentre retrospective cohort study included 744 patients with physician-diagnosed empyema from six hospitals between 2006 and 2021. The exposure was VATS performed within 3 days of empyema diagnosis, the primary outcome was 30-day mortality, and secondary outcomes were 90-day mortality, length of hospital stay, and time from diagnosis to discharge. We used propensity score weighting to account for potential confounders. For outcome analyses, we used logistic regression for mortality outcomes and gamma regression for the number of days. RESULTS Among the 744 patients, 53 (7.1%) underwent VATS within 3 days, and 691 (92.9%) initially received conservative treatment. After propensity score weighting, the differences in 30- and 90-day mortalities between the immediate VATS and initial conservative treatment groups were 1.18% (95% confidence interval [CI], -10.7 to 13.0%) and -0.08% (95% CI, -10.3 to 10.2%), respectively. The differences in length of hospital stay and time from diagnosis to discharge were -3.22 (95% CI, -6.19 to -0.25 days) and -5.04 days (95% CI, -8.19 to -1.90 days), respectively. CONCLUSIONS Our real-world study showed that immediate VATS reduced the length of hospital stay and the time from diagnosis to discharge. Considering the small sample and differences in protocols between countries, further large-scale studies are warranted.
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Affiliation(s)
- Akihiro Shiroshita
- Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Yuya Kimura
- Clinical Research Center, National Hospital Organization Tokyo Hospital, Tokyo, Japan
| | - Atsushi Yamada
- Department of Diagnostic Radiology, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Chigusa Shirakawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Cong Yue
- Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
- Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hokuto Suzuki
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenya Sato
- Department of Thoracic Medicine, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan
| | - Kiyoshi Nakashima
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Masafumi Takeshita
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Takehiro Okuno
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Tatsuya Nitawaki
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Hiroshi Igei
- Department of Respiratory Medicine, National Hospital Organization Tokyo Hospital, Tokyo, Japan
| | - Jun Suzuki
- Department of Diagnostic Imaging, Saitama Medical University International Medical Center, Saitama, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Masahiro Ohgiya
- Department of Respiratory Medicine, National Hospital Organization Tokyo Hospital, Tokyo, Japan
| | - Yuki Kataoka
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
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Liu X, Wang X, Sheng J, Jiang Y, Li L, Dai X. Open decortication for patients presenting with stage III tuberculous empyema with low density lines on CT imaging. Sci Rep 2023; 13:9658. [PMID: 37316645 DOI: 10.1038/s41598-023-36420-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 06/03/2023] [Indexed: 06/16/2023] Open
Abstract
To explore the influence of CT findings on the optimal timing of open decorticationin patients with stage III tuberculous empyema. A total of 80 patients with stage III tuberculous empyema who had undergone open decortications were recruited; 44 patients had chest CT findings indicating low-density lines, while 36 patients did not show this imaging finding. Demographic data, perioperative data and preoperative and postoperative chest CT images were collected. In the low-density line group, the duration of disease (P = 0.0030) and the preoperative anti-tuberculosis time (P = 0.0016) were longer than those of the group without low-density lines, and the ESR (P = 0.0218), CRP (P = 0.0027) and leukocyte count (P = 0.0339) were lower in the low-density line group. Additionally, in the median operative time (P = 0.0003), intraoperative blood loss (P < 0.0001), volume of catheter drainage during 48 h after operation (P = 0.0067), chest tube duration (P < 0.0001), and length of hospital stay (P = 0.0154) were significantly lower in the low-density line group than in the group without low-density lines. A total of 88.64% of participants in the low-density line group showed hyperplasia with hyaline degeneration in pathological examination, which was observed only in 41.67% of patients without low-density lines. In addition, gaseous necrosis was considerably higher in patients without a low-density line (P = 0.004), while the low-density line group had a higher rate of treatment success (P < 0.05). Patients with stage III tuberculous empyema presenting with low-density lines around the thickened fibrous pleural rind on preoperative CT imaging may be good candidates for open decortication.
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Affiliation(s)
- Xiaoyu Liu
- Wuhan Pulmonary Hospital, Wuhan Institute for Tuberculosis Control, Wuhan, 430030, Hubei, China
| | - Xuan Wang
- Wuhan Pulmonary Hospital, Wuhan Institute for Tuberculosis Control, Wuhan, 430030, Hubei, China
| | - Jian Sheng
- Wuhan Pulmonary Hospital, Wuhan Institute for Tuberculosis Control, Wuhan, 430030, Hubei, China
| | - Yuhui Jiang
- Wuhan Pulmonary Hospital, Wuhan Institute for Tuberculosis Control, Wuhan, 430030, Hubei, China
| | - Li Li
- Wuhan Pulmonary Hospital, Wuhan Institute for Tuberculosis Control, Wuhan, 430030, Hubei, China.
| | - Xiyong Dai
- Wuhan Pulmonary Hospital, Wuhan Institute for Tuberculosis Control, Wuhan, 430030, Hubei, China.
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Bayileyegn N, Mengiste DT. Necrotizing fasciitis of the chest wall caused by empyema necessitans following tuberculosis: Case report and literature review. Int J Surg Case Rep 2023; 106:108300. [PMID: 37150161 DOI: 10.1016/j.ijscr.2023.108300] [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: 03/29/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/09/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Empyema is a serious complication characterized by pus and bacteria in the pleural space which may progress to necrosis, cavitation, or fistulas in the thoracic cavity. Infection and trauma are the commonest causes in the developed countries while tuberculosis is the commonest cause of empyema in developing countries. Empyema necessitans is a rare complication of pleural space infections. CASE PRESENTATION A 50 years old male patient presented to our hospital with right side chest pain and shortness of breath of 3-week duration. He had completed treatment of pulmonary tuberculosis 6 months ago. The patient was apparently healthy for the last six months after the treatment. The patient was acutely sick looking and has tachycardia with pulse rate of 115, respiratory rate was 36 and arterial oxygen saturation of 80 % with atmospheric air but becomes 96 % with facemask humidified oxygen. Tube thoracostomy and chest wall debridement was done for empyema necessitans with chest wall necrotizing fasciitis. CLINICAL DISCUSSION Empyematous collection with time may lead to a more complicated scenario called empyema necessitans. Empyema necessitans is the dissection of puss thru the pleural space and collection in the torso/ free rupture with or without collection of air. The most common cause of empyema globally is untreated parapneumonic effusion. Tuberculosis constitutes for most of the cases of empyema necessitans in third world countries. Debridement and wound care are monumental for the management of necrotizing fasciitis in addition to broad spectrum antibiotics. CONCLUSION Timely treatment/drug adherence to pneumonia and tuberculosis decreases the rate of having empyema and subsequent complication. Chest wall necrotizing fasciitis is extremely rare and judicious management with debridement and wound care is appropriate whenever it happens. Broad spectrum antibiotics with drainage are the norm of management of empyema/empyema necessitans.
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Affiliation(s)
- Nebiyou Bayileyegn
- Department of Surgery, Jimma University Medical Center, Jimma, Ethiopia.
