| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Guest Access | Sign In via User Name/Password
|
|
|
|||||||
Guest Access | Sign In via User Name/Password |
|||||||||
Chief, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital.
Correspondence to: Professor Anthony P.C. Yim, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, SAR, China; e-mail: yimap@cuhk.edu.hk
Empyema thoracis has been recognized as a disease entity since the time of Hippocrates and historically has been associated with high mortality. During World War I, the overall empyema mortality rate among US military forces was 61%.1
There are few conditions in which management depends as much on the timing of treatment in the course of the disease. Although this has been recognized for a long time, the importance of timely intervention in empyema management has not been emphasized enough. Over 30 years ago, the American Thoracic Society described three stages in the natural course of empyema, namely the exudative, fibrinopurulent, and organizing phases.2 While the free-flowing exudative phase can be adequately treated by tube drainage and antibiotics, the transition to the fibrinopurulent phase is often associated with the development of thick pus and multiple loculations, rendering simple drainage and antibiotics inadequate. Surgical intervention is indicated at this stage to adequately evacuate the infected material and to create a unified space for drainage. If this is not done, the empyema will progress to the stage of fibrotic encasement of the lung, which requires more complex surgical procedures for infection control and eradication.3 Decortication and suction drainage usually result in lung re-expansion, otherwise pleurocutaneous window, intrathoracic transposition of skeletal muscle, or thoracoplasty remain life-saving but now uncommon options for treating a closed-space infection.
These three stages exist as a continuum, and the transition from exudative to fibrinopurulent phase is not always clear cut. In this issue of CHEST (see page 751), Huang and colleagues attempt through retrospective review to identify factors that are associated with failure of tube thoracostomy in the treatment of complicated parapneumonic effusions and empyema. They identified the presence of loculation and pleural effusion leukocyte count (< 6,400/µL) as independent factors predicting treatment failure. They recommend early surgical intervention for these two subgroups of patients.
The surgical approach to empyema has evolved over the years. During World War I, empyema treated by thoracotomy was associated with a mortality of > 30%.1 This prompted the establishment of the Empyema Commission, which recommended chest tube drainage for treatment. While some of the principles expounded by Dr. Evarts Graham (such as early evacuation of septic material, obliteration of the infected cavity, and attention to nutritional status) remain important today, the surgical approach used to implement some of these principles has been changed with the advent of new technology.
Thoracoscopy4 and, more recently, video-assisted thoracic surgery (VATS) present less invasive approaches to the management of empyema by minimizing access trauma. Essentially the same operation can be performed with VATS as in open surgery. VATS has been found to be particularly useful for treating the fibrinopurulent phase of empyema, in which multiple loculations could be easily disrupted to allow adequate drainage of a unified pleural space.5 Comparative study between VATS and thoracotomy as a surgical approach to treatment of fibrinopurulent empyema shows similar rates of success, but the former offers a substantial advantage in terms of resolution of the disease, hospital stay, and cosmesis.6 The less invasive nature of this approach, coupled with the subtle transition of empyema to stages progressively more difficult to treat argue strongly for early surgical intervention.7 In fact, the management algorithm of empyema needs to be redefined in this age of VATS. Conventional surgical algorithms were developed based on the morbidity associated with standard thoracotomy, but with the much lower morbidity of VATS, these "old" protocols will need to be re-evaluated. We advocate VATS for patients with empyema when a well-placed large-bore chest drain (32F or above) on suction does not result in complete resolution of pleural effusion radiologically after 2 days. For those few patients who are at prohibitively high risk for general anesthesia, additional chest drain guided by ultrasound or CT scan should be considered. Partially drained empyema does not constitute adequate treatment in my mind, even though the patient may show clinical signs of improvement in terms of fever or leukocytosis. The importance of timely intervention in the management of empyema cannot be overemphasized. Mutilating procedures to combat closed-space infection for those patients who missed early treatment will hopefully remain historical.
References
This article has been cited by other articles:
|
|
 |
|
  G. F. Tassi, R. J. O. Davies, and M. Noppen Advanced techniques in medical thoracoscopy. Eur. Respir. J., November 1, 2006; 28(5): 1051 - 1059. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. S. H. Ng, T. W. Lee, and A. P. C. Yim Iatrogenic causes of hilar radiopaque densities Eur. Respir. J., August 1, 2005; 26(2): 358 - 358. [Full Text] [PDF]
|
|
|
|
 |
|
 J. R. Roberts Minimally invasive surgery in the treatment of empyema: intraoperative decision making Ann. Thorac. Surg., July 1, 2003; 76(1): 225 - 230. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. K. Lim and A. P. C. Yim Management of Pleural Empyema Chest, September 1, 1999; 116(3): 845 - 846. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
