Surgery for parapneumonic pleural empyema – What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome?

Schweigert, Michael; Solymosi, Norbert; Dubecz, Attila; Fernández, M.; Stadlhuber, Rudolf J.; Öfner, Dietmar; Stein, Hubert J.

doi:10.1016/j.surge.2014.05.002

Cited by 33 publications

(27 citation statements)

References 22 publications

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“…Thus IPFT represents a less invasive and costly alternative to video-assisted thoracic surgery or other surgical interventions, which demonstrate comparable efficacy (16,44,45,58,60,71) in pediatric practice. IPFT also represents a preferred choice in high-risk (1, 22) and otherwise inoperable patients (10,43,49,56,57,69) or those with empyema/ loculation who refuse surgery. The reasons for the inconsistent results of IPFT in adult patients remain unclear but likely reflect the empiric approaches that are currently used.…”

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confidence: 99%

The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits

Komissarov

Florova

Azghani

et al. 2015

American Journal of Physiology-Lung Cellular and Molecular Phys

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The time required for the effective clearance of pleural adhesions/organization after intrapleural fibrinolytic therapy (IPFT) is unknown. Chest ultrasonography and computed tomography (CT) were used to assess the efficacy of IPFT in a rabbit model of tetracycline-induced pleural injury, treated with single-chain (sc) urokinase plasminogen activators (scuPAs) or tissue PAs (sctPA). IPFT with sctPA (0.145 mg/kg; n ϭ 10) and scuPA (0.5 mg/kg; n ϭ 12) was monitored by serial ultrasonography alone (n ϭ 12) or alongside CT scanning (n ϭ 10). IPFT efficacy was assessed with gross lung injury scores (GLIS) and ultrasonography scores (USS). Pleural fluids withdrawn at 0 -240 min and 24 h after IPFT were assayed for PA and fibrinolytic activities, ␣-macroglobulin/ fibrinolysin complexes, and active PA inhibitor 1 (PAI-1). scuPA and sctPA generated comparable steady-state fibrinolytic activities by 20 min. PA activity in the scuPA group decreased slower than the sctPA group (k obs ϭ 0.016 and 0.042 min Ϫ1 ). Significant amounts of bioactive uPA/␣-macroglobulin (but not tPA; P Ͻ 0.05) complexes accumulated at 0 -40 min after IPFT. Despite the differences in intrapleural processing, IPFT with either fibrinolysin was effective (GLIS Յ 10) in animals imaged with ultrasonography only. USS correlated well with postmortem GLIS (r 2 ϭ 0.85) and confirmed relatively slow intrapleural fibrinolysis after IPFT, which coincided with effective clearance of adhesions/organization at 4 -8 h. CT scanning was associated with less effective (GLIS Ͼ 10) IPFT and higher levels of active PAI-1 at 24 h following therapy. We concluded that intrapleural fibrinolysis in tetracycline-induced pleural injury in rabbits is relatively slow (4 -8 h). In CT-scanned animals, elevated PAI-1 activity (possibly radiation induced) reduced the efficacy of IPFT, buttressing the major impact of active PAI-1 on IPFT outcomes. fibrinolytic therapy; fibrinolysis; plasminogen activator inhibitor 1; pleural injury; urokinase; tissue plasminogen activator INTRAPLEURAL FIBRINOLYTIC THERAPY (IPFT) activates the endogenous fibrinolytic system, resolving intrapleural adhesions and complex fibrinous deposits that sequester pockets of inflammation loculations, thus improving drainage and clinical outcome, in part by decreasing surgical interventions (10). There are multiple reports of successful (88 -100% efficacy) IPFT in adult (1,7,8,16,17,29,42,47,48,66,67,72) and in pediatric (2,3,6,11,20,40,41,58,59,61,63,67) patients with empyema although outcomes in adult patients are inconsistent in these trials. Thus IPFT represents a less invasive and costly alternative to video-assisted thoracic surgery or other surgical interventions, which demonstrate comparable efficacy (16,44,45,58,60,71) in pediatric practice. IPFT also represents a preferred choice in high-risk (1, 22) and otherwise inoperable patients (10,43,49,56,57,69) or those with empyema/ loculation who refuse surgery. The reasons for the inconsistent results of IPFT in adult patients remain unclear but likely reflect...