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Bedawi EO, Ricciardi S, Hassan M, Gooseman MR, Asciak R, Castro-Añón O, Armbruster K, Bonifazi M, Poole S, Harris EK, Elia S, Krenke R, Mariani A, Maskell NA, Polverino E, Porcel JM, Yarmus L, Belcher EP, Opitz I, Rahman NM. ERS/ESTS statement on the management of pleural infection in adults. Eur Respir J 2023; 61:2201062. [PMID: 36229045 DOI: 10.1183/13993003.01062-2022] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Sara Ricciardi
- Unit of Thoracic Surgery, San Camillo Forlanini Hospital, Rome, Italy
- PhD Program Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Maged Hassan
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Michael R Gooseman
- Department of Thoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull York Medical School, University of Hull, Hull, UK
| | - Rachelle Asciak
- Department of Respiratory Medicine, Queen Alexandra Hospital, Portsmouth, UK
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Olalla Castro-Añón
- Department of Respiratory Medicine, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte de Lemos, Lugo, Spain
- C039 Biodiscovery Research Group HULA-USC, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Karin Armbruster
- Department of Medicine, Section of Pulmonary Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
- Respiratory Diseases Unit, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Sarah Poole
- Department of Pharmacy and Medicines Management, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Elinor K Harris
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Stefano Elia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
- Thoracic Surgical Oncology Programme, Policlinico Tor Vergata, Rome, Italy
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Alessandro Mariani
- Thoracic Surgery Department, Heart Institute (InCor) do Hospital das Clnicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Jose M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth P Belcher
- Department of Thoracic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Chinese Academy of Medical Health Sciences, University of Oxford, Oxford, UK
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8
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Hosokawa T, Tanami Y, Sato Y, Deguchi K, Takei H, Oguma E. Role of ultrasound in the treatment of pediatric infectious diseases: case series and narrative review. World J Pediatr 2023; 19:20-34. [PMID: 36129633 PMCID: PMC9490683 DOI: 10.1007/s12519-022-00606-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 08/05/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Infectious diseases are common in pediatric patients. In these patients, ultrasound is a useful imaging modality that involves no irradiation or sedation and can be performed repeatedly at the patient's bedside. The purpose of this review was to show pediatric cases with infectious disease that used ultrasound to decide the methods of treatment. DATA SOURCES Literature review was performed using Pubmed as the medical database source. No year-of-publication restriction was placed. The mesh terms used were: "ultrasound", "sonography", "infectious disease", "treatment", "antibiotics", "surgical intervention", "pediatric", "children", "deep neck abscess", "pyothorax", "empyema", "pneumonia", "urinary tract infection", "intra-abdominal abscess", "soft tissue infection", "septic arthritis", "osteomyelitis", and "surgical site infection". RESULTS We presented pediatric case series with infectious diseases, including deep neck abscess, pyothorax and empyema, pneumonia, urinary tract infection, intra-abdominal abscess, soft tissue infection, septic arthritis and osteomyelitis, and surgical-site infection. Ultrasound was useful for evaluating the extent and location of inflammation and abscess and for decision-making concerning surgical intervention. CONCLUSION Knowledge of these sonographic findings is important for sonographers during examinations and for physicians when determining the treatment plan and period of antibiotic therapy for infected lesions.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku, Saitama, 330-8777, Japan.
| | - Yutaka Tanami
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku, Saitama, 330-8777 Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku, Saitama, 330-8777 Japan
| | - Kuntaro Deguchi
- Department of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Haruka Takei
- Department of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku, Saitama, 330-8777 Japan
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9
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Klausen MB, Laursen C, Bendixen M, Naidu B, Bedawi EO, Rahman NM, Christensen TD. Does the time to diagnosis and treatment influence outcome in adults with pleural infections. Eur Clin Respir J 2023; 10:2174645. [PMID: 36743828 PMCID: PMC9897775 DOI: 10.1080/20018525.2023.2174645] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective To investigate the effect of early diagnosis and intervention in adult patients with complicated parapneumonic pleural effusion or pleural empyema and the impact on outcomes. Methods A systematic review based on a literature search of the PubMed database was performed. Results Eleven eligible studies were included; nine observational studies and two randomised controlled trials totalling a study population of 10,717 patients. The studies were conducted from 1992 to 2018, all in Europe and Northern America except one. Results varied between studies, but a trend towards better outcome in patients with shorter duration of symptoms and quicker initiation of treatment was found. We found that duration of symptoms before treatment may affect length of hospital stay, rate of conversion to open surgery, and frequency of complications. Conclusion We found that an earlier intervention in adults suffering from complicated parapneumonic pleural effusion and pleural empyema may potentially improve the outcome of patients in terms of length of stay, conversion to open surgery, and general complications following treatment, but not regarding mortality. Further studies are required to specify the timing of each intervention, and direct comparison in early management of interventions.
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Affiliation(s)
- Mads Brögger Klausen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Morten Bendixen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Babu Naidu
- Department of Thoracic Surgery, Queen Elizabeth Hospital Birmingham, UK & Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Eihab O Bedawi
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Najib M Rahman
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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10
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Which Surgery for Stage II-III Empyema Patients? Observational Single-Center Cohort Study of 719 Consecutive Patients. J Clin Med 2022; 12:jcm12010136. [PMID: 36614937 PMCID: PMC9821231 DOI: 10.3390/jcm12010136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Recent guidelines support the use of thoracoscopic surgery in stage II-III empyema; however, there is still debate regarding the best surgical approach. The aim of our study is to compare postoperative outcomes of VATS and open surgical approaches for the treatment of post-pneumonic empyema. METHODS Observational cohort study on prospectively collected cases of post-pneumonic empyema surgically treated in a single center (2000-2020). Patients were divided into an open group (OT, posterolateral muscle sparing thoracotomy) and VATS group (VT, 2 or 3 port ± utility incision). The primary outcome of the study was empyema resolution, assessed by the recurrence rate. Secondary outcomes were mortality, complications, pain and return to daily life. All patients were followed up at 1, 3 and 6 months after surgery in the outpatient clinic with a chest radiograph/CT scan. RESULTS In total, 719 consecutive patients were surgically treated for stage II-III empyema, with 644 belonging to the VT group and 75 to the OT group. All patients had a clinical history of pneumonia lasting no more than 6 months before surgery, and 553 (76.9%) had stage II empyema. Operative time was 92.7 ± 6.8 min for the OT group and 112.2 ± 7.4 for the VT group. The conversion rate was 8.4% (46/545) for stage II and 19.2% (19/99) for stage III. Twelve patients (1.86%) in the VT group and four patients (5.3%) in the OT group underwent additional surgery for bleeding. Postoperative mortality was 1.25% (9/719): 5.3% (4/75) in OT and 0.77% (5/644) in VT. Postoperative stay was 10 ± 6.5 days in OT and 8 ± 2.4 in VT. Overall morbidity was 14.7% (106/719): 21.3% (16/75) in OT and 13.9% (90/644) in VT. In VT, six patients (0.93%) showed recurrent empyema: five were treated with chest drainage and one with additional open surgery. CONCLUSIONS Our findings suggest that the VATS approach, showing a 99% success rate, shorter length of stay and lower postoperative morbidity, should be considered the treatment of choice for thoracic empyema.
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11
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Porcel JM. Nonmalignant Pleural Effusions. Semin Respir Crit Care Med 2022; 43:570-582. [PMID: 36104027 DOI: 10.1055/s-0042-1748186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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12
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Ohuchi M, Inoue S, Ozaki Y, Fujita T, Ueda K, Kitamura S, Namura Y. Efficacy, safety, and optimal timing of single-trocar video-assisted flexible thoracoscopic debridement under local anesthesia for complicated parapneumonic empyema. Gen Thorac Cardiovasc Surg 2022; 70:634-641. [PMID: 35118586 DOI: 10.1007/s11748-022-01780-z] [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: 11/24/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Thoracoscopic debridement under local anesthesia is a useful approach for complicated parapneumonic effusion or empyema (CPE) and is a less invasive procedure than video-assisted thoracoscopic surgery under general anesthesia. There are various methods of thoracoscopic debridement under local anesthesia, although the optimal timing of treatment is unknown. The objective of this study was to verify the efficacy and safety of our video-assisted flexible thoracoscopic debridement (VAFTS-D) procedure under local anesthesia, and to investigate the clinical features associated with the success of VAFTS-D. METHODS The study included 71 consecutive patients with CPE who underwent VAFTS-D. The primary outcome was success of VAFTS-D. We retrospectively analyzed the efficacy and safety of VAFTS-D from the clinical data obtained from hospital medical records, and used univariate logistic analyses to identify potential predictors of the outcome. RESULTS VAFTS-D was considered successful in 62 of 71 patients (87.3%). Two of the remaining nine patients died and the other seven patients required subsequent operation under general anesthesia. Complications due to VAFTS-D occurred in six patients (8.5%). Duration of empyema < 10 days (P = 0.024) and negative bacterial culture in pleural effusion (P = 0.029) were independently associated with the success of VAFTS-D by univariate logistic regression analysis. CONCLUSION VAFTS-D might be an acceptable first-line procedure in patients with suspected CPE. VAFTS-D should be performed as early as possible for a successful outcome, and to obtain useful information on the pleural cavity.
