CHRISMED Journal of Health and Research

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 6  |  Issue : 2  |  Page : 83--86

Surgical management for pleural empyema – Single-center experience


Elamaran Elamurugan1, Pajanivel Ranganadin2, Jaya Velraj3, Duvuru Ram1, Karthik Panchanatheeswaran1,  
1 Department of Cardiothoracic and Vascular Surgery, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
2 Department of Pulmonary Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
3 Department of Anesthesiology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India

Correspondence Address:
Elamaran Elamurugan
Department of Cardiothoracic and Vascular Surgery, Mahatma Gandhi Medical College and Research Institute, Pillayarkuppam, Puducherry - 607 403
India

Abstract

Background: Pleural empyema occurs due to primary lung parenchymal infection or due to other pathologies. In this study, we analyzed the surgical management of empyema at our center. Patients and Methods: This study is a retrospective analysis of the patients who were surgically managed for pleural empyema between September 2014 and September 2017. A total of 54 patients underwent surgical management in the form of video-assisted thoracoscopic surgery (VATS) decortication or open procedure or a combination of both. The study population was evaluated for comorbid conditions, association with tuberculosis, bacteriological culture, length of hospital stay, morbidity and mortality. Results: Primary empyema was present in 52 patients while two patients had secondary empyema. Mycobacterium tuberculosis was associated in 17 (32%) patients, while 25 patients had other bacterial organisms. VATS decortication was performed in 21 (39%) patients and 23 (43%) patients underwent the open procedure. The remaining 10 patients underwent the combined procedure. The operative time and mean duration of hospital stay were less in the VATS group compared to the open group. Conclusion: In our experience, early surgical management of Stage II and Stage III empyema is successful with VATS. The nature of the disease process and the learning curve for VATS plays an important role in the conversion to open procedure.



How to cite this article:
Elamurugan E, Ranganadin P, Velraj J, Ram D, Panchanatheeswaran K. Surgical management for pleural empyema – Single-center experience.CHRISMED J Health Res 2019;6:83-86


How to cite this URL:
Elamurugan E, Ranganadin P, Velraj J, Ram D, Panchanatheeswaran K. Surgical management for pleural empyema – Single-center experience. CHRISMED J Health Res [serial online] 2019 [cited 2019 Jul 19 ];6:83-86
Available from: http://www.cjhr.org/text.asp?2019/6/2/83/258967


Full Text



 Introduction



Pleural empyema is defined as collection of pus within the thoracic cavity, which can occur due to primary infection of the lung parenchyma and secondary to thoracic trauma or due to spread of infection from adjacent structures including esophagus, liver and the mediastinum, bronchogenic carcinoma, infections of the cervical and thoracic vertebrae and also following any surgical or therapeutic intervention in the thoracic cavity.[1],[2]

The pathophysiology of empyema involves exudative stage (Stage I), fibrinopurulent stage (Stage II), and organizing stage (Stage III). Surgical management is indicated beyond exudative stage. Surgical management involves video-assisted thoracoscopic surgery (VATS) decortication and open decortication. In the present study, we have performed a retrospective analysis of all the patients who underwent surgical management for pleural empyema at our center.

 Patients and Methods



The study was a retrospective analysis of the patients who were surgically managed for pleural empyema between September 2014 and September 2017. A total of 54 patients who were managed surgically were included in the study. Informed consent was obtained from all patients for inclusion in the study. Primary empyema was present in 52 patients while the remaining two patients had empyema secondary to esophageal fistula and teratoma, respectively. All patients underwent surgical management in the form of VATS decortication or open procedure or a combination of both.

Inclusion criteria for video-assisted thoracoscopic surgery decortication

History of empyema <6 weeksPleural peel thickness <1 cm as measured by ultrasound or computed tomography scan.

Exclusion criteria for video-assisted thoracoscopic surgery decortication

Obliterated pleural space due to fibrothoraxContraindications/inability to provide lung isolationUnable to achieve complete lung expansion/complete decortication.

The patients who were not fitting in the criteria for VATS were directly planned for open procedure.

The parameters for conversion to open surgery were

Intaoperative finding of thick pleural peelInability to do complete decortication.

Video assisted thoracoscopic surgery decortication

VATS decortication was performed after lung isolation by a double lumen endotracheal tube or by using a bronchial blocker with a single-lumen endotracheal tube. This maneuver helps in producing lung expansion as well as lung collapse as and when required during the procedure. The patient is positioned in lateral position for posterolateral thoracotomy.

We use a 4 cm utility incision made in 4th or the 5th intercostal space and camera is placed through the same incision. A SurgiSleeve wound protector is placed in position. The thoracic cavity is entered, and the pathology is examined. A Yankauer suction is used to evacuate the effusion or abscess and also to break the fibrinous strands. The empyema cavity is drained, and decortication is performed all around the lung. Decortication is performed from the apex of the lung to the base or vice versa. Yankauer suction, peanut, and decortication forceps are utilized for the procedure. We make sure that the entire lung is free of adhesions including the diaphragmatic surface. Ventilation is given intermittently to assess the completeness of decortication. After the procedure, irrigation is done with saline and wash is given. Postprocedure, the lungs are assessed for expansion and air-leak. Standard apical and basal drains are placed. The patients are extubated on the table. The drains are connected to negative suction immediately post procedure. Drain removal was done as when the drainage was <100 ml/24 h and no air leak was present.

