Open thoracotomy and decortication for chronic empyema

Effectiveness of Single Chest Tube vs Double Chest Tube Application Postdecortication: Prospective Randomized Controlled Study

BACKGROUND

Draining the chest cavity with 2 tubes is a common practice among thoracic surgeons. This research was conducted in Addis Ababa from March 2021 to May 2022. A total of 62 patients were included.

STUDY DESIGN

This study was conducted to investigate the superiority of either single or double tube insertion after decortication. Patients were randomized in a ratio of 1:1. In group A, 2 tubes were inserted; in group B, single 32F tubes were inserted. Statistical analyses were performed using Statistical Package for Social Sciences version 27.0, Student's t test and Pearson chi-square test.

RESULTS

The age range of patients was 18 to 70 years, with a mean of 44 ± 14.4434 years; the male to female ratio was 2.9:1. The dominant underlying pathologies were tuberculosis and trauma (45.2% vs 35.5%); the right side was more involved (62.3%). Drain output was 1,465 ± 1,887.9751 mL in group A vs 1,018 ± 802.5662 mL in group B (p value = 0.00001); the duration of drains was 7.5498 ± 11.3137 days in group A vs 3.8730 ± 1.4142 days in group B (p value = 0.000042). The degree of pain was 2.6458 ± 4.2426 vs 2.000 ± 2.1213 in group A and group B, respectively (p value = 0.326757). The length of hospital stay was 21.5818 ± 11.9791 days in group A vs 13.6091 ± 6.2048 days in group B (p value = 0.00001). Group A had air leak of 90.3% vs 74.2% in group B; subcutaneous emphysema was 9.7% in group A and 12.9% in group B. There was no fluid recollection, and no patients required tube reinsertion.

CONCLUSIONS

The placement of a single tube after decortication is effective in reducing drain output, time of drain, and hospital stay. There was no association with pain, and there was no effect on other endpoints.

Surgical management of empyema thoracis - experience of a decade in a tertiary care centre in India

Introduction and purpose

Empyema thoracis (ET) is defined as the accumulation of pus in the pleural cavity. Early stages of ET are treated medically and the late stages surgically. Decortication, thoracoplasty, window procedure (Eloesser flap procedure) and rib resections are the open surgical procedures executed. There are no strict guidelines available in developing nations to guide surgical decision-making, as to which procedure is to be followed.

Methods

Details of all adult patients treated surgically for ET, between the years 2009 and 2019, and maintained in a live database in our institute, were retrieved and analysed. Medically managed patients were excluded.

Results

There were 437 patients in the study. The average age was 38 years. There was right side preponderance with a male:female ratio of 5:1. Tuberculosis was the commonest aetiology identified in 248 (57%) patients and diabetes was the commonest co-morbidity present in 97 (22%) patients. There was a higher incidence of a window procedure (WP) in tubercular patients 145 (59%). Only 26 (14%) of the non-tubercular patients underwent a WP. Post-operative complications were persistent air leak in 12 (6%) patients and premature closure of a window in 7 (4%) patients. There were 4 (0.9%) post-operative mortalities.

Conclusion

Surgical management of late stages of ET provides good results with minimal morbidity and mortality. In developing nations like India, the high incidence of tuberculosis and late presentations make the surgical management difficult and the strategies different from those in developed nations. No clear guidelines exist for the surgical management of ET in developing nations. There is a need for a consensus on the surgical management of empyema in such countries.

Early Functional Results of Surgery for Organizing Phase of Empyema Thoracis in a High Output Centre for Thoracic Surgery

Objective: To determine the early functional outcome of pulmonary decortication (PD) in patients having organized empyema thoracic (ET). 

Methodology: This is a prospective study conducted at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Center, Karachi from July 2019 to June 2020. The study included 76 patients referred to the department for assessment and surgery for the indication of organized empyema thoracis. After careful assessment and evaluation of the patients’ computed tomography (CT) scans and pulmonary function tests (PFTs) in addition to their symptoms, history, etiology of empyema, physical examination and nutrition status, they were recommended pulmonary decortication to release the underlying entrapped lung. Functional improvement was measured in terms of forced vital capacity (FVC) and forced expiratory volume in one second (FEV₁) three to six months after PD.

Results: A total of 76 empyema thoracis patients were included in the study. The mean age of participants was 33.4±11.9 years. The mean duration of empyema symptoms was 7.21±3.7 months. Majority were males (n=61; 80.3%). The full-lung expansion was achieved in 43 patients and partial lung expansion was achieved in 27 patients. The lung failed to expand in five patients. There was one death (lung failed to expand) due to respiratory failure as a result of septicemia. Most of the patients who achieved full-lung expansion had tuberculosis (26; 60.5%), followed by penetrating lung injury (7; 16.2%) and ruptured pulmonary hydatid cysts (5; 11.6%). Statistically significant association was found between etiology and full-lung expansion (p=0.042). Early functional improvement was seen in all patients with PD as mean FEV₁ improved from 1.23±0.27 to 2.02±0.5 (63% increase; p<0.001) and FVC from 2.10±0.27 to 2.72±0.41 (29.7% increase; p<0.001).