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Affiliation(s)
- Masatsugu Ohuchi
- Department of General Thoracic Surgery, National Hospital Organization, Higashi-Ohmi General Medical Center, 255 Gochi-cho, Higashiomi, Shiga, 527-8505, Japan.
| | - Shuhei Inoue
- Department of General Thoracic Surgery, National Hospital Organization, Higashi-Ohmi General Medical Center, 255 Gochi-cho, Higashiomi, Shiga, 527-8505, Japan
| | - Yoshitomo Ozaki
- Department of General Thoracic Surgery, National Hospital Organization, Higashi-Ohmi General Medical Center, 255 Gochi-cho, Higashiomi, Shiga, 527-8505, Japan
| | - Takuya Fujita
- Department of Respiratory Surgery, Kohka Public Hospital, 1256 Matsuo, Minakuchi-cho, Koka, Shiga, 528-0074, Japan
| | - Keiko Ueda
- Division of General Thoracic Surgery, Department of Surgery, Shiga University of Medical Science, Seta-Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Shoji Kitamura
- Department of Thoracic Surgery, Ijinkai Takeda Hospital, 28-1 Isidamoriminami-cho, Kyoto-shi Fushimi-ku, Kyoto, 601-1495, Japan
| | - Yuki Namura
- Department of Thoracic Surgery, Ijinkai Takeda Hospital, 28-1 Isidamoriminami-cho, Kyoto-shi Fushimi-ku, Kyoto, 601-1495, Japan
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13
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Abstract
The rising incidence and high morbidity of pleural infection remain a significant challenge to health care systems worldwide. With distinct microbiology and treatment paradigms from pneumonia, pleural infection is an area in which the evidence base has been rapidly evolving. Progress in recent years has revolved around characterizing the microbiome of pleural infection and the addition of new strategies such as intrapleural enzyme therapy to the established treatment pathway of drainage and antibiotics. The future of improving outcomes lies with personalizing treatment, establishing optimal timing of intrapleural agents and surgery, alongside wider use of risk stratification to guide treatment.
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Affiliation(s)
- Dinesh N Addala
- Oxford University Hospitals NHS Foundation Trust; Department of Respiratory Medicine, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK.
| | - Eihab O Bedawi
- Oxford University Hospitals NHS Foundation Trust; Department of Respiratory Medicine, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust; Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, Headington OX3 9DU, UK
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14
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Patella M, Minerva EM, Porcellini I, Cianfarani A, Tessitore A, Cafarotti S. Tracking the outcomes of surgical treatment of Stage 2 and 3 empyema: introduction and consolidation of minimally invasive approach. ANZ J Surg 2021; 91:2182-2187. [PMID: 34405522 DOI: 10.1111/ans.17133] [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: 12/08/2020] [Revised: 06/16/2021] [Accepted: 07/24/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We described the results of surgical treatment of empyema, tracing outcomes throughout the passage from the open thoracotomy (OT) approach to video-assisted thoracoscopic surgery (VATS) in a single institute. METHODS We retrospectively analyzed the records of 88 consecutive patients treated for Stage 2 and 3 empyema (2010-2019). We divided the study period into three groups: OT period (2010-2013), early VATS (2014-2017, from the introduction of VATS program, until acme of learning curve), and late VATS (2018-2019). Groups were compared to investigate the outcomes evolution. RESULTS Most relevant findings of the study were significant variation in postoperative length of stay (median [interquartile range]: 9 days [7.5-10], 10 [7.5-17.5], and 7 [5-10] for OT period, early VATS, and late VATS, respectively, p = 0.005), hospital admission referral to thoracic surgery interval (7.5 days [4.5-11], 6.5 [3-9], and 2.5 [1.5-5.5], p = 0.003), chest tube duration (5.5 days [5-7.5], 6 [4-6], 4 [3-5], p = 0.003), and proportion of operation performed by residents (3 [15%], 6 [16.7%], 14 [43.6%], p = 0.01). CONCLUSIONS Our findings pictured the trajectory evolution of outcomes during introduction and consolidation of VATS treatment of empyema. During the early phase, we observed a decline in some indicators that improved significantly in the late VATS period. After a learning curve, all outcomes showed better results and we entered into a teaching phase.
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Affiliation(s)
- Miriam Patella
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | | | - Iride Porcellini
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Agnese Cianfarani
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Adele Tessitore
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Stefano Cafarotti
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
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15
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Girotti PNC, Tschann P, Di Stefano P, Möschel M, Hübl N, Königsrainer I. Retrospective case-control study on the outcomes of early minimally invasive pleural lavage for pleural empyema in oncology patients. Thorac Cancer 2021; 12:2710-2718. [PMID: 34402204 PMCID: PMC8520807 DOI: 10.1111/1759-7714.14109] [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: 06/10/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Oncology patients carry a substantial risk of developing pleural empyema. Here, we report the preliminary results of our early video-assisted thoracoscopic surgery (VATS) lavage strategy in cases of empyema occurring in patients undergoing (radio-) chemotherapy. METHODS This was a retrospective case-control study comparing early VATS lavage (test group, current therapy since January 2018, n = 46) versus VATS pleurectomy (historical control; before January 2018, n = 46). RESULTS Five patients in the control group and one in the test group developed recurrence of empyema within 30 days. Complications were more severe and more frequently observed in the historical control group than in the test group (30/46 vs. 12/46 CI: 5%-95%, p = < 0.05). Early VATS lavage saved operating time, allowed a shorter ICU stay (2.6 days CI: 5%-95% vs. 5.1 days CI: 5%-95%, p = ns) and an earlier hospital discharge (6.1 days CI: 5%-95% vs. 13.5 days CI: 5%-95%, p < 0.05). Moreover, radio and/or chemotherapy could be reinitiated earlier (15 ± 20.5 days CI: 5%-95% vs. 40 ± 12 days CI: 5%-95%, p < 0.05). CONCLUSIONS In this retrospective cohort study, early VATS lavage was found to have a beneficial effect especially on hospital stay and enabling an earlier restart of radio- and/or chemotherapy.
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Affiliation(s)
| | - Peter Tschann
- Department of General-Visceral and Thoracic Surgery, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Paolo Di Stefano
- Department of General-Visceral and Thoracic Surgery, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Martin Möschel
- Department of General-Visceral and Thoracic Surgery, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Nikolaus Hübl
- Department of General-Visceral and Thoracic Surgery, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Ingmar Königsrainer
- Department of General-Visceral and Thoracic Surgery, Landeskrankenhaus Feldkirch, Feldkirch, Austria
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16
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Evaluation and management of pleural sepsis. Respir Med 2021; 187:106553. [PMID: 34340174 DOI: 10.1016/j.rmed.2021.106553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/21/2022]
Abstract
Pleural sepsis stems from an infection within the pleural space typically from an underlying bacterial pneumonia leading to development of a parapneumonic effusion. This effusion is traditionally divided into uncomplicated, complicated, and empyema. Poor clinical outcomes and increased mortality can be associated with the development of parapneumonic effusions, reinforcing the importance of early recognition and diagnosis. Management necessitates a multimodal therapeutic strategy consisting of antimicrobials, catheter/tube thoracostomy, and at times, video-assisted thoracoscopic surgery.
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17
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Ljuhar D, Rayner J, Hyland E, King S. Management of thoracic empyema in children: a survey of the Australia and New Zealand Association of Paediatric Surgeons (ANZAPS). Pediatr Surg Int 2021; 37:897-902. [PMID: 33751198 DOI: 10.1007/s00383-021-04887-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To define the spectrum of management for thoracic empyema in children in Australia and New Zealand. METHODS Online survey of members of the Australian and New Zealand Association of Paediatric Surgeons (ANZAPS), limited to consultant/attending paediatric surgeons. RESULTS A total of 54/80 (67.5%) members, from 16 paediatric surgical centres, responded. The majority (33/54, 61%) preferred chest drain with fibrinolytics, whilst 21/54 (39%) preferred video-assisted thoracoscopic surgery (VATS) with drain insertion. Urokinase was the most commonly used fibrinolytic (64%). There were no significant differences in management preferences between practising surgeons in Australia and New Zealand (p = 0.54), nor between consultants who had been practising a shorter (< 5 years) or longer (> 20 years) amount of time (p = 0.21). The practices described by the surveyed ANZAPS members were in line with the Thoracic Society of Australia and New Zealand recommendations for the management of paediatric empyema. CONCLUSION Across Australia and New Zealand there exists significant variation surrounding the intra- and post-intervention management of thoracic empyema in children. The surveyed paediatric surgeons demonstrated a preference for fibrinolytics over the use of VATS. All management regimens were within published local guidelines.
