Empyema thoracis: a clinical study

Clinico-radiological profile of the patients with empyema thoracis: A prospective analytical study

BACKGROUND

Empyema thoracis is defined as the presence of pus in the pleural cavity and carries significant morbidity and mortality. This study aimed to explore the demographic and clinico-radiological characteristics of patients with empyema thoracis.

MATERIAL AND METHODS

The present study was conducted in a tertiary care teaching hospital in North India. The patients diagnosed with empyema thoracis were included in the study. Demographic, etiologic, clinical, radiographic, and outcome data were prospectively collected and analyzed.

RESULTS

The study included 48 patients. The median age of empyema thoracis patients was 37(IQR 26-45) years. Common presenting symptoms were breathlessness (n = 37,77%) and chest pain (n = 34,70%). Contrast-enhanced computed tomography (CECT) of the chest showed type III empyema in 52% (21) patients followed by type 1 and type II in 25% and 22%, respectively. CECT thorax showed the collapse of lung and consolidation in (n = 28, 70%) and (n = 24, 60%) patients, respectively. All the patients, except for one, were managed with underwater seal intercostal tube drainage (ICD) procedure for the management of empyema. The median time to remove the ICD tube among 35 patients was 14 (IQR 9-21) days. Forty patients (83.3%) responded to the treatment and were discharged. Eight patients (16.7%) deteriorated and succumbed to the disease.

CONCLUSION

Patients of empyema thoracis required a prolonged period of chest tube drainage and carried significant morbidity and mortality.

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.

The Utility of Intraoperative Microbiological, Cytological, and Histopathological Sampling in the Setting of an Empyema Necessitating Lung Decortication Surgery

INTRODUCTION AND AIMS

 Empyema thoracis is a pleural space pathology that indicates accumulation of purulent material in the pleural space. It is often associated with an underlying infectious process, such as pneumonia, but can also be a ramification of a more sinister etiology, such as lung carcinoma, often warranting lung decortication surgery for prompt resolution. Although radiological imaging is used to form a preliminary diagnosis, its true predictive value remains questionable, and intraoperative microbiological, cytological, and histopathological samples are thus instrumental in yielding helpful diagnostic information. This study aims to gauge whether intraoperative microbiological, cytological, and histopathological analyses yield any additional diagnostic information in establishing the etiology underlying empyema, necessitating decortication surgery.  Methods: Microbiological, cytological, and histopathological records of 43 patients undergoing decortication surgery were included in this study. Only patients who were diagnosed with late stages of empyema and subsequently underwent decortication surgery were included in this study.  Results: The sample consisted of 43 patients, including 23 males and 20 females. For microbiology, 4.88% of the bronchoalveolar lavage (BAL) samples, 7.69% of tissue fluid samples, and 7.32% of pleural fluid samples were positive for an infectious microorganism. For cytology/histopathology, 0.00% of BAL samples, 5.41% of pleural fluid samples, and 7.32% of tissue samples were positive for an underlying infective etiology.  Conclusion: For the study and analysis of the microbiological samples, a myriad of all three different modalities of diagnosis is essential. However, tissue sampling is the preferred modality of diagnosis for cytology/histopathology owing to its ability to detect positive cases that might otherwise evade prompt detection.

Triple Cultures Increase the Diagnostic Sensitivity of Mycobacterial Tuberculosis Empyema

BACKGROUND

There is a continuous debate on the appropriate diagnostic approach and surgical management of mycobacterial empyema, with widely varied diagnostic practices and surgical outcomes. The aim of this study is to highlight the diagnostic approach and clinical features of patients who required surgical intervention for mycobacterial empyema.

METHODS

We performed a 5-year retrospective cohort study of all patients with mycobacterial empyema requiring surgery in a single institution from November 2009 to November 2014.

RESULTS

Eighteen patients (15 males and 3 females, median age 48.5 years) required surgery. Seventeen patients required decortication via posterolateral thoracotomy and one patient underwent video-assisted thoracic surgery drainage and pleural debridement. Prolonged air leak was the commonest surgical complication (50%, n = 9). 94.4% (n = 17) had necrotizing granulomatous inflammation on histological examination. The sensitivity of mycobacterium smear and culture ranged between 12.5% and 75% for pleural tissue, sputum, and pleural fluid individually. The combination of all 3 samples increased the diagnostic yield to 100%.

CONCLUSION

With the implementation of pleural tissue culture at surgery, the novel combination of sputum, pleural fluid, and pleural tissue culture provides excellent diagnostic yield.

