|Year : 2006 | Volume
| Issue : 3 | Page : 100-102
Decortication in chronic pleural empyema
SP Rai1, SK Kaul2, RK Tripathi3, D Bhattacharya1, M Kashyap4
1 Department of Respiratory Medicine, Military Hospital, (CTC) Pune - 411040., India
2 Department of Cardio-thorasic Surgery, Military Hospital, (CTC) Pune - 411040., India
3 Department of Anesthesiology, Military Hospital, (CTC) Pune - 411040., India
4 Department of Pathology, Military Hospital, (CTC) Pune - 411040., India
S P Rai
Classified Specialist Medicine & Respiratory Medicine, Military Hospital, (CTC) Pune - 411040.
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: The aim of present study is to evaluate the role of decortication in management of chronic pleural empyema.
Methods: From Jan 2003 to Jun 2004, 25 patients of chronic empyema who were subjected to decortication at our tertiary care hospital were evaluated prospectively. Patients were subjected to detailed clinical, radiological and other diagnostic evaluation for etiology, duration of treatment and response. Decision for decortication was taken on the basis of long duration of treatment, poor response to antibiotics, intercostal tube drainage, thrombolytic therapy and thickness of pleural peel. All the patients were followed up for six months.
Results: Out of 25 patients, who were subjected to decortication, 24 patients were male and one was female with average age 33 years (range 19-50 years). The mean duration of symptoms was 6.4 months (range 1-24 months). The mean duration of preoperative antitubercular treatment (ATT) was 5 months (range 2 weeks to 12 months). Preoperative spirometry showed moderate restriction (FVC -53%, FEV 1 -61.7%). Postoperatively all patients showed good recovery. Spirometry after decortication showed satisfactory improvement (FVC-68%, FEV 1 -72.8%). Only one patient had complication in the form of left subclavian artery injury.
Conclusion: Decortication is the safe and effective treatment for chronic organized empyema, enabling complete expansion of the lung.
Keywords: Chronic pleural empyema, Decortication, Spirometry.
|How to cite this article:|
Rai S P, Kaul S K, Tripathi R K, Bhattacharya D, Kashyap M. Decortication in chronic pleural empyema. Lung India 2006;23:100-2
| Introduction|| |
Empyema thoracis remains a common thoracic problem with challenging management strategies. Tube thoracostomy, catheter drainage, thoracoscopy drainage, intrapleural thrombolytic, decortication and open drainage have all been used with success rates ranging from 10 to 90% , . The variable success rates and management strategies depend in part on stage of the empyema at presentation. Empyema thoracis has many causes but the most common cause is pulmonary infection. Prompt treatment with antimicrobial drugs along with drainage of empyema cavity is essential to prevent thickening of pleura and entrapment of lung. If empyema is not managed properly it progresses through exudative phase and firbrinopurulent phase to organizing chronic phase. An empyema cavity is formed and visceral pleural fibrosis limits re-expansion of the lung. Because of the presence of thick pus and encapsulation by chronic inflammatory tissue, poor drug penetration poses a genuine problem. Sub-therapeutic drug levels resulting in failure of medical treatment and development of acquired drug resistance are constant threats. Because many of the infections that cause empyema are indolent, a physician often sees patient after it has reached the firbrino-purulent or organized stage. Antimicrobial, tube thoracostomy and intrapleural thrombolytic have a limited role in these patients. Decortication is the safe and effective treatment in the organized empyema, enabling complete expansion of lung ,.
| Material and Methods|| |
All patients of chronic empyema who were subjected to decortication at our tertiary care center between Jan 2003 to Jun 2004 were evaluated. The patients included 24 male (serving soldiers) and one female who had earlier received treatment at peripheral hospitals and subsequently transferred to our center because of poor response. A detailed history and meticulous clinical examination was carried out. Investigations included tuberculin test, pleural fluid analysis, chest x-ray, ultrasound thorax, CT scan of chest, spirometry and fibre-optic bronchoscopy. Decision for decortication was taken on the basis of long duration of treatment, poor response to antibiotic intercostals drainage, persistence of empyema cavity and thick pleural peel. Preoperatively all patients were put on ATT for minimum duration of two weeks. Postoperatively a full course of ATT was given if histopathology of resected pleura confirmed tubercular etiology and it was stopped in nontubercular cases. All patients were reviewed clinically, radiologically and by spirometry, two months after decortication and then six monthly.
