Current surgical treatment of thoracic empyema in adults

Abstract

A review of the recent literature on treatment modalities of adult thoracic empyema was conducted in order to expose the controversies and verify where consensus exists. Critical reading filtered through clinical experience was the method followed. The roles of surgical drainage, lavage techniques, debridement via VATS, decortication, thoracoplasty and open window thoracostomy were considered using the Oxford Center of Evidence Based Medicine criteria. The roles of the different therapeutical modalities were interpreted in the light of the triphasic nature of empyema thoracis. The randomised controlled trials came up with conflicting results. With two exceptions all of the papers reviewed provide level (2b) or below evidences. The lack of a single ideal treatment modality or policy reflects the complexity of the diagnosis and staging of this heterogeneous disease. Basic elements of intervention--drainage, different evacuation techniques, decortication, thoracoplasty and open window thoracostomy--are well-established technical modalities; however, neither a universally acceptable primary modality nor the gold standard of their sequence is available. Drainage remains to be the initial treatment modality in Phase I disease. Debridement via VATS is a safe, reliable and efficient method in the fibrinopurulent phase. Organised pleural callus requires formal decortication. Open window thoracostomy is a simple and safe procedure for high-risk patients and results in quick detoxication. Thoracoplasty kept its final role in pleural space management. Acute postoperative bronchial stump insufficiency requires immediate surgery. Evacuation of toxic material is mandatory. No single-stage procedure offers a solution. An optimised agressivity treatment modality should be tailored to the condition of the patient and to the potential of the persisting cavity. Decision-making involves a triad consisting of the aetiology of empyema (i.e. primary vs secondary), general condition of the patient and stage of disease, while considering the triphasic nature of development of thoracic empyema. The current attitudes show that the present concepts are based mainly on expert opinion. Flexibility and patience on behalf of the surgeon and nursing staff, the patient and the hospital management, as well as a good understanding of the complexity of this condition are the cornerstones of the treatment. No exclusive sequence of procedures leading to a uniformly predictable successful outcome is available. Individualised approaches can be recommended based on institutional practice and local protocols. Thoracic empyema in general seems to remain resilient to fit completely into the categories of evidence-based medical approach.

Video-assisted thoracic surgery in pleural empyema: predictors of complications and treatment failures

“…Clinically it may provide better clues for the decision to perform the early surgical approach. The positive culture from the pleural space is assessed by different authors in 10-60% of patients (5,6,8,15,24,25,(28)(29)(30)(31)(32). Such a low percentage of positive cultures may represent an effective antibiotic treatment prior to sample collection.…”

“…Unfortunately, there is a lack of data regarding the optimal timing of surgical intervention, so there is no consensus regarding this issue. Some recent studies identified that delayed referral to surgery or longer anamnesis lead to higher conversion rate and consequently increases morbidity and mortality (1,3,12,15,21,24,25,27). Chung and colleagues in their recent retrospective analysis of 120 cases of VATS empyemectomies stated that patients with the symptom duration of less than four weeks showed better early results compared to those with the symptom duration greater than four weeks (16).…”

“…Pleural empyema is a complex clinical entity that has defied randomized controlled trials and efforts to define the best clinical practices because of the multitude of patient factors that determine treatment outcomes (3,15). Even with moderate or minimal infectious or respiratory symptoms, pleural empyema exposes the patient to devastating morbidity if neglected or operated on too late (8).…”

A 3- Year Review of Patients with Chronic Empyema Treated Surgically at Tikur Anbessa Specialized Referral Hospital, Addis Ababa, Ethiopia

“…As technology and medical science develops, in the last decades the video-assisted thoracic surgery (VATS) [8][9] has been demonstrated as an effective procedure in selected patients, allowing an optimal debridement of early organized pleural effusions. In the late phase of the pleural infectious process, when a thick pleural peel encases the lung, a pulmonary decortication is required and open approach is often needed [10][11] .…”

Outcome and mortality analysis in complicated parapneumonic effusion and empyema

“…Mortality and morbidity varies between 3% and 33%. [10][11][12][13] The most important issue to prevent morbidity or mortality is the prevention of disease progression and adequate aggressive treatment. ET carries many complications such as sepsis, respiratory failure, lung collapse, bronchopleural fistula (BPF), or gastropleural fistula.…”