Thoracic empyema in patients with liver cirrhosis: clinical characteristics and outcome analysis of thoracoscopic management

Video-assisted thoracoscopic surgery for thoracic empyema in patients on maintenance hemodialysis

OBJECTIVE

Thoracic empyema in uremic patients on maintenance hemodialysis is a challenging situation. The clinical characteristics are rarely reported, and the surgical outcomes remain unclear. We report our experience with video-assisted thoracoscopic surgery in these patients during 10-year period of time.

METHODS

Between 2005 and 2015, we retrospectively reviewed the clinical characteristics, bacteriological studies, and thoracoscopic surgical results of 23 empyema patients undergoing maintenance hemodialysis.

RESULTS

The mean patient age was 67.1 ± 12.9 years. All patients had additional preexisting systemic diseases. The mean duration of hemodialysis was 34.7 ± 25.8 months. The infections causing empyema were pneumonia in 11 (47.8%), blood stream infection in 8 (34.8%), and uremic pleuritis in 4 (17.4%). Among the 22 identified microorganisms, the most common pathogen was methicillin-resistant Staphylococcus aureus (31.8%). After thoracoscopic surgery, 8 patients (34.8%) required additional procedures for complications, including 2 patients who required repeated thoracoscopy for hemothorax and 6 (26.1%) patients who required open drainage for residual empyema. The mean hospital stay was 62.4 days, and 6 patients (26.1%) died in the hospital. Univariate and multivariate analyses revealed that maintenance hemodialysis longer than 5 years was a significant factor associated with in-hospital mortality (odds ratio: 14.8, 95% confidence interval 1.5-151.6; p < 0.0001).

CONCLUSION

While surgical management of thoracic empyema in uremic patients undergoing maintenance hemodialysis is associated with high rates of complication and mortality, thoracoscopic surgery is feasible, especially for patients undergoing hemodialysis for less than 5 years.

Detection of the major bacterial pathogens among children suffering from empyema in Ahvaz city, Iran

Introduction

Empyema is one of the important causes of pediatric hospital admissions.

Aim

In this study, we had investigated the frequency rates of S aureus, S pneumoniae, H influenzae, and P aeruginosa using PCR and bacterial culture among children suffering from empyema in Ahvaz city, Iran.

Methods

This was a descriptive study conducted on the patients hospitalized in ICUs of two teaching Hospitals of Ahvaz, Iran, between March and September 2018 on 105 pleural fluid (PF) samples of the children less than 16 years of age with the diagnosis of empyema thoracis. These specimens were inoculated on the bacterial culture media and identified using biochemical characteristics. Then, the existence of the four pathogens mentioned above was evaluated using PCR method.

Result

In this study, these bacteria agents were identified in 81 (77.14%) and 30 (28.57%) cases using the PCR assay and bacterial culture, respectively. Moreover, the PCR assay identified the infectious agents in 51 (68%) of PFs where the culture method failed. S pneumoniae (63 cases) was recognized as the most common pathogen, followed by P aeruginosa(19 cases), S aureus(15 cases), and H influenzae (9 cases) using the bacterial culture and PCR. Co‐infections were detected in 21 samples (20%) using PCR and one sample using the bacterial culture (P aeruginosa and S pneumoniae).

Conclusion

In this study, we found the higher frequencies of these microorganisms using PCR than culture. In addition, we showed that PCR was a sensitive and accurate method that unaffected by antibiotic therapy and could detect well co‐infections.

Predictors of Outcomes After Thoracic Surgery in Orthotopic Liver Transplant Recipients With Pleural Disease

Orthotopic liver transplant (OLT) recipients are at high risk for postoperative pulmonary complications. We aim to determine factors associated with morbidity and mortality in OLT recipients that required thoracic surgery for pleural space complications. A retrospective review was performed of 42 patients who underwent thoracic surgery after OLT between 2005 and 2015. Preoperative data and postoperative outcomes were reviewed. Time to mortality was summarized using Kaplan-Meier curves. Outcomes associated with 30-day morbidity and mortality as well as long-term mortality were analyzed with univariate analysis. Between 2005 and 2015, 1735 OLTs were performed at our institution. We identified 42 patients who required thoracic surgery. Of these 42 OLT recipients, 33 patients required thoracic surgery for pleural space complications. The median interval between OLT and thoracic surgery for pleural space complications was 5.7 months (interquartile range 2.2-14.1). The most common surgical indications were chronic pleural effusion (n = 12, 36.4%) and empyema (n = 10, 30.3%). The most common thoracic operations were decortication and empyema evacuation. The 30-day morbidity was 69.7%. Bilirubin and empyema were significantly associated with 30-day morbidity (odds ratio [OR] = 2.3, P = 0.023; OR = 16.3, P = 0.015). The 30-day, 1-year, and 5-year mortality rates were 15.2%, 57.6%, and 70.2%, respectively. Vasopressor requirement was significantly associated with 30-day mortality (OR = 10.2, P = 0.031). The development of pleural space complications requiring surgery in OLT recipients suggests a poor prognosis. Hyperbilirubinemia and pleural space infections were associated with high postoperative morbidity in OLT recipients requiring thoracic surgery for pleural space complications.

