Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) for decortication or debridement in the management of empyema thoracis has increased the available treatment options but requires validation. We present and evaluate our technique and experience with thoracoscopic management of pleural empyema, irrespective of chronicity. METHODS: From May 1, 2000, to April 30, 2002, VATS debridement and decortication in 70 consecutive patients presenting with pleural space infections was performed with endoscopic shaver system. A retrospective review was performed and the effect of this technique on perioperative outcome was assessed. RESULTS: The VATS evacuation of infected pleural fluid and decortication was successfully performed in 65 of 70 patients. The mean duration of preoperative symptoms before referral was 23 +/- 1.8 days. The mean duration of hospitalization before transfer was 13.5 +/- 1.5 days. Blood loss was 330 +/- 200 mL. Intercostal drainage was required for 5 +/- 3 days. The postoperative hospital stay was 5 +/- 0.7 days. There were no operative mortalities. CONCLUSIONS: Video-assisted thoracoscopic decortication with endoshaver system is a simple and effective method in the management of the fibropurulent or organic pleural empyema.     

Thoracoscopic-assisted management of postpneumonic empyema in children refractory to medical response

Background: Empyema frequently complicates the hospitalization of children; and in advanced stages, it often requires surgical intervention. In this study, we investigated the use of video-assisted thoracic surgery (VATS) for the management of postpneumonic empyema in children who have had an unsatisfactory medical response. Methods: We did a retrospective review of the medical records of 51 consecutive patients with loculated empyema (mean age, 5 years; range, 2 months to 15 years) hospitalized at Chang Gung Memorial Hospital between 1995 and 2000. All patients underwent debridement of the necrotic lung tissue and evacuation of the loculated empyema cavity using a VATS approach. Results: The mean operating time for the 51 patients was 90 min (range, 50–210); mean blood loss was 70 cc. Fever subsided within 72 h postoperatively in all patients. On average, chest tubing was removed on the 7th postoperative day (range, 4–18 days). However, in one patient who suffered from a prolonged air leak, the chest tube was not removed until day 18. The mean postoperative stay for all patients was 13.7 days (range, 9–23). No deaths occurred, and all of the children made a good recovery. A follow-up revealed that one of the 51 children patient suffered a left upper lung abscess 7 months after discharge. Left upper lobectomy was performed in this case, and the patient was discharged uneventfully 10 days after the operation. Conclusions: VATS is a safe and effective treatment for pediatric empyema. Thoracoscopic-assisted surgery facilitates visualization, evacuation, and debridement of the necrotizing lung tissue. Early surgical intervention can avoid lengthy hospitalization and prolonged intravenous antibiotic therapy, and it can accelerate clinical recovery.     

Pleural sinography in the management of thoracic empyema. A study of 52 cases

Pleural sinography is indicated in the management of empyema thoracis. The factors influencing the successful completion and interpretation of this procedure are discussed. A retrospective study of 86 sinograms from 52 patients with pleural empyema was undertaken to identify how the information obtained influenced management decisions and affected therapy. Pleural sinography is a valuable study within the limitations of correct performance and interpretation.     

Randomised trial of intrapleural urokinase in the treatment of childhood empyema

BACKGROUND: The role of intrapleural fibrinolytic agents in the treatment of childhood empyema has not been established. A randomised double blind placebo controlled trial of intrapleural urokinase was performed in children with parapneumonic empyema. METHODS: Sixty children (median age 3.3 years) were recruited from 10 centres and randomised to receive either intrapleural urokinase 40 000 units in 40 ml or saline 12 hourly for 3 days. The primary outcome measure was length of hospital stay after entry to the trial. RESULTS: Treatment with urokinase resulted in a significantly shorter hospital stay (7.4 v 9.5 days; ratio of geometric means 1.28, CI 1.16 to 1.41 p=0.027). A post hoc analysis showed that the use of small percutaneous drains was also associated with shorter hospital stay. Children treated with a combination of urokinase and a small drain had the shortest stay (6.0 days, CI 4.6 to 7.8). CONCLUSION: Intrapleural urokinase is effective in treating empyema in children and significantly shortens hospital stay.     

Taurolidine instillation as therapy for empyema thoracis. A prospective study of 50 patients

Fifty patients with chronic empyema thoracis, without bronchopleural fistula, were treated by drainage and twice-daily instillations of 2% taurolidine (Taurolin; Continental Ethicals) for 14 days. No antibiotics were used. Forty-three patients completed the treatment and 7 were withdrawn from the trial, 3 because of evidence of bronchopleural fistula and 1 each because of pain during instillation, associated chest-wall cellulitis, an unexplained, acute epilepsy-like episode during instillation, and inadvertent administration of antibiotics. All 43 patients who completed the trial showed an excellent clinical response with control of the local and systemic toxic effects of sepsis. A rapid falling-off in the volume and purulence of pleural drainage fluid was noted. Twenty-four of the 43 patients (55,8%) were rendered bacteriologically sterile by the treatment. Instillation of 2% taurolidine was therefore an effective form of monotherapy in cases of chronic empyema thoracis without bronchopleural fistula.     

