Surgical treatment of chronic empyema

Abstract

Empyema remains challenging for thoracic surgeons. This review covers diverse aspects of acute empyema and chronic empyema and its surgical treatment. The triphasic nature of thoracic empyema (stages I, II, and III) is also addressed. The principles of empyema treatment are early diagnosis and early treatment. For acute empyema (empyema in stages I and II), early surgical intervention, such as video-assisted thoracoscopic débridement, is recommended when conventional chest tube drainage has failed. Radical treatments of chronic empyema (empyema in stage III) include (1) removal of the empyema space (decortication with or without lung resection) and (2) obliteration of the pleural space with muscle flaps or omentum flaps, or by thoracoplasty. Decortication is the procedure of choice for patients with reexpandable underlying lung. When bronchopleural fistula exists in the underlying lung, the fistula should be securely closed. For those patients whose underlying lung cannot be expected to reexpand, the procedure of choice is either concomitant removal of the affected lung with the empyema space or obliteration of the pleural space. For patients who are not eligible for the above-mentioned radical treatment, open-window thoracostomy can be considered. This procedure is not only performed as a definitive treatment of empyema but also as a preparatory treatment for radical procedures. Radical procedures are performed when patients recuperate. Choosing the most suitable operation based on the stages of empyema, the conditions of the underlying lung, and the conditions of a patient holds the key to success.

Management of Parapneumonic Effusion and Empyema: Medical Thoracoscopy and Surgical Approach

“…Surgery now is a cleaning debridement-like procedure which can usually be achieved by thoracoscopy in experienced hands [19], all the more so if performed early in the course of the disease (delay may lead to chronic empyema which is a totally different story) [20]. So-called ‘medical’ thoracoscopy seems a bit ambitious in this setting as the lung cannot be excluded (patients are not intubated) and pain control may be inefficient when scrubbing sensitive parietal pleurae.…”

Empiema pleural en 343 casos con tratamiento quirúrgico: características, resultados inmediatos y factores asociados a morbilidad y mortalidad

“…Estas fases evolutivas son dinámicas y entre ellas existe un período de transición en que se superponen; para alcanzar la Fase III se requieren entre 5 a 6 semanas de evolución. Esta clasificación del EP permite unificar definiciones, determinar pronósticos y plantear tratamientos 3,4,10,12 . En la serie presentada esta variable no fue consignada, ya que es un dato que en la revisión retrospectiva resulta impreciso y difícil de obtener, esto principalmente por que la mayoría de los casos corresponden a pacientes derivados desde otros hospitales, donde fueron tratados por un tiempo que generalmente no es precisado.…”

“…La morbilidad de la decorticación pleuropulmonar por toracotomía puede alcanzar hasta el 30% y la mortalidad al 10%. Las complicaciones más frecuentemente descritas son fístulas broncopleurales, infección de herida operatoria, hemorragias post operatorias y cavidades residuales 1,3,[7][8][9][10]12,[35][36][37][38] . Otras técnicas como la fenestración o la toracoplastía, se dejan para casos extremos en que las otras alternativas quirúrgicas no logran el objetivo de tratar la infección y lograr expansión pulmonar evitando cavidades residuales, de ser posible, deben evitarse ya que se asocian con un deterioro significativo en la calidad de vida de los pacientes 3,10,[29][30][31] .…”

Thoracomyoplasty in the Treatment of Empyema: Current Indications, Basic Principles, and Results

“…Second, the underlying lung parenchyma must have the ability to reexpand and completely obliterate the pleural space. If these two conditions are not fulfilled, lung decortication becomes a hazardous and very risky procedure and thoracomyoplasty becomes an option that should be taken into consideration [29]. …”