Empyema following pulmonary resection. What is difficult management? รศ.นพ. ธ รว ทย พ นธ ช ยเพชร

Transcription

1 Empyema following pulmonary resection. What is difficult management? รศ.นพ. ธ รว ทย พ นธ ช ยเพชร

2 Post lung resection empyema Post lobectomy % Post-pneumonectomy 2-16% Rt>Lt., mortality 10% Residual space & air-leakage

3 Empyema thoracis The American Thoracic Society(1962) Stage I Exudative or acute phase (1-2 wk.) low viscosity, low cellular, early angioblastic & fibroblastic proliferation Stage II Fibrinopurulent or transitional phase (2-3wk.) more turbid, PMN, fibrin deposit & loculation Stage III Organizing or chronic phase (>3 wk) pleural peel with ingrowth of capillaries, fibroblasts & collagen fibers

4 Empyema Thoracis without BPF Antibiotics, General supports Drainage: (frank pus, ph<7.2, +bacteria) catheter drainage,closed tube thoracostomy? Intrapleural fibrinolytic drug Surgical drainage: (loculation) limited thoracotomy(rib resection), VATS Definitive treatment: Filling of space & Closure(decortication) VATS? Sterilization & Closure Permanent drainage(open window thoracostomy Collapse(Thoracoplasty)

5 Empyema with BPF Tube drainage, Antibiotics, General supports Fistula closure: small: spontaneous closure endobronchial procedures Large & late: reclosure(direct or indirect) permanent drainage rotation flaps(muscle transposition) collapse(thoracoplasty)

6 JAPI VOL. 52 JUNE 2004

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8 ชายไทยอาย 59ป ไอน าหน กลดมา 1 เด อน FOB biopsy poorly diff. carcinoma Operation RUL lobectomy, sleeve resection of RPA, node dissection..21/11/2554 Discharge..24/11/2554

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10 Postop. Diagnosis : squamous cell carcinoma stage T2b N0 = 1B Adjuvant CMT 27/12/2554

11 ไข ไอหนาวส นเสมหะเหล อง 23/1/2555 Diagnosis: lung abscess with empyema thoracis Operation: Rethoracotomy partial rib resection, debridement of RML & closed drainage..24/1/2555 Intermittent irrigation with diluted Betadine solution..open window thoracostomy Debridement & additional rib resection &Eloesser flap 16/2/2555

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13 30/4/2555 ตค 2555 Minor airleak

14 มค 2556 no BPF

15 Assessment of empyema in the postop. patient Is this a postoperative infection? Is this acute or chronic? Is there a bronchopleural fistula? Is there adequate drainage? Is there a space problem? BPF after surgery Early reoperation Transpericardial approach to close fistula Muscle flap over fistula Drainage procedures Chest tube Rib resection Clagett window/eloesser flap Airspace filling procedures Thoracoscoplasty Fill space with muscle and omentum

16 Thoracoplasty

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19 Post pulmonary resection empyema Chest tube drainage & antibiotics No BPF BPF improve Remove chest tube worse Close fistula omentoplasty/myoplasty 2 wk after tube drainage Clagett if needed Do clagett window/eloesser flap for drainage or Space filling procedure

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21 ผ หญ งอาย 75ป ม อาการไอเป นเล อด FOB biopsy adenocarcinoma Operation LUL lobectomy, node dissection 26/2/2009 Massive hemothorax at recovery room..rethoracotomy blood clot evacuation,

22 27/2/ /2/2009

23 เบ ออาหารไข ส งหนาวส น 1 เด อนหล งผ าต ด thoracentesis bloody pleural fluid culture Pseudomonas ICD bloody fluid 1000cc 2/3/ /3/2009

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27 Postpneumonectomy empyema

28 Post-pneumonectomy empyema No BPF Antibiotics & chest tube drainage BPF Convert to open drainage after 2 wk. Early postop.(1 wk.) Late(>1wk.) Chest tube drainage Reoperation close BPF & muscle or omental flap Clagett window & Muscle or omental flap Clagett window If persistent airleak Consider Trans-sternal/transpericardial Bronchial stapler

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38 Muscle flap interposition

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41 Postpneumonectomy empyema Open v/s minimally invasive surgery (171 papers) Minimally invasive surgery : chest tube drainage + or - chemical irrigation VATS debridement Open surgery : open debridement, open window thoracostomy (OWT) thoracomyoplasty Open approach is superior: empyema recurrence rate, mortality and reintervention rate Zahid et al. What is the best treatment of postpneumonectomy empyema. Interactive CardioVascular and Thoracic Surgery 12 (2011)

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