The role of video-assisted thoracoscopic surgery in the treatment of parapneumonic empyema after the failure of fibrinolytics

BACKGROUND: Approximately 10% of patients treated with intrapleural instillation of fibrinolytics fail to respond and therefore need more invasive techniques, such as video-assisted thoracoscopic surgery (VATS). METHODS: During the period 1994-99, we treated 20 consecutive patients with complicated parapneumonic effusion (CPE) and pleural empyema (PE) that did not resolve with urokinase instillation given through the chest tube in a dose of 100,000 IU diluted in 100 ml of normal saline/daily for 3-5 days. The patients' ages ranged from 21 to 68 years (median, 46); 14 were male and six female. All patients had pleural fluid pH <7.1, LACTATE DEHYDRAGENASE (LDH) >1000, glucose <40 mg/dl and were submitted to VATS. RESULTS: Complete drainage was observed in 17 patients (85%), in the other three (15%), the procedure had to be converted to open thoracotomy due to a thickened visceral pleural peel. The mean operative time was 80.3 min (range, 55-140), and the mean duration of postoperative hospital stay was 7.5 days (range, 4-19). CONCLUSION: We found that VATS is a safe, effective, and well-tolerated surgical procedure in CPE and PE patients who have failed to resolve with initial treatment with fibrinolytics.     

Intrapleural streptokinase in the management of empyema.

BACKGROUND--Significant morbidity and mortality result from the ineffective evacuation of empyema. Failure of conventional first line treatment with closed intercostal tube drainage and antibiotic therapy may result in fibrin deposition and loculated empyema. Enzymatic debridement using intrapleural instillation of streptokinase is a non-invasive therapeutic option which may obviate the need for surgical intervention. METHODS--Eleven adults with multiloculated post-pneumonic empyemas who had failed to respond satisfactorily to intercostal tube drainage and antibiotic therapy were treated with intrapleural streptokinase between November 1992 and January 1994. A small catheter was inserted under ultrasound guidance into a loculation within the pleural space. Aliquots of 250,000 units of streptokinase in 100 ml normal saline were instilled into the pleural cavity and the tube clamped for four hours. Response was assessed by clinical outcome, measurement of drain output after unclamping, and subsequent pleural ultrasound, chest radiography, or both. RESULTS--Streptokinase enhanced drainage in all patients. Complete resolution of the empyema with re-expansion of the underlying lung was effected in eight patients, all of whom remain well. Further resolution of minimal pleural thickening was shown on subsequent chest radiographs. Two patients with considerably thickened visceral pleura following empyema drainage underwent successful decortication. The other, with myocarditis and a pyopneumothorax, underwent surgery for non-resolution of the pneumothorax but died perioperatively from cardiac failure. The number of streptokinase instillations per patient ranged from two to six (median three), and the volume of empyema fluid drained per patient ranged from 100 ml to 4870 ml (median 900 ml). Streptokinase was well tolerated in all patients. CONCLUSIONS--Intrapleural streptokinase is an effective adjunct in the management of complicated empyema and may reduce the need for surgery.     

Preoperative use of povidone-iodine. A prospective, randomized study

One hundred one adult orthopedic surgical patients were studied in a randomized, prospective clinical trial to compare the effectiveness of the standard povidone-iodine scrub and paint with povidone-iodine painting alone for presurgical skin preparation. No infections occurred in either group. The scrub-plus-paint group showed a 0.601 logarithmic reduction in bacteria counts, compared with 0.622 with painting alone. Further, 36.8% of the patients in the scrub-plus-paint group had skin counts that actually increased after preparation, compared with 13.8% of patients in the paint-only group. The preparation bacterial counts among inpatients, who received preoperative hexachlorophene showers, were significantly lower than that of outpatients, who did not receive preoperative showers. The data support the use of the preoperative hexachlorophene shower and the omission of scrubbing from the surgical skin preparation technique.     

Selective management of penetrating neck injuries. A prospective study

We assessed the feasibility of a selective policy for operative exploration of penetrating neck wounds. Patients with bleeding, hematomas, crepitations, dysphagia, dysphonia, or impaired mental status rendering their conditions nonevaluative had prompt explorations. All other patients were observed in the hospital. Of the 77 patients in this study, 48 (62%) underwent neck exploration based on the preceding criteria; (85%) had major injuries. Of the 29 patients observed according to protocol, none required subsequent exploration for a missed lesion. Ancillary diagnostic procedures in the observed patients consisted of arteriography in four, esophageal contrast studies in five, esophagoscopy in two, and laryngoscopy in one. The average hospital stay for observation was 1.8 days. Our experience confirms the safety and cost-effectiveness of selective exploration for penetrating neck injuries. Moreover, observation does not mandate extensive ancillary testing for level II and III injuries.     