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Affiliation(s)
- Damir Ljuhar
- Department of Paediatrics, Monash University, Melbourne, Australia.
| | - Jessica Rayner
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Ela Hyland
- Department of Paediatric Surgery and Urology, Canberra Hospital, Canberra, Australia
| | - Sebastian King
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia.,Surgical Research, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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18
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Sundaralingam A, Banka R, Rahman NM. Management of Pleural Infection. Pulm Ther 2021; 7:59-74. [PMID: 33296057 PMCID: PMC7724776 DOI: 10.1007/s41030-020-00140-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/16/2020] [Indexed: 12/16/2022] Open
Abstract
Pleural infection is a millennia-spanning condition that has proved challenging to treat over many years. Fourteen percent of cases of pneumonia are reported to present with a pleural effusion on chest X-ray (CXR), which rises to 44% on ultrasound but many will resolve with prompt antibiotic therapy. To guide treatment, parapneumonic effusions have been separated into distinct categories according to their biochemical, microbiological and radiological characteristics. There is wide variation in causative organisms according to geographical location and healthcare setting. Positive cultures are only obtained in 56% of cases; therefore, empirical antibiotics should provide Gram-positive, Gram-negative and anaerobic cover whilst providing adequate pleural penetrance. With the advent of next-generation sequencing techniques, yields are expected to improve. Complicated parapneumonic effusions and empyema necessitate prompt tube thoracostomy. It is reported that 16-27% treated in this way will fail on this therapy and require some form of escalation. The now seminal Multi-centre Intrapleural Sepsis Trials (MIST) demonstrated the use of combination fibrinolysin and DNase as more effective in the treatment of empyema compared to either agent alone or placebo, and success rates of 90% are reported with this technique. The focus is now on dose adjustments according to the patient's specific 'fibrinolytic potential', in order to deliver personalised therapy. Surgery has remained a cornerstone in the management of pleural infection and is certainly required in late-stage manifestations of the disease. However, its role in early-stage disease and optimal patient selection is being re-explored. A number of adjunct and exploratory therapies are also discussed in this review, including the use of local anaesthetic thoracoscopy, indwelling pleural catheters, intrapleural antibiotics, pleural irrigation and steroid therapy.
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Affiliation(s)
- Anand Sundaralingam
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Radhika Banka
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
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19
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Matsudaira H, Arakawa S, Noda Y, Ohtani A, Kato D, Shibasaki T, Mori S, Hirano J, Ohtsuka T. Optimal timing of video-assisted thoracic surgery for acute pyothorax: a retrospective study. Gen Thorac Cardiovasc Surg 2021; 69:1476-1481. [PMID: 33993392 DOI: 10.1007/s11748-021-01649-7] [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: 02/15/2021] [Accepted: 05/07/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although the value of video-assisted thoracic surgery for acute pyothorax is becoming widely recognized, the optimal timing of surgery has not been established. Therefore, we aimed to determine the optimal timing of video-assisted thoracic surgery in acute pyothorax. METHODS We retrospectively reviewed 38 consecutive video-assisted thoracic surgeries performed for acute pyothorax between January 2013 and December 2017 at our institution. Data were analyzed using the independent samples t test and Mann-Whitney U test. A receiver-operating characteristic curve was used to identify the optimal time for intervention. RESULTS The average time from disease onset to surgery was 17.9 days, and the average preoperative drainage period was 8.3 days. The operation was completed in all patients with video-assisted thoracic surgery curettage and drainage under general anesthesia; single lung ventilation was administered, and one or two thoracic drains were placed. The average postoperative drainage period was 10.8 days. Intraoperative complications were observed in two cases; no perioperative death occurred. Additional surgery was performed in four cases because of poor treatment response. There was no recurrence of pyothorax over a mean postoperative follow-up period of 42.5 months. A receiver-operating characteristic curve showed that the cut-off time from disease onset to surgery was 21.0 days; complication rates were 14.3% and 25.0% for patients operated on before and after 21 days, respectively. CONCLUSIONS Thoracoscopic surgery for acute pyothorax is safe and curative, and should be performed within 21 days of disease onset to avoid postoperative complications.
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Affiliation(s)
- Hideki Matsudaira
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Sinbashi, Minato, Tokyo, 105-8461, Japan
| | - Satoshi Arakawa
- Department of Surgery, The Jikei Katsushika Medical Center, 6-41-2 Aoto, Katsushika, Tokyo, 125-8506, Japan
| | - Yuki Noda
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Sinbashi, Minato, Tokyo, 105-8461, Japan
| | - Ai Ohtani
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Sinbashi, Minato, Tokyo, 105-8461, Japan
| | - Daiki Kato
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Sinbashi, Minato, Tokyo, 105-8461, Japan
| | - Takamasa Shibasaki
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Sinbashi, Minato, Tokyo, 105-8461, Japan
| | - Shohei Mori
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Sinbashi, Minato, Tokyo, 105-8461, Japan
| | - Jun Hirano
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Sinbashi, Minato, Tokyo, 105-8461, Japan
| | - Takashi Ohtsuka
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Sinbashi, Minato, Tokyo, 105-8461, Japan.
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20
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Akamine T, Kitahara H, Hashinokuchi A, Shimokawa M, Miura N, Kometani T, Shikada Y, Sonoda T. Assessment of Intraoperative Microbiological Culture in Patients with Empyema: Comparison with Preoperative Microbiological Culture. Ann Thorac Cardiovasc Surg 2021; 27:346-354. [PMID: 33967122 PMCID: PMC8684835 DOI: 10.5761/atcs.oa.20-00327] [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] [Indexed: 11/21/2022] Open
Abstract
Purpose: Assessing microbiological culture results is essential in the diagnosis of empyema and appropriate antibiotic selection; however, the guidelines for the management of empyema do not mention assessing microbiological culture intraoperatively. Therefore, we tested the hypothesis that intraoperative microbiological culture may improve the management of empyema. Methods: We performed a retrospective analysis of 47 patients who underwent surgery for stage II/III empyema from January 2011 to May 2019. We compared the positivity of microbiological culture assessed preoperatively at empyema diagnosis versus intraoperatively. We further investigated the clinical characteristics and postoperative outcomes of patients whose intraoperative microbiological culture results were positive. Results: The positive rates of preoperative and intraoperative microbiological cultures were 27.7% (13/47) and 36.2% (17/47), respectively. Among 34 patients who were culture-negative preoperatively, eight patients (23.5%) were culture-positive intraoperatively. Intraoperative positive culture was significantly associated with a shorter duration of preoperative antibiotic treatment (p = 0.002). There was no significant difference between intraoperative culture-positive and -negative results regarding postoperative complications. Conclusions: Intraoperative microbiological culture may help detect bacteria in patients whose microbiological culture results were negative at empyema diagnosis. Assessing microbiological culture should be recommended intraoperatively as well as preoperatively, for the appropriate management of empyema.
