Best timing for surgical intervention of empyema. Supervisor: Intern:

Transcription

1 Best timing for surgical intervention of empyema Supervisor: Intern:

2 Brief history 56 y/o male, farmer With anesthesia medication at LMD Admission 30d 7d Dry cough Progressive productive cough with yellow sputum Fever up to 38 O C Left chest pain

3 Brief history Smoking: 1~2 PPD HTN for 10 years w/ regular medication No DM, asthma TPR=38.1 o C/82/20 BP=148/88mmHg Cough w/ yellow sputum, left and lateral chest pain related to respiration, SOB, wheezing, decreased BS and expansion over left side

4 Laboratory data-blood BUN/Cr=22/1.0 GOT/GPT=67/151 WBC=31.56k CK-MB/TnI=34/<0.01 O 2 sat=96.5%

5 Laboratory data-pleural fluid ph=6.914 Color: yellow Clarity: slight turbid WBC=160uL PMN/Eos/Lym/Mono=76/2/9/13

6 3/28

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8 Empyema Thin, free-flowing exudative effusions are often called parapneumonic effusions Well-organized, chronic empyemas have a thick, unyielding, organized pleural peel. In-between these two extremes are empyemas, in the fibrinopurulent phase of development, marked by pleural fluid acidosis and fibrin loculations

9 Empyema Instillation of fibrinolytics, usage of Pigtail cathempyema thoraciser and human recombinant deoxyribonuclease Video assisted thoracic surgery (VATS) Open thoracotomy with decortication

10 Empyema VATS: Grewal showed that length of stay was longer after this procedure than with formal throacotomy. Podbielski and Doski suggested VATS was an attractive alternative to thoracotomy in terms of length of hospital stay and drain in-situ.

11 Empyema Carey suggested In exudative stage, Abx + therapeutic drainage is usually effective. But most patients have already entered the fibrinopurulent stage when they present. In the fibrinopurulent stage, in addition to antibiotics, fibrinolysis, VATS or open thoracotomy will be the treatment regime depending on the patient s clinical condition. In the organizing stage, antibiotics and open thoracotomy should be the gold standard of treatment.

12 PICO P: Fibrinopurulent empyema I : VATS C: VATS vs. fibrinolytic therapy O: Hospital stay

13 Paper-1 Video-Assisted Thoracoscopic Surgery in the Treatment of Complicated Parapneumonic Effusions or Empyemas : Outcome of 234 Patients Retrospective chart review Shi-Ping Luh, Ming-Chih Chou, Liang-Shun Wang, Jia-Yuh Chen and Tsong-Po Tsai Chest 2005;127;

14 Paper pt (108 women, 126 men; median age: 51 years; range, 0.75 ~ 84 years) underwent procedures for parapneumonic effusion (145 pt) or pleural empyema (89 pt) from 1995 to CXR(100%), and 188 pt (80.3%) underwent preoperative CT or sonography. More than 85% (200 patients) received preoperative diagnostic or therapeutic thoracentesis, tube thoracostomy, or fibrinolytics. Empyema refractory to medical control or peel or multiloculated exudates per CT and chest tapping.

15 Paper-1 Septal lysis and debridement irrigation through one port (31 pt, 13.2%) Decortication and debridement through two or three ports (179 pt, 76.5%) Rib resection or larger utility incision for decortication and drainage (24 pt, 10.3%).

16 Paper-1 16 patients (6.8%) needed further surgery for empyema (9 pt required open drainage or thoracoplasty, and 7 pt needed redecortication or repair of bronchopleural fistula). No intraoperative deaths and only 8 (3.4%) perioperative deaths (< 30 days), which were mostly unrelated to surgery.

17 Paper-1 Patients requiring open decortication or repeat procedures (40 pt) had a longer mean duration of preoperative symptoms, longer mean duration of preoperative hospitalization, and a higher ratio of pleural empyema (vs. complicated parapneumonic effusion) than patients undergoing simple VATS.

18 Paper-1 VATS is safe and effective for treatment of complicated parapneumonic effusion and pleural empyema. Earlier intervention with VATS can produce better clinical results.

19 Paper-2 A randomized trial of empyema therapy MA Wait, S Sharma, J Hohn and A Dal Nogare Chest 1997;111;

20 Paper-2 20 patients with confirmed parapneumonic empyema thoracis chest tube pleural drainage + streptokinase (CT-SK) (9) VATS (11)

21 Paper-2 Each group suffered 1 mortality. The VATS group had a significantly higher primary treatment success [10/11, 91% vs. 4/9, 44%; p<0.05], lower chest tube duration ( vs days; p=0.03), and lower number of total hospital days ( vs days; p=0.009). Clinically relevant but not statistically significant differences in hospital costs ($16,642±2,841 vs. $24,052±3,466, p=0.11) also favored the VATS group. All the CT-SK treatment failures could be salvaged with VATS, and none required thoracotomy.

22 Paper-2 In patients with loculated, complex fibrinopurulent parapneumonic empyema thoracis, a primary treatment strategy of VATS is associated with a higher efficacy, shorter hospital duration, and less cost than a treatment strategy that utilizes catheter-directed fibrinolytic therapy.

23 3/30 Post Pre

24 My opinion VATS should be the 1st line strategy for empyema above fibrinopurulent phase.

25 Thanks for your attention! See you in August!

26 Comment st paper background evidence 3.2 nd paper 1997 RCT