Pleural empyema surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]
Overview
Definitive surgical treatment for empyema entails drainage of the infected pleural fluid. A chest tube may be inserted, often using ultrasound guidance. Intravenous antibiotics are given. If this is insufficient, surgical debridement of the pleural space may be required.[1][2][3]Management strategies of Empyema necessitans with pulmonary involvement and lung abscess may involve thoracotomy with pulmonary resection in addition to extended duration antimicrobial therapy.[4][5]
Surgery
Treatment of empyema focuses on the following:[1]
- Controlling the infectious focus
- Drainage of fluid and pus
- Re-expansion of the lung
Surgery should be considered without delay in the following patients:[6][7]
- who fail to improve with antibiotics and chest tube drainage,
- who have persistent infective symptoms, fever, leukocytosis and raised inflammatory markers.
Contrary to popular belief, radiological clearance of pleural collection is not a good indicator of disease progress.
Surgery and Device Based Therapy
Definitive surgical treatment for empyema entails drainage of the infected pleural fluid. A chest tube may be inserted, often using ultrasound guidance. Intravenous antibiotics are given. If this is insufficient, surgical debridement of the pleural space may be required.[1][2][3]
Tube thoracostomy
- Least invasive
- Preferred for unilocuated effusions and free-flowing fluid.
- For solitary lesions a CT scan or ultrasound is used to guide the tube.
- For lesions more than one multiple small catheters are used to drain.
- When draining empyema fluid, thoracostomy tubes are typically placed using either an ultrasound or CT-guided approach. When multiple loculations are present, we typically place small-bore catheters, as multiple tubes may be needed to drain the multiloculated pleural space.
- A trial showed no difference between different sizes of thoracostomy tube. Smaller tubes were preferred due to decreased pain.[8][9]
- British thoracic society recommends flushing the tube every 6 hrs to remain patent.[10]. Smaller tubes are more prone to failure due to blockage.[11]. Chest tubes are placed atleast till the cavity closes or drainage falls below 50 ml/day.
- Confirm correct placement of the tube using CT scans and checking drainage .
Open Thoracostomy
An incision is made through the chest wall to aid drainage at the inferior border of the cavity . A chest tube is inserted and left to drain the remaining cavity . This process is time consuming and requires at least 2-3 months. However a few side effects of anesthesia and chest tube infection still remain.
Empyema necessitans
Management strategies of Empyema necessitans with pulmonary involvement and lung abscess may involve thoracotomy with pulmonary resection in addition to extended duration antimicrobial therapy.[4][5]
References
- ↑ 1.0 1.1 1.2 Reichert M, Hecker M, Witte B, Bodner J, Padberg W, Weigand MA; et al. (2016). "Stage-directed therapy of pleural empyema". Langenbecks Arch Surg. doi:10.1007/s00423-016-1498-9. PMID 27815709.
- ↑ 2.0 2.1 Colice GL, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg B; et al. (2000). "Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline". Chest. 118 (4): 1158–71. PMID 11035692.
- ↑ 3.0 3.1 Ashbaugh DG (1991). "Empyema thoracis. Factors influencing morbidity and mortality". Chest. 99 (5): 1162–5. PMID 2019172.
- ↑ 4.0 4.1 Atay S, Banki F, Floyd C (2016). "Empyema necessitans caused by actinomycosis: A case report". Int J Surg Case Rep. 23: 182–5. doi:10.1016/j.ijscr.2016.04.005. PMC 5022073. PMID 27180228.
- ↑ 5.0 5.1 Gomes MM, Alves M, Correia JB, Santos L (2013). "Empyema necessitans: very late complication of pulmonary tuberculosis". BMJ Case Rep. 2013. doi:10.1136/bcr-2013-202072. PMC 3863066. PMID 24326441.
- ↑ Maskell NA, Davies CW, Nunn AJ, Hedley EL, Gleeson FV, Miller R; et al. (2005). "U.K. Controlled trial of intrapleural streptokinase for pleural infection". N Engl J Med. 352 (9): 865–74. doi:10.1056/NEJMoa042473. PMID 15745977. Review in: ACP J Club. 2005 Sep-Oct;143(2):40
- ↑ Diacon AH, Theron J, Schuurmans MM, Van de Wal BW, Bolliger CT (2004). "Intrapleural streptokinase for empyema and complicated parapneumonic effusions". Am J Respir Crit Care Med. 170 (1): 49–53. doi:10.1164/rccm.200312-1740OC. PMID 15044206.
- ↑ Maskell, NA.; Davies, CW.; Nunn, AJ.; Hedley, EL.; Gleeson, FV.; Miller, R.; Gabe, R.; Rees, GL.; Peto, TE. (2005). "U.K. Controlled trial of intrapleural streptokinase for pleural infection". N Engl J Med. 352 (9): 865–74. doi:10.1056/NEJMoa042473. PMID 15745977. Unknown parameter
|month=ignored (help) - ↑ Rahman, NM.; Maskell, NA.; Davies, CW.; Hedley, EL.; Nunn, AJ.; Gleeson, FV.; Davies, RJ. (2010). "The relationship between chest tube size and clinical outcome in pleural infection". Chest. 137 (3): 536–43. doi:10.1378/chest.09-1044. PMID 19820073. Unknown parameter
|month=ignored (help) - ↑ Davies, CW.; Gleeson, FV.; Davies, RJ. (2003). "BTS guidelines for the management of pleural infection". Thorax. 58 Suppl 2: ii18–28. PMID 12728147. Unknown parameter
|month=ignored (help) - ↑ Horsley, A.; Jones, L.; White, J.; Henry, M. (2006). "Efficacy and complications of small-bore, wire-guided chest drains". Chest. 130 (6): 1857–63. doi:10.1378/chest.130.6.1857. PMID 17167009. Unknown parameter
|month=ignored (help)