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confidence: 99%

The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits

Komissarov

Florova

Azghani

et al. 2015

American Journal of Physiology-Lung Cellular and Molecular Phys

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“…[5,6,7,8] The aim of this study was to analyze the results of the surgical treatment in patients with empyema treated at the Clinic for Thoracic Surgery. The analysis of the results of the surgically treated patients will give recommendations for the treatment of the parapneumonic effusion and the empyema -complications of pneumonia.…”

Section: Surgical Treatment Of Pleural Empyema -Our Results Introductionmentioning

confidence: 99%

“…In this group there were also older patients in bad condition, with many comorbidities, which is the reason why so many lethal outcomes were detected in this group, in 7 (5.6%), which corresponded with the literature. [8] We didn't use fibrinolytic therapy, which corresponded with few papers. [4,11] In the fibrinopurulent phase it is necessary to think about decortication which can be done with classical thoracotomy or with videothoracoscopy (VATS).…”

Section: Discussionmentioning

confidence: 99%

“…After that immediately to determine the stage (phase) to decide the therapeutic and surgical approach. [7,8,9] Very practical are the suggestions of Hamm who suggest if the liquid is not clear or purulent, and if on ultrasonography there is no loculation, to perform pleural drainage; if is loculated to try with fibrinolytics 24-48 hours with pleural drainage, or to try early decortication with VATS. If there isn't success with VATS than open thoracotomy and decortication are necessary.…”

Section: Discussionmentioning

confidence: 99%

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Surgical Treatment of Pleural Empyema – Our Results

Кондов

Спировски

Kondova-Topuzovska³

et al. 2017

Prilozi

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Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce morbidity, mortality and duration of hospital stay. Unfortunately, advanced stages of empyema need to use extensive surgery -decortications or thoracoplasty. Early recognition of the parapneumonic effusion and the adequate treatment with thoracentesis or pleural drainage, which is minimally invasive, is possible not to prograde the process and not to become empyema. aim: To analyze the results of the surgical treatment in patients with empyema treated at Clinic for thoracic surgery. Material and methods:In the retrospective study we analyzed 234 patients with empyema which were treated at the Clinic for Thoracic Surgery in 5 year period (2011)(2012)(2013)(2014)(2015). The mean age of the patients was 51.94 years. They were treated with pleural drainage, decortications or thoracoplasty. results: With pleural drainage were treated 165/234 (70.51%) patients, of which successfully were finished 124/165 (75.15%), but 41/165 (24.85%) were indicated after the decortications. A total of 108/234 (46.15%) were treated with decortications from which, primary decortications were indicated in 67/234 (28.63%) patients. 5/234 (2.14%) patients were treated with thoracoplasty -3 of the patients with decortications and 2 with primary indicated thoracoplasty according to the local findings, long term untreated empyema and bad general condition. The Mean hospitalization was 17.4 days, of which 13.4 days after surgery. In the group with primary drainage it was detected a lethal outcome in 7/124 (5.64%) patients, 5/105 (4.76%) in the group with decortications and 2/5 (40%) in the group with thoracoplasty. conclusion: Early detection of the parapneumonic effusion and the adequate treatment will prevent the appearance of empyema. If the empyema is detected it is necessary as early as possible to start the treatment with minimally invasive pleural drainage. In earlier stages it is possible to use less invasive decortications, using VATS than the open thoracotomy decortication which is more extensive surgical intervention.

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“…20 Empyema often stems from underlying vulnerability-the high long-term mortality likely reflects these patients' substantial burden of comorbid disease. 21…”

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confidence: 99%

Medical and Surgical Management of Empyema

Godfrey

Bramley

Detterbeck

2019

Semin Respir Crit Care Med

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Infection of the pleural space is an ancient and common clinical problem, the incidence which is on the rise. Advances in therapy now present clinicians of varying disciplines with an array of therapeutic options ranging from thoracentesis and chest tube drainage (with or without intrapleural fibrinolytic therapies) to video-assisted thoracic surgery (VATS) or thoracotomy. A framework is provided to guide decision making, which involves weighing multiple factors (clinical history and presentation, imaging characteristics, comorbidities); multidisciplinary collaboration and active management are needed as the clinical course over a few days determines subsequent refinement. The initial choice of antibiotics depends on whether the empyema is community-acquired or nosocomial, and clinicians must recognize that culture results often do not reflect the full disease process. Antibiotics alone are rarely successful and can be justified only in specific circumstances. Early drainage with or without intrapleural fibrinolytics is usually required. This is successful in most patients; however, when surgical decortication is needed, clear benefit and low physiologic impact are more likely with early intervention, expeditious escalation of interventions, and care at a center experienced with VATS.

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Surgery for parapneumonic pleural empyema – What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome?

Cited by 33 publications

References 22 publications

The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits

The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits

Surgical Treatment of Pleural Empyema – Our Results

Medical and Surgical Management of Empyema

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