Open decortication

Open decortication is performed with or without lung isolation and with the patient in lateral position for posterolateral thoracotomy. The lungs are accessed through the bed of the 5th rib. Drainage of the empyema cavity and formal decortication is performed using the same instruments as in VATS decortication with the addition of cautery. Rest of the procedure is the same as for VATS decortication. Concomitant procedures like rib resection were performed for a single case in the series in view of fibrothorax to facilitate adequate exposure, and Eloesser flap was performed for a case of chronic bronchopleural fistula.

Video 1 briefly represents the technique of VATS and open decortication at our center.

The study population was evaluated for comorbid conditions, association with tuberculosis, bacteriological culture length of hospital stay and morbidity.

 Results



The primary empyema was present in 52 patients while two patients had secondary empyema. The study population had 33 (61%) males and 21 (39%) females. The maximum number of patients were in the age group of 41–60 years (n = 18). There were 16 patients in the age group of 21–40 and 12 patients were in the age group of >61 years. Mycobacterium tuberculosis was associated in 17 patients, while 25 patients had other bacterial organisms [Table 1]. Klebsiella pneumonia was the most common isolated organism among other bacterial infections (8 patients). The other organisms isolated were Staphylococcus aureus, Streptococcus, and Enterobacter [Table 2]. Diabetes was associated in twelve patients and eight patients had chronic kidney disease.{Table 1}{Table 2}

VATS decortication was performed in 21 (39%) patients and 23 (43%) patients underwent open procedure [Table 3]. The remaining 10 patients underwent the combined procedure.{Table 3}

Our criteria for a successful outcome were defined as complete expansion of the lung without any residual space or fluid collection. Complete lung expansion occurred in all but two patients who underwent VATS decortication. One patient required redo decortication through open procedure. The other patient is asymptomatic and is on regular follow-up.

The mean operative time for open procedure was 222 min while for VATS was 144 min. There was no mortality in the present series.

The length of hospital stay was less in VATS group (5 days) compared to the open decortication group (8 days). There was surgical site infection in one patient in the open group while no surgical site infection was noted in the VATS group [Table 4].{Table 4}

 Discussion



Surgical intervention for pleural empyema is indicated in Stage II and Stage III empyema. However, the exact timing of intervention in Stage II is still subjective.[3] However, patients developing sepsis with unresolved pleural collection benefit from VATS or open procedure.[3] The literature has many studies comparing VATS decortication to open decortication procedure. However, there has been no consensus in the timing of VATS procedure.[4] Hence, the need for conversion of VATS to open decortication occurs in many patients.

The main advantages of VATS decortication are shorter operative time, lesser complications, less postoperative pain, and lesser duration of hospital stay. However, VATS has a significant learning curve to decrease the operating time.[5]

Contraindications to perform VATS procedure are inability to tolerate single-lung ventilation and bleeding diathesis. The indications for conversion to open procedure are incomplete removal of pleural peel resulting in decreased lung expansion, uncontrolled bleeding, and injury to adjacent structures which cannot be repaired by thoracoscopic assistance.[1]

In our center, we performed VATS for all Stage II empyema and also patients fulfilling criteria for VATS with Stage III empyema. A total of 21 (39%) patients had VATS as the sole treatment modality while 10 (18%) patients required conversion to open procedure. The remaining 23 (43%) patients had open decortication. The conversion rate in the present series was 18%. This rate is higher when compared with the existing literature (0%–11.3%).[5],[6],[7],[8],[9] We owe the higher rate of conversion in view of the nature of the disease (tuberculous etiology and chronic) and learning curve. Our protocol is to wait for 4 weeks postprocedure to redo surgery.

The duration of hospital stay was less in VATS group when compared to the open group. The mean duration of stay in VATS group was 5 days while it was 8 days in the open group. Lesser hospital stay can be attributed to decreased air-leak and early chest drain removal in the VATS group. Early chest tube removal is a result of decreased duration of air leak in VATS group compared to open group. These data correlated with the existing literature.[5]

In the existing literature, there is no difference in relapse rates between VATS decortication and open decortication.[5] In our series, two patients who underwent VATS decortication did not have complete lung expansion, and one of the patients required a redo decortication through open method. The possible reason for this can be attributed to overlooking a diseased area due to narrow vision in VATS.[5]

The limitations of this study are small sample size and the study being a retrospective analysis of data from a single center. Furthermore, we would emphasize that there was a significant learning curve which lead to increased conversion of VATS to open when compared with the literature.

 Conclusion



In our experience, early surgical management of Stage II and Stage III empyema is successful with VATS. Though this study is a retrospective analysis, VATS appears to be an effective mode of treatment in the early management of empyema. The nature of the disease process and the learning curve for VATS plays an important role in the conversion to open procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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