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Affiliation(s)
- Takaki Akamine
- Department of Surgery, Saiseikai Fukuoka General Hospital, Fukuoka, Fukuoka, Japan
| | - Hirokazu Kitahara
- Department of Surgery, Saiseikai Karatsu Hospital, Karatsu, Saga, Japan
| | | | - Mototsugu Shimokawa
- Department of Biostatistics, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Naoko Miura
- Department of Surgery, Saiseikai Fukuoka General Hospital, Fukuoka, Fukuoka, Japan
| | - Takuro Kometani
- Department of Surgery, Saiseikai Fukuoka General Hospital, Fukuoka, Fukuoka, Japan
| | - Yasunori Shikada
- Department of Surgery, Saiseikai Fukuoka General Hospital, Fukuoka, Fukuoka, Japan
| | - Takashi Sonoda
- Department of Surgery, Saiseikai Karatsu Hospital, Karatsu, Saga, Japan
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21
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Gravesteijn B, Krijkamp E, Busschbach J, Geleijnse G, Helmrich IR, Bruinsma S, van Lint C, van Veen E, Steyerberg E, Verhoef K, van Saase J, Lingsma H, Baatenburg de Jong R. Minimizing Population Health Loss in Times of Scarce Surgical Capacity During the Coronavirus Disease 2019 Crisis and Beyond: A Modeling Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:648-657. [PMID: 33933233 PMCID: PMC7933792 DOI: 10.1016/j.jval.2020.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/29/2020] [Accepted: 12/13/2020] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Coronavirus disease 2019 has put unprecedented pressure on healthcare systems worldwide, leading to a reduction of the available healthcare capacity. Our objective was to develop a decision model to estimate the impact of postponing semielective surgical procedures on health, to support prioritization of care from a utilitarian perspective. METHODS A cohort state-transition model was developed and applied to 43 semielective nonpediatric surgical procedures commonly performed in academic hospitals. Scenarios of delaying surgery from 2 weeks were compared with delaying up to 1 year and no surgery at all. Model parameters were based on registries, scientific literature, and the World Health Organization Global Burden of Disease study. For each surgical procedure, the model estimated the average expected disability-adjusted life-years (DALYs) per month of delay. RESULTS Given the best available evidence, the 2 surgical procedures associated with most DALYs owing to delay were bypass surgery for Fontaine III/IV peripheral arterial disease (0.23 DALY/month, 95% confidence interval [CI]: 0.13-0.36) and transaortic valve implantation (0.15 DALY/month, 95% CI: 0.09-0.24). The 2 surgical procedures with the least DALYs were placing a shunt for dialysis (0.01, 95% CI: 0.005-0.01) and thyroid carcinoma resection (0.01, 95% CI: 0.01-0.02). CONCLUSION Expected health loss owing to surgical delay can be objectively calculated with our decision model based on best available evidence, which can guide prioritization of surgical procedures to minimize population health loss in times of scarcity. The model results should be placed in the context of different ethical perspectives and combined with capacity management tools to facilitate large-scale implementation.
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Affiliation(s)
- Benjamin Gravesteijn
- Department of Otorhinolaryngology (ENT), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eline Krijkamp
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Institute for Health Sciences, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Jan Busschbach
- Department of Medical Psychology, Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Institute for Health Sciences, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Geert Geleijnse
- Department of Otorhinolaryngology (ENT), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Isabel Retel Helmrich
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sophie Bruinsma
- Department of Quality and Patient Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Céline van Lint
- Department of Quality and Patient Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ernest van Veen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ewout Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Kees Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan van Saase
- Department of Internal Medicine - Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hester Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rob Baatenburg de Jong
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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22
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White-Dzuro CG, Assi PE, Thomas HC, Thayer WP. Unusual presentation of empyema necessitans: case report and review of the literature. Gen Thorac Cardiovasc Surg 2021; 69:1026-1030. [PMID: 33559044 DOI: 10.1007/s11748-021-01601-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/20/2021] [Indexed: 11/24/2022]
Abstract
Empyema necessitans is characterized by the extension of a pleural empyema into adjacent structures beyond the pleural space. Although rare, it adds significant complications to patients already suffering from pleural empyema. Standard of surgical care has yet to be characterized or described in the literature. Here, we describe the unusual presentation of a 55-year-old man with methicillin-sensitive Staphylococcus aureus empyema necessitans and outline both our surgical intervention and thoracic reconstruction. We present our case's presentation, management, and outcome. We then review the literature and describe a multidisciplinary approach for management. Empyema necessitans is a very rare and morbid condition requiring urgent intervention to promote optimal outcomes.
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Affiliation(s)
- Colin G White-Dzuro
- Vanderbilt University School of Medicine, Nashville, TN, USA. .,Department of Plastic Surgery, Vanderbilt University Medical Center, D-4207 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37212, USA.
| | - Patrick E Assi
- Department of Plastic Surgery, Vanderbilt University Medical Center, D-4207 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37212, USA
| | | | - Wesley P Thayer
- Department of Plastic Surgery, Vanderbilt University Medical Center, D-4207 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37212, USA
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23
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Risk factors associated with surgical intervention in childhood pleural tuberculosis. Sci Rep 2021; 11:3084. [PMID: 33542398 PMCID: PMC7862429 DOI: 10.1038/s41598-021-82936-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/27/2021] [Indexed: 11/08/2022] Open
Abstract
Surgical intervention use is common in the management of childhood pleural tuberculosis (TB), however, its associated risk factors remain unclear. Between January 2006 and December 2019, consecutive children patients (≤ 15 years old) who had a diagnosis of pleural TB were included for the analysis. Surgical intervention was defined as debridement (such as breaking loculations), decortication, and thoracic surgery (such as lobectomy or segmental resection). Patients undergoing surgery were included as surgical group, without surgery were classified as non-surgical group, surgical risk factors were then estimated. Univariate and multivariate logistic regression analysis were performed to evaluate the risk factors for surgical interventions. A total of 154 children diagnosed as pleural TB (definite, 123 cases; possible, 31 cases) were included in our study. Of them, 29 patients (18.8%) were classified as surgical group and 125 patients (81.2%) were classified as non-surgical group. Surgical treatments were analyzed in 29 (18.8%) patients, including debridement (n = 4), decortication (n = 21), and thoracic surgery (n = 4). Further multivariate analysis revealed that empyema (age- and sex-adjusted OR = 27.3, 95% CI 8.6, 87.1; P < 0.001) and frequency of hospitalization (age- and sex-adjusted OR = 1.53, 95% CI 1.11, 2.11; P < 0.01) were associated with the use of surgical interventions in children with pleural TB. In China, surgical interventions are still required in a significant proportion of children with pleural TB, and the surgical risk is found to be associated with the frequency of hospitalization and empyema. These findings may be helpful to improve the management of children with pleural TB and minimize the risk of poor outcomes.
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24
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Chaddha U, Agrawal A, Feller-Kopman D, Kaul V, Shojaee S, Maldonado F, Ferguson MK, Blyth KG, Grosu HB, Corcoran JP, Sachdeva A, West A, Bedawi EO, Majid A, Mehta RM, Folch E, Liberman M, Wahidi MM, Gangadharan SP, Roberts ME, DeCamp MM, Rahman NM. Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement. THE LANCET RESPIRATORY MEDICINE 2021; 9:1050-1064. [PMID: 33545086 DOI: 10.1016/s2213-2600(20)30533-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023]
Abstract
Although our understanding of the pathogenesis of empyema has grown tremendously over the past few decades, questions still remain on how to optimally manage this condition. It has been almost a decade since the publication of the MIST2 trial, but there is still an extensive debate on the appropriate use of intrapleural fibrinolytic and deoxyribonuclease therapy in patients with empyema. Given the scarcity of overall guidance on this subject, we convened an international group of 22 experts from 20 institutions across five countries with experience and expertise in managing adult patients with empyema. We did a literature and internet search for reports addressing 11 clinically relevant questions pertaining to the use of intrapleural fibrinolytic and deoxyribonuclease therapy in adult patients with bacterial empyema. This Position Paper, consisting of seven graded and four ungraded recommendations, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique. Our Position Paper aims to address the existing gap in knowledge and to provide consensus-based recommendations to offer guidance in clinical decision making when considering the use of intrapleural therapy in adult patients with bacterial empyema.