| Results|| |
During the period Jan 2003 to Jun 2004, out of 118 patients of empyema, 25 patients were subjected to decortication. It included 24 male and one female with average age 33 years (range 19-50 years). The mean duration of symptoms at the time of presentation to our hospital was 6.4 months (ranging from one to 24 months). Fever, cough, chest pain, dyspnoea and weight loss were common symptoms in these patients.
The clinical presentation was suggestive of Parapneumonic effusion in 9 patients and tubercular in rest 16 patients. Pleural aspirate was exudative with predominance of lymphocytes in 22 patients. Tuberculin test with PPD5TU was positive in 15 patients. Failure of response was seen in 10 patients who had undergone intercostal tube drainage and 3 patients who had received streptokinase instillation earlier. Twenty three out of 25 patients had received ATT for a mean duration of 5 months (range 2 weeks to 12 months) prior to decortication. Concomitant lung resection was done in three patients (lobectomy - 2, wedge resection - 1). Preoperative spirometry showed moderate restrictive defect, forced vital capacity (FVC) was reduced to 53% (+ 14%) of the predicted value and forced expiratory volume in 1 second (FEV 1 ) to 61.7% (+ 15%) of the predicted value. Postoperatively slight improvement was achieved to 68% (+ 13%) for FVC and 72.8 %(+ 13.8%) for FEV1 . On gross pathological evaluation, the average thickness of pleura was found to be 1 cm (range 0.5 - 4 cm). In 9 patients' tubercular etiology cannot be ascertained as only fibrosis with mild chronic nonspecific inflammation was present. Postoperatively all patients showed satisfactory improvement. Only one patient had complication in the form of left subclavian artery injury, which was repaired. All patients were successfully cured of their disease and there was no recurrence during six months follow-up.
| Discussion|| |
The therapy of empyema thoracis requires appropriate antibiotics, prompt drainage and lung re-expansion. Pneumonia remains the main etiological factor behind empyema thoracis. Tuberculosis may be the most frequent cause of empyema in population with high tuberculosis prevalence.
Success rate of various therapeutic procedures in management of empyema depends at least partly on the stage of empyema at presentation  . In the initial exudative stage, effusion will resolve with the resolution of pneumonia. In this stage antimicrobial and thoracocentesis or chest tube placements usually result in cure. In the second fibrino-purulent stage, antibiotics with chest tube drainage may resolve the empyema. Ultrasound showing evidence of fibrinous organization (i.e. fronds, septations, loculations, or thickening of visceral pleural surface) points to fibrinopurulent stage  . The optimal management of these empyema includes breakdown of adhesions to effect drainage of infected pleural fluid  The use of fibrinolytics intrapleurally appears to enhance intercostal tube drainage, reducing the requirement for subsequent surgical mechanical debridement. Early surgical intervention may be indicated for medical treatment failure and, as a suitable alternative to other medical interventions An empirical treatment strategy which combines adjunctive intrapleural fibrinolysis with early surgical intervention results in shorter hospital stays and may reduce mortality in patients with pleural sepsis  . But if empyema is not managed properly in early stage, it will progress to fibrino-purulent and organized chronic stage. Various factors responsible for this progression in our study were attributed to lack of chest physiotherapy, delay in intercostal tube drainage and inadequate and improper antibiotics. In a randomized control trial, Wait at al evaluated the effectiveness of tube thoracostomy and intrapleural streptokinase versus. VATS in patients with loculated parapneumonic empyema. They found a benefit to early VATS. 
Because of high prevalence of tuberculosis in our country, most of the patients with chronic empyema were attributed to tuberculosis  . Histopathology of rescected pleura in 9 out of 25 patients were confirmed non-tubercular. These patients were being treated as tubercular empyema because of poor response to antibiotics. In tubercular empyema, initial aspirate were exudative suggesting that in most of these patients empyema developed predominantly because of introduction of infection during aspiration, which is preventable.
