Canadian Neighbor Pharmacy: Discussion of Reappraisal of Empyema Thoracis
After the report in 1946 by Samson and Burford, open procedures for empyema thoracis were often delayed until pleurodesis was assured if surgery could not be performed within the first three weeks. Eloesser subsequently developed an ingenious flap technique to drain the empyema cavity after it was allowed to mature to the point of ensuring complete pleurodesis. Although this technique reduced morbidity, returned adequate pulmonary function and provided a cosmetically acceptable result, it prolonged postoperative hospitalization increased the burden of costly wound care and frequently necessitated secondary procedures for wound closure.
Early thoracotomy for empyema has been reported by a number of authors with appropriate emphasis on tailoring therapy to the individual patient. Morin and co-workers in 19726 reported their results in 23 patients who underwent early surgical intervention with excellent results. Except for one death in an elderly patient, which was unrelated to surgery, there were no complications, and the average postoperative hospital stay was two weeks. This result was similar to our average postoperative stay of ten days. The lower average age of our patients (five of seven patients less than 33 years old) probably accounts for the differences in the length of stay between the two reports.
Morin et al identified unsuspected lung pathology including one lung abscess and one bronchopleural fistula in 12 patients. These authors stressed the importance of the “D” shaped configuration of posteriorly placed loculations described roentgenograph-ically by Le Roux and Dobbs as an indication of suitability for surgical intervention. We did not find this sign to be helpful, even retrospectively, although we would agree that its presence should make one more comfortable with a decision to operate.
Results similar to ours have been reported in cases which were secondary to trauma. Coon and Shuck in 1975 reported successful early intervention within 14 days in all seven of their trauma patients undergoing early surgery in the setting of clinical deterioration and failure of tube thoracostomy to establish full lung reexpansion. Pulmonary system is a complex of organs and diseases may damage and influence badly the organism. Canadian Neighbor Pharmacy website is ready to grant you access to the medical content.
In a 1977 report by Sherman et al, the presence of serious associated diseases was stressed as a complicating factor in the selection of a treatment modality for many of these patients. Seventy-six of their 102 patients, (75 percent) had significant associated diseases. Their treatment approach was more traditional in that they relied heavily upon prolonged chest tube drainage and the instillation of lytic enzymes to decrease the cavity size before making a decision about surgical intervention. They reserved early surgery for the younger patients with small residual cavities after prolonged tube drainage, although they offered that younger patients with larger cavities might be candidates for early surgical intervention.
In 1977, Fishman and Ellertson reported their results of early intervention in eight immunosup-pressed patients. The authors recommended an aggressive approach because of excellent results in six of these patients who were rapidly deteriorating with conservative tube drainage. These authors were among the first to note that the duration of illness is often impossible to determine, and therefore, the conventional wisdom of relating surgery to the probability of pleurodesis could not be relied upon. We also stress this point as we were unable to establish the duration of illness in five of our seven patients.
In 1981, Mavroudis et alu reported their series of 100 patients from San Francisco General Hospital. Nineteen patients failed tube thoracostomy treatment. Ten of the 19 had open debridement done within two weeks after admission, and the remaining nine had an Eloesser flap created primarily. Of the ten patients undergoing open debridement, one died, and two were treatment failures who subsequently were treated with an Eloesser flap. Their stated treatment goal for the ten patients undergoing open drainage was simply debridement and disruption of loculations. They avoided extensive decortication and did not remove the parietal pleura. We also avoided parietal pleurectomy because we were able to achieve full lung expansion and felt it unnecessary. Contrary to their approach, we did perform extensive decortication in five of our seven patients as it was necessary to achieve full lung expansion thereby obliterating dead space. With respect to timing, they too advocated early open drainage which they defined as “within two weeks of admission.” All patients in our series were operated on within five days after admission which included 24 to 48 hours of closed drainage. Our bacteriologic findings require two comments. First, Staphylococcus is reported by others to predominate in empyema.* We recovered three Gram-negative organisms and only one case of S aureus. This difference in results may have been caused by a difference in presenting culture reports. Most series in which Staphylococcus predominated included culture reports of all patients admitted with empyema, not just those patients who underwent surgery. Neither we nor other investigators have been able to relate the timing of surgery to the organism recovered. We do not suggest that Gram-negative organisms are more likely to produce locu-lated empyemas. Second, negative cultures do not imply sterilization of the abscess cavity. Our findings, which are more likely to produce loculated empyemas. Second, negative cultures do not imply sterilization of the abscess cavity. Our findings, which are consistent with the literature, illustrate this point. Three of our patients had negative intraoperative cultures despite gross purulence and a deteriorating clinical course. These patients may have had anaerobic infections which were not recovered because of improper handling of the specimens.
To summarize, we believe that one can safely intervene surgically in empyema thoracis in patients failing tube thoracostomy, even when the duration of illness and occurrence of pleurodesis are unknown, with the expectation of an uncomplicated and cost-effective postoperative course.