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Affiliation(s)
- Udit Chaddha
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Abhinav Agrawal
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, New Hyde Park, NY, USA
| | - David Feller-Kopman
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Viren Kaul
- Department of Pulmonary and Critical Care Medicine, Crouse Health-SUNY Upstate Medical University, Syracuse, NY, USA
| | - Samira Shojaee
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mark K Ferguson
- Section of Thoracic Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Kevin G Blyth
- Institute of Cancer Sciences and Glasgow Pleural Disease Unit, University of Glasgow, Glasgow, UK
| | - Horiana B Grosu
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John P Corcoran
- Interventional Pulmonology Service, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD, USA
| | - Alex West
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Adnan Majid
- Department of Surgery, Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Ravindra M Mehta
- Department of Pulmonary and Critical Care, Apollo Hospitals, Bangalore, India
| | - Erik Folch
- Complex Chest Disease Center, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Moishe Liberman
- Division of Thoracic Surgery, University of Montreal, Montreal, QC, Canada
| | - Momen M Wahidi
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, NC, USA
| | - Sidhu P Gangadharan
- Department of Surgery, Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Mark E Roberts
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI, USA
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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25
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Iliopoulou M, Skouras V, Psaroudaki Z, Makarona M, Vogiatzakis E, Tsorlini E, Katsifa E, Spyratos D, Siopi D, Kotsiou O, Xitsas S, Martsoukou M, Sigala I, Kalomenidis I. Bacteriology, antibiotic resistance and risk stratification of patients with culture-positive, community-acquired pleural infection. J Thorac Dis 2021; 13:521-532. [PMID: 33717525 PMCID: PMC7947506 DOI: 10.21037/jtd-20-2786] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Community-acquired pleural infection (CAPI) is a growing health problem worldwide. Although most CAPI patients recover with antibiotics and pleural drainage, 20% require surgical intervention. The use of inappropriate antibiotics is a common cause of treatment failure. Awareness of the common causative bacteria along with their patterns of antibiotic resistance is critical in the selection of antibiotics in CAPI-patients. This study aimed to define CAPI bacteriology from the positive pleural fluid cultures, determine effective antibiotic regimens and investigate for associations between clinical features and risk for death or antibiotic-resistance, in order to advocate with more invasive techniques in the optimal timing. Methods We examined 158 patients with culture positive, CAPI collected both retrospectively (2012-2013) and prospectively (2014-2018). Culture-positive, CAPI patients hospitalized in six tertiary hospitals in Greece were prospectively recruited (N=113). Bacteriological data from retrospectively detected patients were also used (N=45). Logistic regression analysis was performed to identify clinical features related to mortality, presence of certain bacteria and antibiotic resistance. Results Streptococci, especially the non-pneumococcal ones, were the most common bacteria among the isolates, which were mostly sensitive to commonly used antibiotic combinations. RAPID score (i.e., clinical score for the stratification of mortality risk in patients with pleural infection; parameters: renal, age, purulence, infection source, and dietary factors), diabetes and CRP were independent predictors of mortality while several patient co-morbidities (e.g., diabetes, malignancy, chronic renal failure, etc.) were related to the presence of certain bacteria or antibiotic resistance. Conclusions The dominance of streptococci among pleural fluid isolates from culture-positive, CAPI patients was demonstrated. Common antibiotic regimens were found highly effective in CAPI treatment. The predictive strength of RAPID score for CAPI mortality was confirmed while additional risk factors for mortality and antibiotic resistance were detected.
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Affiliation(s)
| | - Vasileios Skouras
- Department of Pulmonary Medicine, 401 General Army Hospital, Athens, Greece
| | - Zoe Psaroudaki
- Department of Clinical Microbiology, "Evangelismos" Hospital, Athens, Greece
| | - Magda Makarona
- Microbiology Laboratory and National Reference Center for TB, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Evangelos Vogiatzakis
- Microbiology Laboratory and National Reference Center for TB, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Eleni Tsorlini
- Department of Microbiology, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Katsifa
- Department of Microbiology, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dionisios Spyratos
- Department of Pulmonary Medicine, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitra Siopi
- Department of Pulmonary Medicine, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ourania Kotsiou
- Department of Respiratory Medicine, University of Thessaly, Larissa, Greece
| | - Stelios Xitsas
- Department of Microbiology, University Hospital of Larissa, Larissa, Greece
| | - Maria Martsoukou
- Department of Microbiology, "Sismanoglion" General Hospital, Athens, Greece
| | - Ioanna Sigala
- 1st Department of Critical Care and Pulmonary Medicine, National and Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
| | - Ioannis Kalomenidis
- 1st Department of Critical Care and Pulmonary Medicine, National and Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece
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Pleural empyema in children - benefits of primary thoracoscopic treatment. Wideochir Inne Tech Maloinwazyjne 2020; 16:264-272. [PMID: 33786143 PMCID: PMC7991945 DOI: 10.5114/wiitm.2020.97443] [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: 04/12/2020] [Accepted: 04/30/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Pleural empyema is the condition of the pleural cavity when initially sterile pleural effusion has become infected. In the majority of cases, it is of parapneumonic origin. Parapneumonic effusions and pleural empyemata usually continuously progress in severity. The American Thoracic Society divides them into three stages: exudative, fibrinopurulent and organizing. The therapy depends on the stage. Aim To assess whether thoracoscopy should be considered better than conservative treatment and to assess the feasibility of the thoracoscopic approach to the 3rd phase of pleural empyema. Material and methods The clinical course of 115 patients treated from 1996 to 2017 was analyzed. 45 patients operated on thoracoscopically after the failure of conventional treatment were compared with 70 patients treated by primary thoracoscopic drainage and decortication. Results The results of the study demonstrated that patients treated primarily by thoracoscopy had a shortened length of hospital stay (16.6 vs. 19.3 days), reduced drainage time (7.9 vs. 9.8 days), and shorter time of general therapy (31.8 vs. 38.0 days). They required fibrinolysis less frequently (12.8 vs. 26.7% of patients) and had reduced risk of reoperation (10 vs. 15.6% of cases). Operation time in the 3rd stage was only 15 min longer. The difference in length of hospital stay was only 0.8 days in favor of less severe cases. Conclusions The thoracoscopic approach is safely feasible in the 3rd stage of pleural empyema and should be considered as the preferred approach. Furthermore, the post-operative stay and general course of the disease are milder whenever surgery would not be delayed by prolonged conservative treatment attempts.
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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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28
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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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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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31
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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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Evaluation of clinical risk factors for developing pleural empyema secondary to liver abscess. BMC Gastroenterol 2019; 19:215. [PMID: 31842761 PMCID: PMC6915871 DOI: 10.1186/s12876-019-1128-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the clinical manifestation and predictive risk factors of pleural empyema developing during treatment of the pyogenic liver abscess. METHODS Medical records of patients with the liver abscess in our institution were reviewed retrospectively. Enrolled patients were classified into four groups; Group 1: patients without pleural effusion, Group 2: patients with pleural effusion and who were treated noninvasively, Group 3: patient with pleural effusion and who were treated with thoracentesis, and Group 4: patients with pleural effusion that developed into empyema. Patient characteristics, clinical manifestation, and possible risk factors in development of empyema were analyzed. RESULTS A total of 234 patients was enrolled in this study. The incidence rate of empyema was 4.27% (10 patients). The mean interval for developing pleural effusion was 5.6 ± 6.35 days. In multivariate analysis, risk factors for developing pleural effusion included the location of the liver abscess near the right diaphragm (segment 7 and 8, OR = 2.30, p = 0.048), and larger diameter of the liver abscess (OR = 1.02, p = 0.042). Among patients who developed pleural effusions, presences of mixed microorganisms from culture of liver aspirates (OR = 10.62, p = 0.044), bilateral pleural effusion (OR = 46.72, p = 0.012) and combined biliary tract inflammation (OR = 21.05, p = 0.040) were significantly associated with the need for invasive intervention including surgery on effusion. CONCLUSION The location of the liver abscess as well as pleural effusion, elevated inflammatory markers, and combined biliary tract inflammation may be important markers of developing pleural complication in patients with pyogenic liver abscess.