Thoracoscopic Decortication of Stage III Tuberculous Empyema Is Effective and Safe in Selected Cases

BACKGROUND

Open decortication of advanced tuberculous empyema remains standard of care. As with other aspects of thoracic surgery, minimally invasive approaches are making inroads into procedures traditionally performed open. In this retrospective analysis, we sought to examine feasibility, efficacy, and outcomes of thoracoscopic decortication of stage III tuberculous empyema in our experience.

METHODS

The records of all patients in whom thoracoscopic decortication of stage III tuberculous empyema was performed between March 2012 and December 2015 were examined. Demographic and perioperative data were analyzed to assess the surgical outcomes of this study group. To assess long-term efficacy, patients were followed for a minimum of 6 months.

RESULTS

One hundred patients fit the study criteria, of these 67 were men. Ninety cases were successfully completed thoracoscopically. Mean operative time was 204 ± 34.2 minutes with mean blood loss of 384 ± 28 mL. Median chest drain duration and hospital stay was 7 days. There was no perioperative deaths. Morbidity rate was 33%, composed mostly of prolonged air leak (29%). Six-month follow-up revealed completely expanded lung in all patients except one with small apical asymptomatic air space. Intraoperative cultures were positive for mycobacteria in 25% patients. Six (6%) of these patients had multidrug-resistant tuberculosis and required a modification in their antituberculous therapy.

CONCLUSIONS

Thoracoscopic decortication of advanced tuberculous empyema is feasible, safe, and effective with good short- and long-term results in selected patients. In a substantial portion of patients, operative cultures required modifying drug treatment to treat underlying tuberculosis.

Population-based cohort study investigating the correlation of diabetes mellitus with pleural empyema in adults in Taiwan

We assessed the association between diabetes mellitus and the risk of pleural empyema in Taiwan.A population-based retrospective cohort study was conducted using the database of the Taiwan National Health Insurance Program. There were 28,802 subjects aged 20 to 84 years who were newly diagnosed with diabetes mellitus from 2000 to 2010 as the diabetes group and 114,916 randomly selected subjects without diabetes mellitus as the non-diabetes group. The diabetes group and the non-diabetes group were matched by sex, age, comorbidities, and the year of index date. The incidence of pleural empyema at the end of 2011 was estimated. A multivariable Cox proportional hazards regression model was used to estimate the hazard ratio (HR) and 95% confidence interval (95% CI) for pleural empyema associated with diabetes mellitus.The overall incidence of pleural empyema was 1.65-fold higher in the diabetes group than that in the non-diabetes group (1.58 vs 0.96 per 10,000 person-years, 95% CI 1.57-1.72). After adjusting for confounders, a multivariable Cox proportional hazards regression model revealed that the adjusted HR of pleural empyema was 1.71 in subjects with diabetes mellitus (95% CI 1.16-2.51), compared with those without diabetes mellitus. In further analysis, even in the absence of any comorbidity, the adjusted HR was 1.99 for subjects with diabetes mellitus alone (95% CI 1.18-3.38).Diabetic patients confer a 1.71-fold increased hazard of developing pleural empyema. Even in the absence of any comorbidity, the risk remains existent.

Adult thoracic empyema: A comparative analysis of tuberculous and nontuberculous etiology in 75 patients

Background:

Thoracic empyema is a disease of significant morbidity and mortality, especially in the developing world where tuberculosis remains a common cause. Clinical outcomes in tuberculous empyema are complicated by the presence of concomitant fibrocavitary parenchymal disease and frequent bronchopleural fistulae. We performed a prospective study over a one-and-a-half-year period with the objective of comparing the clinical profiles and outcomes of patients with tuberculous and nontuberculous empyema.

Materials and Methods:

A prospective study of adult cases of nonsurgical thoracic empyema admitted in a tertiary care hospital in eastern India was performed over a period of 18 months. A comparative analysis of clinical characteristics, treatment modalities, and outcomes of patients with tuberculous and nontuberculous empyema was carried out.

Results:

Seventy-five cases of empyema were seen during the study period, of which 46 (61.3%) were of nontuberculous etiology while tuberculosis constituted 29 (38.7%) cases. Among the nontuberculous empyema patients, Staphylococcus aureus (11, 23.93%) was the most frequent pathogen isolated, followed by Gram-negative bacilli. Tuberculous empyema was more frequent in younger population compared to nontuberculous empyema (mean age of 32.7 years vs. 46.5 years). Duration of illness and mean duration of chest tube drainage were longer (48.7 vs. 23.2 days) in patients with tuberculous empyema. Also the presence of parenchymal lesions and bronchopleural fistula often requiring surgical drainage procedures was more in tuberculous empyema patients.

Conclusion:

Tuberculous empyema remains a common cause of empyema thoracis in a country like India. Tuberculous empyema differs from nontuberculous empyema in the age profile, clinical presentation, management issues, and has a significantly poorer outcome.