Post-pneumonectomy empyema: Current management strategies

Optimizing the management of complicated pleural effusion: From intrapleural agents to surgery

Pleural effusion is a frequent complication of acute pulmonary infection and can affect its morbidity and mortality. The possible evolution of a parapneumonic pleural effusion includes 3 stages: exudative (simple accumulation of pleural fluid), fibropurulent (bacterial invasion of the pleural cavity), and organized stage (scar tissue formation). Such a progression is favored by inadequate treatment or imbalance between microbial virulence and immune defenses. Biochemical features of a fibrinopurulent collection include a low pH (<7.20), low glucose level (<60 mg/dl), and high lactate dehydrogenase (LDH). A parapneumonic effusion in the fibropurulent stage is usually defined "complicated" since antibiotic therapy alone is not enough for its resolution and an invasive procedure (pleural drainage or surgery) is required. Chest ultrasound is one of the most useful imaging tests to assess the presence of a complicated pleural effusion. Simple parapneumonic effusions are usually anechoic, whereas complicated effusions often have a complex appearance (non-anechoic, loculated, or septated). When simple chest tube placement fails and/or patients are not suitable for more invasive techniques (i.e. surgery), intra-pleural instillation of fibrinolytic/enzymatic therapy (IPET) might represent a valuable treatment option to obtain the lysis of fibrin septa. IPET can be used as either initial or subsequent therapy. Further studies are ongoing or are required to help fill some gaps on the optimal management of parapneumonic pleural effusion. These include the duration of antibiotic therapy, the risk/benefit ratio of medical thoracoscopy and surgery, and new intrapleural treatments such as antibiotic-eluting chest tubes and pleural irrigation with antiseptic agents.

The postoperative chest in lung cancer

Most of the complications following lung cancer surgery occur in the early postoperative period and can result in significant morbidity and mortality. Delayed complications can also occur. Diagnosing these complications can be challenging because clinical manifestations are non-specific. Imaging plays an important role in detecting these complications in a timely manner and facilitates prompt interventions. Hence, it is important to have knowledge of the expected anatomical alterations following lung cancer surgeries, and the spectrum of post-surgical complications and their respective imaging findings to avoid misinterpretations or delay in diagnosis.

Management of Bronchopleural Fistula Complicated by Skin Wound Necrosis after Thoracomyoplasty

Skin necrosis is a rare complication after thoracomyoplasty and usually needs conservative treatment. We described positive findings with surgical approach. A 54-year-old man showed bronchopleural fistula after undergoing right pneumonectomy for lung cancer, treated with thoracomyoplasty. On the 20th postoperative day, a skin wound lesion was noted, whose deterioration required a skin flap transposition. Patient was discharged from hospital on the 7th postoperative day and did not show relapse at the 7th year follow-up. Surgery can be the most viable alternative to medical treatments in the management of a chest wall cutaneous complication even in high-risk patients.

Radiological contribution to the diagnosis of early postoperative complications after lung resection for primary tumor: a revisional study

In the post-operative course of the interventions of lung resection for primary tumor, complications of different nature and severity can arise, recognizing different pathogenetic mechanisms and differing according to the type of resection performed and to the time elapsed after surgery. The low diagnostic accuracy of chest radiography requires a thorough knowledge of the radiologist about all radiographic findings, both normal and pathological, which can be found in the immediate post-operative period (within 30 days after surgery). This article aims to describe the incidence, the clinical features and the radiological aspects of immediate complications following pulmonary resections, with specific reference to those in which the diagnostic imaging provides a fundamental contribution.

Thoracoplasty for Postpneumonectomy Empyema Associated with Bronchopleural Fistula: A Case Series

Thoracoplasty is a historical procedure, initially devised for the treatment of refractory tuberculous empyema. Advances in medical treatments have nearly eliminated the need for this surgical procedure in pulmonary tuberculosis and it is rarely performed or taught in modern day surgical practice. However, few indications still exist, most prominently, in the treatment of postpneumonectomy refractory empyema often but not always associated with a bronchopleural fistula. In this case report, we present two cases of postpneumonectomy refractory empyema treated by thoracoplasty with long-term follow-up.

Postoperative complications after thoracic surgery for lung cancer

Lung cancer is the leading cause of cancer-related deaths in the United States. Several surgical techniques are currently used as part of the standard of care for early-stage lung cancer. Differentiating normal postoperative changes from complications is essential in the management of these patients. This article will review the various surgical approaches used, ranging from wedge resection to pneumonectomy, and will outline their expected postsurgical changes. Early and late postsurgical complications will be described, some of which are unique to the type of surgery performed. In addition, local tumor recurrence is a form of postoperative complication and must be distinguished from typical postoperative or postradiation change. Knowledge of both common and uncommon postoperative complications is crucial in the follow-up of lung cancer patients.

SUMMARY STATEMENT

Familiarity with the appearance of postoperative complications in lung cancer patients is vital to distinguish it from the normal postoperative or postradiation appearance in follow-up imaging.