Conclusion: Based on the results obtained in the present study, it is concluded that pulmonary decortication in carefully selected patients has a vital role in significantly improving early functional results in terms of pulmonary functions.

Use of thopaz in patients of empyema thoracis undergoing decortication

Introduction:

The management of empyema thoracis has evolved over the years. After all lung surgeries chest drain is required, however they suffer from inter observer variability and impair mobility of the patient. However, the newer digital thoracic drain system are portable and have alarms for various situations, furthermore they eliminate inter-observer variability. One such device is Thopaz™ (Medela inc, Switzerland). We wanted to compare efficacy of Thopaz™ with our conventional intercostal chest tube drain in patients undergoing decortications for empyema thoracis.

Materials and Methods:

One hundred patients were enrolled in study and were randomized into conventional and thopaz group with 50 patients in each group with help of opaque envelopes.

Results:

Both the groups were comparable in demographic parameters. Majority of the patients in our study were children and young adults. Majority of empyema thoracis involved right side with nontubercular empyema thoracis being the most common cause of decorticartion. Patients managed with Thopaz had a significantly shorter air leak duration, shorter duration of postdecortication chest tube placement and shorter postoperative hospital stay. All postoperative complications were less in Thopaz group.

Conclusions:

Patients with empyema thoracis undergoing open decortications when managed with digital chest drainage system (Thopaz) experienced faster reduction in air leak, a shorter duration of chest tube placement and in hospital stay. Thopaz usage is also associated with reduction in rate of postoperative complications. We recommend that this digital chest tube drainage system is a very useful tool in armamentarium of thoracic surgeon after lung surgeries.

Surgical outcome of empyema thoracis patients with special correlation to pre-operative contrast-enhanced computerized tomography (CECT) thorax morphometry

Purpose

Empyema thoracis is a very common disease. The surgical outcome of empyema patients depends upon various factors. To the best of our knowledge, there is no study in literature describing the surgical outcome of patients in relation to the contrast-enhanced computerized tomography (CECT) thorax morphometric findings. In this study, we examined the surgical outcome of empyema thoracis patients in relation to both clinical and radiological findings.

Materials and methods

It is a prospective hospital-based study conducted between October 2016 and August 2018. A total of 30 patients, who underwent decortication during the study period, were included. They were divided into three performance groups (excellent performance, average performance and poor performance groups) according to the outcome. The surgical outcome was correlated with the pre-operative clinical, radiological, intra-operative and post-operative parameters.

Results

Intra-operative ability to complete decortication, intra-operative expansion of the lungs and presence of broncho-pleural fistula were significantly different between the three performance groups. Duration of the disease, pre-operative duration of antitubercular therapy (ATT) intake and duration of pre-operative intercostal drain (ICD) were statistically insignificant between groups. In computed tomography (CT) morphometry, residual lung volume of the involved lung and volume of empyema were found to be significantly different between the performance groups. The residual volume of the involved lung (expressed in terms of the percentage of lung volume of the normal opposite lung) can predict the complete expansion of the lung with sensitivity of 71% and specificity of 70%.

Conclusion

The pre-operative residual lung volume of the involved lung, empyema volume, completeness of decortication, intra-operative expansion of the lung and presence or absence of broncho-pleural fistula can determine the surgical outcome in empyema thoracis patients.

Video-assisted thoracoscopic surgery versus open thoracotomy in the management of empyema: A comparative study

Introduction:

With a rise in the incidence of thoracic empyema, surgical interventions also have evolved from the traditional open decortication to the current minimally invasive video-assisted thoracoscopic surgery (VATS). In this study, we determine the feasibility of VATS and also put the superiority of VATS over open thoracotomy (OT) to test.

Subjects and Methods:

Prospective single-centre comparative analysis of clinical outcome in 60 patients undergoing either VATS or OT for thoracic empyema was done between 1^st September, 2014, and 1^st November, 2018. Furthermore, another group of patients, who were converted intraoperatively from VATS to OT, was studied descriptively.

Results:

Nearly 75% of the patients were male with a mean age of 45.16 years. Every second patient had associated tuberculosis (TB), attributed to the endemicity of TB in India. When compared with OT, VATS had a shorter duration of surgery (268.15 vs. 178.33 min), chest tube drainage (11.70 vs. 6.13 days), post-operative hospital stay (13.56 vs. 7.42 days) and time to return to work (26.96 vs. 12.57 days). Post-operative pain and analgesic requirement were also significantly reduced in the VATS group (P < 0.0001). Conversion rate observed was 14.2%, the most common reason being the presence of dense adhesions.