Drainage, fibrinolytics, or surgery: a comparison of treatment options in pediatric empyema

Background

The current treatments of pediatric empyemas include tube thoracostomy with or without the instillation of fibrinolytics, video-assisted thoracoscopic surgery (VATS), and open thoracotomy with decortication. Whereas success has been reported for all of these techniques, VATS has been suggested as the best method because of decreased length of stay.

Methods

A chart review of children who presented with parapneumonic effusions from February 2000 to June 2002 was conducted. The patients were divided into 4 groups depending on the treatment received: group I, chest tube alone (n = 18); group II, chest tube and fibrinolytics (n = 24); group III, chest tube, fibrinolytic, and surgery (n = 5); and group IV, surgery alone (n = 6). Preadmission, in-hospital, and outcome variables for the groups were recorded and compared using the Kruskall-Wallis test, with a P value less than .05 considered significant. All the patients who received fibrinolytics (group II and III) were grouped into subjects who received immediate transpleural fibrinolytics versus those who received fibrinolytics 48 hours after chest tube insertion. Length of stay (LOS), need for surgery, and hospital costs were compared between the early and late fibrinolytic groups using the Wilcoxon rank-sum test, with a P value less than .05 considered significant.

Results

Comparison of duration of symptoms, duration of preadmit antibiotics, initial white blood cell count, total lymphocyte count, and antibiotics showed no significance among the 4 groups. When comparing outcome variables, the “nonsurgery groups” (groups I and II) had shorter LOS, intensive care unit stay, and hospital charges when compared with the “surgery groups” (groups III and IV). The timing of fibrinolytic instillation (immediate versus later) did not significantly affect in the LOS, hospital charges, or the tendency to need surgery eventually in the patients who received intrapleural fibrinolytics (group II and III combined). LOS was predicted by preadmit duration of symptoms (P = .025) and overall duration of fever (P < .01). The level of pleural glucose seemed to be predictive of need for surgery (P = .015). Overall, 11 of 54 children (20.2%) eventually needed surgery.

Conclusions

Tube drainage with intrapleural instillation of fibrinolytics can be performed successfully in a large number of children with empyemas. Ultrasound characterization of the fluid and, perhaps, glucose levels may guide surgical versus nonsurgical therapy. In centers in which percutaneous drainage and tissue plasminogen activator are available, this option may be a safe and less costly alternative to surgery.     

Early management of meconium ileus in infants with cystic fibrosis: A prospective population cohort study

BackgroundContemporary early outcome data of meconium Ileus (MI) in cystic fibrosis (CF) are lacking on a population level. We describe these and explore factors associated with successful non-operative management.MethodsA prospective population-cohort study using an established surveillance system (BAPS-CASS) was conducted October 2012–September 2014. Live-born infants with bowel-obstruction from inspissated meconium in the terminal ileum and CF were reported. Data are described as median (interquartile range, IQR).Results56 infants were identified. 14/56(25%) had primary laparotomy (13/23 complicated MI, 1/33 simple), the remainder underwent contrast enema. Twelve, (12/33 (36%) with simple MI) achieved decompression. 8/12 (67%) who decompressed had >1 enema vs 3/20 (15%) with simple MI who had laparotomy after enema. The number of enemas per infant (1–4), contrast agents and their concentration, were highly variable. Enterostomy was formed at 24/44(55%) of laparotomies. In infants with simple MI, time to full enteral feeds was 6 (2–10) days in those decompressing with enema vs 15 (9–19) days with laparotomy after enema. Case fatality was 4% (95% CI 0.4–12%). Two infants, both preterm died, both in the second month after birth.ConclusionsInfants with simple MI achieving successful enema decompression were more likely to have had repeat enemas than those who proceeded to laparotomy. Successful non-operative management was associated with a shorter time to full feeds. The early management of infants with MI is highly variable and not standardised across the UK and Ireland.     