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Nayak R, Brogly SB, Lajkosz K, Lougheed MD, Petsikas D. Outcomes of Operative and Nonoperative Treatment of Thoracic Empyema: A Population-Based Study. Ann Thorac Surg 2019; 108:1456-1463. [DOI: 10.1016/j.athoracsur.2019.05.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/29/2019] [Accepted: 05/28/2019] [Indexed: 11/25/2022]
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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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Piracha S, Ahmed SSM, Mohd Afzal S, Ganaie MB. Empyema thoracis secondary to community-acquired Panton-Valentine leukocidin (PVL) methicillin-resistant Staphylococcus aureus (MRSA) infection. BMJ Case Rep 2019; 12:12/4/e228297. [PMID: 30948401 DOI: 10.1136/bcr-2018-228297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a case of a previously fit middle-aged man presenting to the outpatient setting with unilateral pleural effusion, with minimal symptoms. On subsequent investigations, he was diagnosed with empyema thoracis secondary to Panton-Valentine leukocidin (PVL)-toxin positive community-acquired methicillin-resistant Staphylococcus aureus (MRSA). The patient was treated with prolonged antibiotics and pleural drainage, and he remained haemodynamically stable throughout hospital admission. PVL is a cytolytic exotoxin produced by some strains of S. aureus Such strains often cause recurrent skin and soft tissue infections, usually in previously fit and healthy individuals. Less commonly, invasive infections occur; these carry a high mortality rate if associated with necrotising pneumonia or septic shock. PVL genes are present in approximately 2% of clinical isolates of S. aureus in the UK. PVL-producing MRSA infections are on the rise and present significant clinical and public health challenges.
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Affiliation(s)
- Shahbaz Piracha
- Department of Respiratory Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Syeda Saba Muneer Ahmed
- Department of Respiratory Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Samira Mohd Afzal
- Department of Infectious Diseases, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Muhammad Badar Ganaie
- Department of Respiratory Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
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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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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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Concurrent Versus Sequential Intrapleural Instillation of Tissue Plasminogen Activator and Deoxyribonuclease for Pleural Infection. J Bronchology Interv Pulmonol 2018; 25:125-131. [PMID: 29346247 DOI: 10.1097/lbr.0000000000000461] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of pleural infection with instillation of sequential intrapleural tissue plasminogen activator (tPA) and human recombinant deoxyribonuclease (DNase) twice daily for a total of 6 doses has been shown to decrease surgical referral and improve radiographic imaging. This labor-intensive regimen was empirically chosen. Thus, it remains unclear whether the 2 drugs can be administered immediately one after the other (concurrent administration) instead of instilling them separately with a 1-hour to 2-hour interval in between (sequential administration). The aim of this study was to compare the efficacy and safety of sequential versus concurrent tPA/DNase therapy in patients with pleural infection. METHODS This was a prospective observational study. Consecutive patients with pleural infection who received concurrent and sequential tPA/DNase were included. The initiation and number of doses of tPA/DNase therapy were based on the amount of pleural fluid drainage, clinical response and radiographic findings. RESULTS A total of 38 patients with pleural infection received tPA/DNase treatment: 18 in the sequential group and 20 in the concurrent group. Treatment was successful in 77.7% in the sequential group and 75% in concurrent group (P=0.57). There was no statistically significant difference between the 2 treatment groups (sequential and concurrent) in median pleural fluid drainage (P=0.45), median volume of pleural effusion estimated on chest computed tomography scan (P=0.4) or median hemithorax occupied by effusion on chest radiography (P=0.83) following intrapleural therapy. One patient required a blood transfusion for gradual pleural blood loss in each treatment group. Pain needing escalation of analgesia affected 3 patients in each arm but none required cessation of therapy. CONCLUSION A simpler regimen of concurrent administration of intrapleural tPA/DNase as compared with sequential intrapleural therapy is safe, effective, and represents a viable option for the management of pleural infection.
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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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Elsayed HH, Mostafa A, Fathy E, Diab HS, Nofal IM, AbdelHamid OA, El-Bawab HY, ElNori AA. Thoracoscopic management of early stages of empyema: is this the golden standard? J Vis Surg 2018; 4:114. [PMID: 29963403 DOI: 10.21037/jovs.2018.05.18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/08/2018] [Indexed: 11/06/2022]
Abstract
Background Empyema is a well-known disease that significantly increases the morbidity and mortality associated with pneumonia. There are a number of treatment modalities available but recently video assisted thoracoscopic surgery (VATS) has been suggested as a reliable tool in management of empyema; particularly in early stages. The aim of this study is to assess the safety and effectiveness of using initial VATS for all surgically fit patients with early stages of empyema. Methods Sixty-six patients with early stage empyema were prospectively studied between December 2013 and March 2016. Patients were divided into two groups: group A (28 patients) were managed conservatively without surgery for stage I (exudative) phase empyema by the chest physicians; and group B (38 patients) were managed by the thoracic surgeons by VATS for stage I (exudative) and stage II (fibrino-purulent) empyema. Comparison was made between both groups. Results There was no statistically significant difference between the groups from the point of view of age, sex or pre-intervention comorbidities (P>0.05). Average hospital stay in group A was 22 days (7-131 days), it was 4.1 days (2-14 days) in group B (P=0.004; 95% CI: 10.3-25.5) with a resultant lower cost. Three patients (10.7%) in group A suffered from major morbidity during treatment while none in group B suffered a major postoperative morbidity (P=0.039). There were 2 mortalities (7.1%) in group A and no deaths in group B (P=0.094). During a mean follow up period of 8 months [6-14] in group A 14.3% of the patients underwent open decortication, whereas in group B, 5.3% of the patients underwent the same procedure (P=0.047). Conclusions Thoracoscopic management of early stages of empyema should be the golden standard of management in surgically fit patients; particularly in the fibro-exudative phase of empyema. It is an effective and safe technique that reduces hospital stay, cost, complications and avoids the need for a decortication via a thoracotomy in most cases.
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Affiliation(s)
- Hany Hasan Elsayed
- Thoracic Surgery Department, Ain Shams University Hospital, Cairo, Egypt
| | - Ahmed Mostafa
- Thoracic Surgery Department, Ain Shams University Hospital, Cairo, Egypt
| | - Essam Fathy
- Thoracic Surgery Department, Ain Shams University Hospital, Cairo, Egypt
| | - Haytham S Diab
- Pulmonology Department, Ain Shams University Hospital, Cairo, Egypt
| | | | | | | | - Ahmed A ElNori
- Thoracic Surgery Department, Ain Shams University Hospital, Cairo, Egypt
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Jagelavicius Z, Jovaisas V, Mataciunas M, Samalavicius NE, Janilionis R. Preoperative predictors of conversion in thoracoscopic surgery for pleural empyema. Eur J Cardiothorac Surg 2018; 52:70-75. [PMID: 28369294 DOI: 10.1093/ejcts/ezx054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 01/03/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Thoracoscopy is an effective treatment method for pleural empyema; however, it is still not well defined as to which patient subgroups could benefit from it the most. The aim of the study was to identify preoperative factors that could facilitate selecting appropriate surgical intervention and to evaluate early postoperative period. METHODS Seventy-one patients were prospectively included in the study, which was conducted from January 2011 to June 2014. Thoracoscopic surgery for Stage II/III pleural empyema was performed in all patients. Thoracoscopy failed in 18 (25.4%) patients, requiring conversion to thoracotomy. The preoperative factors that could possibly predict conversion were analysed. RESULTS Obliterated pleural space (12 patients) and failure to achieve lung re-expansion (6 patients) were the main reasons for conversion. Multivariable logistic regression analysis demonstrated that each day of illness [odds ratio 1.1 (95% confidence interval 1.0-1.2], P = 0.004] and frank pus [odds ratio 4.4 (95% confidence interval 1.2-15.3), P = 0.021] were independent predictors of conversion. Using receiver-operating characteristic analysis, it was determined that the duration of illness had a high predictive value for conversion [area under the curve 0.8 (95% confidence interval 0.7-0.9), P < 0.001]. The cut-off value for duration of illness was 16 days (sensitivity 94.4%, specificity 54.7%). The conversion group had a significantly greater need for postoperative intensive care unit stay ( P = 0.022) but a lower rate of reoperations ( P = 0.105). CONCLUSIONS Duration of illness and frank pus discovered during thoracocentesis can help in selecting the patient for appropriate intervention. Earlier surgery for pleural empyema can reduce the rate of conversion and reoperation.