Conclusion:

We conclude that VATS, a minimally invasive procedure with its substantial advantages over thoracotomy and better functional outcome, should be preferred whenever feasible to do so. Also if needed, conversion of VATS to the conventional open procedure, rather than a failure, is a wise surgical judgement.

Change in Pulmonary Function Following Decortication for Chronic Pleural Empyema

OBJECTIVES

Chronic empyema is the final stage of the triphasic pathogenesis of empyema that is characterized by fibrin deposits in both pleural surfaces, leading to the formation of a thickened pleural peel. This restricts the lung movements, giving rise to a trapped lung and impairment of pulmonary function. The aim of this study was to determine the change in pulmonary function following decortication for chronic empyema.

MATERIALS AND METHODS

A total of 35 patients with chronic pleural empyema who underwent decortication via a posterolateral thoracotomy between July 2016 and July 2017 were reviewed and followed-up for 6±3 months after surgery. All patients underwent a pulmonary function test using spirometry before and after surgery. Pre-operation spirometry values [mean forced expiratory volume in 1s (FEV₁) and mean forced vital capacity (FVC)] were compared with the post-operation data obtained during follow-up and the change was quantified by statistical analysis.

RESULTS

FEV₁ was 70.51% before surgery vs. 83.43% after surgery (p<0.001). FVC was 69.74% before surgery vs. 85.40% after surgery (p<0.001). There was no influence of bacteriology, side of occurrence of the lesion, smoking habit, or diabetes mellitus present before the operation on the patients' lung function (p>0.01).

CONCLUSION

Decortication and pleurectomy via a posterolateral thoracotomy resulted in significant clinico-functional improvement in patients with chronic empyema, regardless of the bacteriology, side of occurrence of the lesion, smoking habit, or diabetic status of the patient.

A systematic review of comorbidities and outcomes of adult patients with pleural infection

Background

Pleural infection remains an important cause of mortality. This study aimed to investigate worldwide patterns of pre-existing comorbidities and clinical outcomes of patients with pleural infection.

Methods

Studies reporting on adults with pleural infection between 2000 and 2017 were identified from a search of Embase and MEDLINE. Articles reporting exclusively on tuberculous, fungal or post-pneumonectomy infection were excluded. Two reviewers assessed 20 980 records for eligibility.

Results

211 studies met the inclusion criteria. 134 articles (227 898 patients, mean age 52.8 years) reported comorbidity and/or outcome data. The majority of studies were retrospective observational cohorts (n=104, 78%) and the most common region of reporting was East Asia (n=33, 24%) followed by North America (n=27, 20%). 85 articles (50 756 patients) reported comorbidity. The median (interquartile range (IQR)) percentage prevalence of any comorbidity was 72% (58–83%), with respiratory illness (20%, 16–32%) and cardiac illness (19%, 15–27%) most commonly reported. 125 papers (192 298 patients) reported outcome data. The median (IQR) length of stay was 19 days (13–27 days) and median in-hospital or 30-day mortality was 4% (IQR 1–11%). In regions with high-income economies (n=100, 74%) patients were older (mean 56.5 versus 42.5 years, p<0.0001), but there were no significant differences in prevalence of pre-existing comorbidity nor in length of hospital stay or mortality.

Conclusion

Patients with pleural infection have high levels of comorbidity and long hospital stays. Most reported data are from high-income economy settings. Data from lower-income regions is needed to better understand regional trends and enable optimal resource provision going forward.

In pleural infection, patients from higher-income countries tend to be older with more comorbidities and are more likely to be referred for fibrinolytic treatment in comparison to patients from lower-income countrieshttp://bit.ly/2K2M5HL

Surgical and nonsurgical outcomes for treating a cohort of empyema thoracis patients: A monocenteric retrospective cohort study

Background

There are several studies reporting high success rates for surgical and nonsurgical treatments of empyema separately. The aim of current retrospective cohort study is to find the best treatment in low socio-economic areas.

Material and methods

A total of 149 patients were treated in the referring hospital from January 2002 to December 2008. The current retrospective cohort study was carried out by nonsurgical (medically & thoracenthesis & chest tube drainage with or without fibrinolytic agents) and surgical (VATS &open thoracotomy decortication methods) procedures in single center performed in thoracic and respiratory medicine wards. The independent t-test on demographic data was the statistical test tool.