A prospective,multicentre study on the use of epidermal grafts to optimise outpatient wound management

Current wound management through the use of a split‐thickness skin graft often requires hospital admission, a period of immobility, attentive donor site wound care and pain management. This study evaluates the feasibility of using a novel epidermal graft‐harvesting device (CelluTome) that allows pain‐free epidermal skin grafting in the outpatient clinic setting. A prospective series of 35 patients was performed in 2 centres, involving 10 acute and 25 chronic wounds. All patients were subjected to epidermal grafting in the outpatient specialist clinic, without the use of anaesthesia, and allowed to return home after the procedure. Completely healed wounds were noted in 22 patients (62·9%). The overall mean time for 50% and 100% reduction in wound size was 3·31 ± 2·33 and 5·91 ± 3·48 weeks, respectively. There was no significant difference in healing times between the acute and chronic wounds (50% reduction in wound size; acute 2·20 ± 0·91 weeks versus chronic 3·73 ± 2·63 weeks, P = 0·171. Hundred percent reduction in wound size; acute 4·80 ± 1·61 weeks versus chronic 6·83 ± 4·47 weeks, P = 0·183). The mean time for donor site healing was 5·49 ± 1·48 days. The mean pain score during graft harvest was 1·42 ± 0·95, and the donor site Vancouver Scar Scale was 0 for all cases at 6 weeks. This automated device offers autologous skin harvesting in the outpatient setting with minimal or no pain and a scar free donor site, equally benefiting both the acute and chronic wounds. It has the potential to save NHS resources by eliminating the need for theatre space and a hospital bed while at the same time benefiting patient care.     

Early versus delayed stabilization of femoral fractures. A prospective randomized study

A prospective randomized study comparing the results of early with delayed reduction and stabilization of acute femoral fractures in adults was performed over a two-year period in 178 patients. Only patients who were more than sixty-five years old and had a fracture of the hip were excluded. Arterial blood gases, injury-severity score at the time of admission, pulmonary function, days in the hospital, days in the intensive-care unit, and hospital costs were recorded for all patients. The patients were divided into two groups: those who had an isolated fracture of the femur and those who had multiple injuries. When stabilization of the fracture was delayed in the patients who had multiple injuries, the incidence of pulmonary complications (adult respiratory-distress syndrome, fat embolism, and pneumonia) was higher, the hospital stay was longer, and the number of days in the intensive-care unit was increased. The cost of hospital care showed a statistically significant increase for all patients who had delayed treatment of the fracture compared with those who had early stabilization.     

Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors

Purpose

The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision.

Methods

From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization.

Results

The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia.

Conclusion

The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.     

Fractures of the acetabulum. Early results of a prospective study

One hundred two patients with 105 displaced fractures of the acetabulum were treated for fractures involving at least one column of the acetabulum and displaced at least 5 mm (rim fractures were excluded). The patients were primarily young adults with multiple injuries secondary to motor-vehicle-associated trauma. Fractures were classified according to the classification of Letournel. The most common fractures were the complex associated types with 44 complete both column, 19 T-shaped, and 18 associated transverse and posterior wall. Seventeen fractures were treated closed, and 88 were treated operatively. Closed treatment with skeletal traction was undertaken if roof arc measurements demonstrated a satisfactory remaining acetabular dome following fracture and in some cases of apparent congruence following complete both column fractures. Fractures not meeting these criteria were operated upon through the Kocher-Langenbeck, extended iliofemoral, or ilioinguinal approach. Ninety percent of the operations produced a satisfactory reduction of the fracture (3 mm or less displacement). A follow-up study longer than one year was obtained for 50 fractures. Clinical results were 80% satisfactory overall. Operative complications included 3% infection, 5% nerve palsy, and 7% significant ectopic bone. Operative treatment can produce satisfactory fracture reductions and clinical results with an acceptably low complication rate.     

Flutamide versus stilboestrol in the management of advanced prostatic cancer. A controlled prospective study

In a prospective randomised study the effect of flutamide 750 mg daily was compared with that of stilboestrol 3 mg daily in the treatment of 40 previously untreated patients with advanced prostatic cancer. There was a good subjective response to both treatments. After 12 months, a response was demonstrated in 13 of 20 patients treated with flutamide and 8 of 20 patients treated with stilboestrol. The difference was not statistically significant. Treatment with stilboestrol caused more frequent, and more severe, side effects than flutamide.     

Controversies in the management of subdural empyema

Summary Forty one cases of subdural empyema treated between 1977 and 1988 at the Postgraduate Institue of Medical Education and Research, Chandigarh, have been analysed. The patients ranged from 9 days to 80 years of age. There were 22 children, including 11 infants. Fever, altered sensorium and seizures were the most common symptoms present for 1 day to 6 months. Otogenic infection was the commonest aetiological factor followed by postoperative and post-traumatic causes. Thirty seven patients had supratentorial empyemas, including 4 with parafalcine collections, three had infratentorial empyemas, and in one there was extension of the empyema from the supratentorial to the infratentorial compartment. Therapeutic modalities used included percutaneous needle aspirations in infants and burr hole evacuation and craniotomies in adults. A wide spectrum of organisms was detected. Mortality in this series was 24%, which was mainly attributable to the deteriorated neurological status prior to treatment.A detailed review of the literature has been given, highlighting various controversies in the management of SDE. Important prognostic factors and a treatment plan are suggested.