Late empyema, which have reached the organized phase are characterized by the presence of thick pleural peel causing varying degree of pulmonary parenchyma entrapment. Granuloma, lymph mononuclear infiltration, necrosis and fibrosis suggestive of tubercular etiology was seen in 16 out of 25 patients. There are many surgical studies that show decortications to be safe and effective for treating empyema ,,,, . In general, both VATS and open decortications have been shown to be safe and effective in the organized empyema enabling complete lung expansion ,,,, . It allows a more rapid recovery with a decreased number of chest tube days and decreased length of hospital stay. Our results were omparable to earlier studies, which have shown significant improvement in pulmonary functions after decortications  The success rate for decortication is 90-95%. In our series success rate was 100%. Broncho-pleural fistula is a common complication in management of these patients however we did not encounter any such patient. Only one of our patients had complication in the form of left subclavian artery injury which was repaired. Excellent success rate achieved was possibly because most of our patients were young healthy soldiers who were not having any other co morbid diseases, expertise of surgeon and better post operative care.
This study emphasizes that decortication should be considered early in a patient of chronic organized empyema, enabling complete expansion of the lung and preventing morbidity.
| References|| |
|1.||Rzyman W, Skokowski J, Romanowicz G, Lass P, Dziadzivszko R. Decortication in chronic pleural empyema: effect on lung function. Eur Cardiothorac J Surg 2002; 21:502-507. |
|2.||Lee KS, Im Ja, Kim YH, Hwang SH, Bal WK, Lee BH. Treatment of thoracic multiloculated empyema with intracavitary Urokinase: a prospective study Radiology 1991; 179:771-75. |
|3.||Le Mense GP, Strange C, Sahn SA. Empyema thoracis - therapeutic management and outcome. Chest 1995; 107: 1532-37. |
|4.||Renner H, Gabor S, Pinter H, Friehs G, Juettner FMS. Is aggressive surgery in pleural empyema justified? Eur J Cardiothorac Surg 1999; 14:117-122. |
|5.||Thourani VH, Brady KM, Mansour KA, Miller JI, Lee RB. Evaluation of treatment modalities for thoracic empyema: a cost effectiveness analysis. Ann Thorac Surg 1998; 66:1121-27. |
|6.||Shankar S, Gulati M, Kang M, et al. Image-guided percutaneous drainage of thoracic empyema: Can sonography predict the outcome? Eur Radiol 2000; 10:495-499. [PUBMED] [FULLTEXT]|
|7.||Cameron R J.. Management of complicated parapneumonic effusions and thoracic empyema. Intern Med J 2002; 32: 408- 414. |
|8.||Lim T.K, Chin N.K. Empirical treatment with fibrinolysis and early surgery reduces the duration of hospitalization in plural sepsis. Eur Respir J 1999;13:514-18 |
|9.||Wait MA, Sharma S Hohn J, et al. A randomized trial of empyema therapy. Chest 1997;111:1548-51. |
|10.||Mackinlay TA , Lyons GA , Piedras MB , Mackinlay DA . Surgical treatment of postpneumonic empyema World Journal of Surgery 1999;23:1110-13. |
|11.||Bouros D, Antoniou KM, Ch alk iadakis G, Drositis J, Petrakis I, Siafakas N. The role of video-assisted thoracoscopic surgery in the treatment of parapneumonic empyema after the failure of fibrinolytics. Surgical Endoscopy 2002;16:151-4. |
|12.||Grewal H, Jackson RI, Wagner CW, Smith SD. Early videoassisted thoracic surgery in the management of empyema. Pediatrics 1999; 103 : 1-5. |
|13.||Weissberg D, Refaely Y. Pleural empyema: 24- year experience. Ann Thorac Surg 1996; 62:1026-29. [PUBMED] [FULLTEXT]|
|14.||Al-Kattan KM. Management of tuberculous empyema. Eur Cardiothorac J Surg 2000; 17:251-254. |
|15.||Vansonnenberg E, Nakamoto SK, Mueller PR, et al. CT and ultrasound guided catheter drainage of empyema after chest tube failure. Radiology 1984; 151:349-53. [PUBMED] [FULLTEXT]|