Risk of empyema in patients with chronic liver disease and cirrhosis: A nationwide, population-based cohort study

BACKGROUND

Empyema is an important complication for patients with chronic liver disease and cirrhosis (CLDC). However, no study has investigated this relationship by using a population-based cohort study.

METHODS

We used the National Health Insurance Research Data of Taiwan to identify a cohort of 76 027 CLDC patients newly diagnosed in 2000-2010 and a comparison cohort without CLDC of same size matched by age, gender and the year of diagnosis. The occurrence of empyema was monitored until the end of 2011. The hazard ratios (HRs) of empyema were estimated using the Cox model.

RESULTS

The overall incidence of empyema was 66% greater in the CLDC group than in the non-CLDC group (3.85 vs 2.32/10 000 person-years, P<.001), with an adjusted HR of 1.54 (95% confidence interval [CI]=1.24-1.90). Compared with those without CLDC, adjusted HRs of empyema were 4.96 (95% CI=3.40-7.24) for patients with cirrhosis and 4.75 (95% CI=3.11-7.24) for patients with alcoholic CLDC. Further analyses revealed significant adjusted HRs of empyema among CLDC patients with ascites (5.76, 95% CI=4.13-8.04) and with gastrointestinal haemorrhage (1.60, 95% CI=1.03-2.48), compared to those without the respective disorders. Analyses using propensity score matched CLDC and non-CLDC cohorts revealed similar results.

CONCLUSION

The present study shows that CLDC patients have an increased risk of empyema. These patients need timely monitor for the risk of empyema, particularly for those with comorbid cirrhosis, alcoholic disorder, gastrointestinal haemorrhage and ascites.

Acute thoracic empyema: clinical characteristics and outcome analysis of video-assisted thoracoscopic surgery

BACKGROUND/PURPOSE

Acute thoracic empyema is a common clinical problem worldwide, resulting in substantial morbidity and mortality. The objective of this study was to report its clinical characteristics and to evaluate whether thoracoscopic surgery is associated with a lower rate of in-hospital mortality compared with nonoperative drainage.

METHODS

Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriological studies, and treatment outcomes of 602 patients with acute thoracic empyema. Thoracoscopic surgery was performed in 417 (69.2%) patients, while the remaining patients underwent nonoperative drainage. After treatment, 77 patients (12.8%) died in the hospital. A propensity score-based process, matched on potential risk factors for in-hospital mortality, was performed to select patients with equalized potential prognostic factors in the thoracoscopy and nonoperative groups. The log-rank test was used to compare the survival time with discharge between the two matched groups.

RESULTS

Multivariate analysis showed that age, malignancy, chronic lung disease, chronic renal insufficiency, liver cirrhosis, polymicrobial infection, and positive bacterial culture were risk factors for in-hospital mortality. The propensity score-matched analysis showed that the in-hospital mortality difference was significant (p = 0.014) and the Kaplan-Meier survival analysis revealed a higher survival rate to discharge (p < 0.001 by log-rank test), both favoring thoracoscopy over nonoperative drainage.

CONCLUSION

Acute thoracic empyema carries a high mortality rate, especially in elderly patients with coexisting medical conditions and polymicrobial and positive bacterial cultures. Our study results also showed that thoracoscopy is feasible and might provide better chances for survival in borderline operable patients than nonoperative drainage.

Management of pleural empyema with a vacuum-assisted closure device and reconstruction of open thoracic window in a patient with liver cirrhosis

The patient is a 21-year-old female, diagnosed with cryptogenic cirrhosis at the age of 9. She presented with left post-pneumonic empyema that did not remit with conventional medical management and evolved with fistulization to the skin in the 7th intercostal space in the left subscapular region. We performed an open thoracic window procedure, and on the 6th day the patient was sent home with a portable vacuum-assisted closure device, with changes of the material every 4 days until the cavity was completed obliterated (92 days). Imaging tests showed full expansion of the lung, and chest wall reconstruction was performed with titanium rods. The high mortality of empyema in patients with liver disease requires both implementing and searching for new adjuvant therapies, like the use of vacuum-assisted closure systems and reconstruction with titanium rods. Controlled studies with a wide range of cases are needed for proper evaluation.