Results

The complete cure and mortality rates for 130 patients were 27% (35 out of 130 patients) and 0.3% (1 out of 130 patients), respectively. Thirteen out of 149 patients that were estimated to be at stage II underwent VATS decortication. The results showed zero success rates for this procedure which was then converted to open thoracotomy decortication. And, 113 patients who underwent thoracotomy decortication had a cure rate of 96.4% (109 patients) and mortality rate of 1.8% (2 patients). Four (3.5%) patients needed thoracoplasty, 2 died and 2 (1.8%) needed open window thoracostomy resulted in empyema necessitans that remained uncured. Total hospitalization lengths for the patients treated by tube thoracostomy and thoracotomy decortication were (15.4 ± 2.1) and (6.2 ± 1.8) days (P < 0.001), respectively. The success rates between surgical and nonsurgical treatments were 98.2% and 27.1%. And, the difference between them was significant (P < 0.001).

Conclusion

Because of the advanced stages of empyema in our patients, thoracotomy decortication procedure is often the first rank choice with success rates higher than nonsurgical techniques. However, nowadays, the success rates of nonsurgical and VATS management of empyema thoracis are mostly reported in the literature.

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Outcomes of surgical and nonsurgical management for treating empyema thoracis patients were presented based on STROCSS criteria.

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Due to advanced stages of empyema in low socioendemic areas, thoracotomy decortication procedure proposed higher success rates.

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Success and cure rates, and hospitalization time showed significant differences between surgical and nonsurgical procedures.

Trends and practice patterns in the management of thoracic empyema

Background

This study explored the modern treatment of thoracic empyema. We evaluated outcomes of various operative approaches in both academic and nonacademic institutions.

Methods

We queried the Society of Thoracic Surgeons National Database for patients undergoing thoracic procedures with a primary diagnosis of empyema between 2009 and 2011. We compared treatment outcomes of patients having procedures at academic ( n = 1101, 28.3%) and nonacademic ( n = 2790, 71.7%) medical centers.

Results

Empyema treatments recorded in the database included tube thoracostomy ( n = 325, 8.4%), video-assisted thoracic surgery ( n = 1992, 51.2%), and thoracotomy ( n = 1574, 40.5%). Academic centers had higher rates of treatment by thoracostomy (13.8% vs. 6.2%), similar treatment rates of video-assisted thoracic surgery (49.9% vs. 51.7%), and lower rates of thoracotomy (36.3% vs. 42.1%) compared to nonacademic centers ( p < 0.001). Academic centers treated almost twice as many complicated empyemas with fistulas (11.4% vs. 6.5%, p < 0.001). Postoperative length of stay was higher in the academic centers (interquartile range 5–13 vs. 4–11 days, p = 0.001), while mechanical ventilation >48 h was more frequent in the nonacademic centers (7.6% vs. 4.4%, p = 0.013).

Conclusion

Surgeons in both academic and nonacademic centers use selective surgical approaches for treatment of thoracic empyema, depending on the clinical condition of the patient, with fairly equivalent results across all procedure types.

Traumatic thoracobiliary (pleurobiliary and bronchobiliary) fistula

BACKGROUND

Traumatic thoracobiliary fistula is a rare but serious complication. A series of thoracobiliary fistulas secondary to penetrating trauma and analysis of trends in management are presented.

METHODS

We retrospectively reviewed all patients with traumatic thoracobiliary fistula, treated from April 2008 to February 2010. There were 5 patients: 4 suffered gunshot wounds and 1 was stabbed. The mean injury severity score was 22.

RESULTS

Initial treatment was insertion of a chest tube in all cases. One patient underwent damage-control surgery and hepatic packing, and 3 were managed with laparotomy, a perihepatic closed drain, and suture of the diaphragm. Two patients developed bronchobiliary fistulas and 3 had pleurobiliary fistulas. Diagnostic procedures involved determination of bilirubin in pleural effusion, computed tomography, magnetic resonance cholangiography, hepatobiliary iminodiacetic scans, and endoscopic retrograde cholangiography. Definitive treatment included sphincterotomy and stenting in 4 cases, pulmonary decortication in 5, fistulectomy in 2, hepatic suture in 2, perihepatic closed drain placement in 4, and suture of the diaphragm in 4.

CONCLUSIONS

Traumatic thoracobiliary fistulas are complex lesions. A multidisciplinary approach is required for a timely and successful outcome. Endoscopic retrograde cholangiography is very useful as the initial procedure to confirm the diagnosis and also for treatment.

Pleurectomy decortication in the treatment of the "trapped lung" in benign and malignant pleural effusions

Trapped lung is defined by the inability of the lung to expand and fill the thoracic cavity because of a restricting "peel." This restriction may be secondary to a benign inflammatory or fibrotic cortex or to a malignant visceral pleural tumor. This condition has a significant impact on the patient's quality of life by causing dyspnea. This article discusses the role of surgery in relieving the trapped lung, including decortication in benign disease and pleurectomy in malignant disease. The surgical approaches of video-assisted thoracoscopy and thoracotomy are contrasted and the future potential for surgical trials in this condition is outlined.