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Affiliation(s)
- Zymantas Jagelavicius
- Centre of General Thoracic Surgery, Clinic of Infectious and Chest Diseases, Dermatovenerology and Allergology, Faculty of Medicine, Vilnius University, Vinius, Lithuania.,Department of General Thoracic Surgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Vytautas Jovaisas
- Department of General Thoracic Surgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Mindaugas Mataciunas
- Radiology and Nuclear Medicine Centre, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Narimantas Evaldas Samalavicius
- Clinic of Internal Diseases, Family Medicine and Oncology, Faculty of Medicine, Vilnius University, Centre of Oncosurgery, National Cancer Institute, Vilnius, Lithuania
| | - Ricardas Janilionis
- Centre of General Thoracic Surgery, Clinic of Infectious and Chest Diseases, Dermatovenerology and Allergology, Faculty of Medicine, Vilnius University, Vinius, Lithuania.,Department of General Thoracic Surgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
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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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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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Li B, Liu C, Li Y, Yang HF, Du Y, Zhang C, Zheng HJ, Xu XX. Computed tomography-guided catheter drainage with urokinase and ozone in management of empyema. World J Radiol 2017; 9:212-216. [PMID: 28529685 PMCID: PMC5415891 DOI: 10.4329/wjr.v9.i4.212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/31/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To retrospectively compare the outcomes of catheter drainage, urokinase and ozone in management of empyema.
METHODS Retrospective study included 209 patients (111 males and 98 females; age range 19 to 72 years) who were diagnosed with empyema. The patients were divided into 3 groups based on the therapy instituted: catheter drainage only (group I); catheter drainage and urokinase (group II); catheter drainage, urokinase and ozone (group III). Drainage was considered successful if empyema was resolved with closure of cavity, clinical symptoms were resolved, and need for any further surgical procedure was avoided. Success rate, length of stay (LOS), need for further surgery and hospital costs were compared between the three groups using the Kruskall-Wallis nonparametric test, with P < 0.05 considered significant.
RESULTS Of the 209 patients with empyema, all catheters were placed successfully under CT guidance. Sixty-three patients were treated with catheters alone (group I), 64 with catheters and urokinase (group II), and 82 with catheters, urokinase and ozone (group III). Group I, group II and group III had success rates of 62%, 83% and 95% respectively (P < 0.05). Group I and group II had statistically longer LOS (P < 0.05) and higher hospital costs (P < 0.05) compared to group III. There were statistically significant differences between the three groups when comparing patients who converted into further surgery.
CONCLUSION The combination of chest tube drainage, urokinase and ozone is a safe and effective therapeutic modality in thoracic empyema.
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Mier JM, Cortés-Julián G, Berrios-Mejía J, Víctor-Valdivia Z. [The benefits of digital chest drainage in pleural decortication in thoracic empyema. Prospective, randomized, control trial]. CIR CIR 2017; 85:522-525. [PMID: 28087049 DOI: 10.1016/j.circir.2016.11.007] [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: 11/03/2016] [Accepted: 11/26/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prolonged air leak after pleural decortication is one of the most frequent complications. OBJECTIVE The aim of this study is to compare the effects of prolonged air leak between the digital chest drainage (DCD) system and the classic drainage system in patients with empyema class IIB or III (American Thoracic Society classification) in pleural decortication patients. MATERIAL AND METHODS A total of 37 patients were enrolled in a prospective randomized control trial over one year, consisting of 2blinded groups, comparing prolonged air leak as a main outcome, the number of days until removal of chest drain, length of hospital stay and complications as secondary outcomes. RESULTS The percentage of prolonged air leak was 11% in the DCD group and 5% in the classic group (P=0.581); the mean number of days of air leak was 2.5±1.8 and 2.4±2.2, respectively (P=0.966). The mean number of days until chest tube removal was 4.5±1.8 and 5.1±2.5 (P=0.41), the length of hospital stay was 7.8±3.7 and 8.9±4.0 (P=0.441) and the complication percentages were 4 (22%) and 7 (36%), respectively (P=0.227). DISCUSSION In this study, no significant difference was observed when the DCD was compared with the classic system. This was the first randomized clinical trial for this indication; thus, future complementing studies are warranted.
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Affiliation(s)
- José M Mier
- Servicio de Cirugía Cardiotorácica, Instituto Nacional de Enfermedades Respiratorias INER, Ciudad de México, México.
| | - Gildardo Cortés-Julián
- Servicio de Cirugía Cardiotorácica, Instituto Nacional de Enfermedades Respiratorias INER, Ciudad de México, México
| | - Juan Berrios-Mejía
- Servicio de Cirugía Cardiotorácica, Instituto Nacional de Enfermedades Respiratorias INER, Ciudad de México, México
| | - Zotés Víctor-Valdivia
- Servicio de Cirugía Cardiotorácica, Instituto Nacional de Enfermedades Respiratorias INER, Ciudad de México, México
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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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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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48
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Concurrent Intrapleural Instillation of Tissue Plasminogen Activator and DNase for Pleural Infection. A Single-Center Experience. Ann Am Thorac Soc 2016; 13:1512-8. [DOI: 10.1513/annalsats.201602-127oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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49
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Hsiao CH, Chen KC, Chen JS. Modified single-port non-intubated video-assisted thoracoscopic decortication in high-risk parapneumonic empyema patients. Surg Endosc 2016; 31:1719-1727. [PMID: 27519590 DOI: 10.1007/s00464-016-5164-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/30/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction are risky to receive surgical decortication under general anesthesia. Non-intubated video-assisted thoracoscopy surgery is successfully performed to avoid complications of general anesthesia. We performed single-port non-intubated video-assisted flexible thoracoscopy surgery in an endoscopic center. In this study, the possible role of our modified surgery to treat fibrinopurulent stage of parapneumonic empyema with high operative risks is investigated. METHODS We retrospectively reviewed fibrinopurulent stage of parapneumonic empyema patients between July 2011 and June 2014. Thirty-three patients with coronary artery disease and reduced left ventricular ejection fraction were included in this study. One group received tube thoracostomy, and the other group received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. Patient demographics, characteristics, laboratory findings, etiology, and treatment outcomes were compared. RESULTS Mean age of 33 patients (24 males, 9 females) was 76.2 ± 9.7 years. Twelve patients received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication, and 21 patients received tube thoracostomy. Visual analog scale scores on postoperative first hour and first day were not significantly different in two groups (p value = 0.5505 and 0.2750, respectively). Chest tube drainage days, postoperative fever subsided days, postoperative hospital days, and total length of stay were significantly short in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication (p value = 0.0027, 0.0001, 0.0009, and 0.0065, respectively). Morbidities were low, and mortality was significantly low (p value = 0.0319) in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. CONCLUSIONS Single-port non-intubated video-assisted flexible thoracoscopy surgery decortication may be suggested to be a method other than tube thoracostomy to deal with fibrinopurulent stage of parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction.
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Affiliation(s)
- Chen-Hao Hsiao
- Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan
- Genome and Systems Biology Degree Program, National Taiwan University and Academia Sinica, Taipei, Taiwan
| | - Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan S. Rd, Taipei, 10002, Taiwan
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan S. Rd, Taipei, 10002, Taiwan.
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.
- Division of Experimental Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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50
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Corcoran JP, Wrightson JM, Belcher E, DeCamp MM, Feller-Kopman D, Rahman NM. Pleural infection: past, present, and future directions. THE LANCET RESPIRATORY MEDICINE 2016; 3:563-77. [PMID: 26170076 DOI: 10.1016/s2213-2600(15)00185-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/13/2015] [Accepted: 05/05/2015] [Indexed: 02/09/2023]
Abstract
Pleural space infections are increasing in incidence and continue to have high associated morbidity, mortality, and need for invasive treatments such as thoracic surgery. The mechanisms of progression from a non-infected, pneumonia-related effusion to a confirmed pleural infection have been well described in the scientific literature, but the route by which pathogenic organisms access the pleural space is poorly understood. Data suggests that not all pleural infections can be related to lung parenchymal infection. Studies examining the microbiological profile of pleural infection inform antibiotic choice and can help to delineate the source and pathogenesis of infection. The development of radiological methods and use of clinical indices to predict which patients with pleural infection will have a poor outcome, as well as inform patient selection for more invasive treatments, is particularly important. Randomised clinical trial and case series data have shown that the combination of an intrapleural tissue plasminogen activator and deoxyribonuclease therapy can potentially improve outcomes, but the use of this treatment as compared with surgical options has not been precisely defined, particularly in terms of when and in which patients it should be used.
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Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Elizabeth Belcher
- Department of Cardiothoracic Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Malcolm M DeCamp
- Division of Thoracic Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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