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Eur J Cardiothorac Surg 2002;22:595-598
© 2002 Elsevier Science NL

Management of multiloculated empyema thoracis in children: thoracotomy versus fibrinolytic treatment

Akin Eraslan Balci^*, evval Eren, Refik Ülkü, Mehmet Nesimi Eren

Department of Thoracic & Cardiovascular Surgery, Dicle University School of Medicine, 21280 Diyarbakir, Turkey

Received 13 March 2002; received in revised form 6 June 2002; accepted 19 June 2002.

* Corresponding author. Tel.: +90-412-2488001, ext. 4506; GSM: +90-535-7719008; fax: +90-412-2488440
e-mail: abalci{at}dicle.edu.tr

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions References

 
Objective: Progression of empyema, with the development of fibrinous adhesions and loculations, makes simple drainage difficult or impossible. The appropriate management remains controversial. Intrapleural fibrinolytic treatment to facilitate drainage of loculated empyema instead of open thoracotomy has been advocated recently. The aim of this study was to evaluate the effectiveness of the intrapleural fibrinolytic application. Methods: In our clinic we used urokinase in 28 patients and performed thoracotomy and decortication in another 43. The two groups of patients had similar characteristics. Mean age was 10.2 (range: 3–14 years). All had undergone medical treatment and tube thoracostomy. Empyema severity score (ESS) was measured in all. Results: Fibrinolytic treatment, and thoracotomy and decortication had complete response rates of 67.8 and 100%, respectively. Treatment was ineffective in six (21.4%) out of 28 patients who underwent urokinase instillation; they recovered after thoracotomy. In three (10.7%) patients, partial resolution was observed. One patient died of sepsis and pleural hemorrhage. Mean hospital stay after urokinase was 10.7 (range: 6–17) days. In the thoracotomy group, all patients recovered completely. No deaths occurred. Postoperative complications were incisional infection in two patients, atelectasis in one and reoperation after hemorrhage in one. Mean hospital stay after surgery was 9.5 (5–19) days. The ESS of cases operated on was lower postoperatively (0.3 versus 0.8). Conclusion: Continued conservative therapy risks morbidity and mortality. Thoracotomy–decortication can be used successfully and must remain the preferred method in the treatment of multiloculated pediatric empyema.

Key Words: Empyema • Decortication • Urokinase

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions References

 
Progression of empyema, with the development of fibrinous adhesions and loculations, makes simple drainage difficult or impossible. Loculated, undrained empyema is manifested by persistent fever and pleural effusion despite tube thoracostomy. The appropriate management at this point in the disease remains controversial. Patients often are subjected to multiple procedures and long hospitalization before the empyema is successfully treated [1]. Fibrinolytic treatment has been advocated because of being safe and effective and sparing most patients with empyema the morbidity and mortality of thoracotomy [2–4]. The use of intrapleural fibrinolytic agents in the management of complicated parapneumonic effusions has been widely reported in adults. Such agents promote drainage of fluid through the thoracostomy tube.

We studied whether fibrinolytic agent (urokinase) instillation via a chest tube can be an alternative to surgery in loculated postpneumonic empyema in children.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions References

 
Between 1996 and 2002, 568 children were hospitalized with postpneumonic empyema in our clinic. Following the findings from physical examinations and X-ray studies, we made a more precise diagnosis of pleural effusion in suspected cases with pleural aspiration. Empyema was diagnosed in the clinical setting of pneumonia, with pleural fluid demonstrated on chest X-rays and recovered by thoracentesis that contained >1.000 WBCs per cubic centimeter. Microbiologic studies of pleural aspiration fluid showed that Staphylococcus aureus was the most common pathogen. No agent was isolated from the cultures of 77 (13.5%) patients. Initially all patients were treated with wide-spectrum antibiotics and later with more sensitive drugs. In acute empyemas and parapneumonic effusions, the initial treatment was pleural aspiration plus lavage; 49 (8.6%) patients were treated in this manner. The second step was chest tube treatment. Patients whose conditions did not improve clinically with iv antibiotics and closed tube thoracostomy drainage were considered for decortication or intrapleural fibrinolytic therapy. Twenty-one percent of 568 children (119 children) underwent thoracostomy and decortication after chest tube drainage for empyema.

Of all 568 patients, 92 (11%) had multiloculated empyemas (MEs). In the operated group (OG), 44.5% had MEs (46/119). Three of them were excluded because their test results were lost. All decortications were performed via posterolateral thoracotomy. The pleural space was entered through the fifth intercostal space. Rib resection was not performed to gain exposure. The intrapleural gelatinous debris and fibrin mass were evacuated. There was inclination for the lung to reexpand without formal decortication. Therefore, the fibrinous peel on the surface of the visceral and parietal pleurae was carefully removed. A plane of cleavage between the visceral pleura and the peel could usually be initially started in the interlobar fissure.

After 1997 there were 36 patients with ME treated with fibrinolytic therapy. No air leaks were present. Of the 36, eight were excluded because of loss of test results (four cases), absence of control computed tomography (CT, two cases), and referral to other clinics (two cases). For the urokinase instillation, the method described by Stringel and Hartman was used [5]: 20 ml of sterile urokinase solution, concentration 1000 IU/ml (Abbott), was freshly reconstituted in the pharmacy with sterile water and instilled via the thoracostomy tube. The tube was then clamped for 2 h followed by suction. Patients were rotated in several positions to facilitate pleural distribution. The procedure was repeated three times a day for 3 days for a total dose of 180,000 IU of urokinase. During this period, clinical course was evaluated by monitoring for fever, chest tube drainage, WBC counts, erythrocyte sedimentation rate (ESR) and daily chest radiograms. Patients were also observed for signs of anaphylaxis, respiratory decompensation, chest pain and bleeding. If significant clinical improvement occurred with partial radiographic response, patients were offered decortication. If patients were in clinically stable condition but had no decrease in cavity size, they were also offered decortication. Complete response was defined as resolution of symptoms and signs of infection with complete drainage of fluid and no residual space radiographically. Non-responders were patients who underwent decortication.

Multiloculation was detected both clinically and radiologically. The main multiloculation criteria were viscous pleural fluid with septations consisting of fibrin clusters detected by ultrasonography, no improvement in the chest X-ray view on chest tube insertion, viscous and less empyema fluid drainage than expected relative to initial films and continued fluid aspiration with thoracentesis after chest tube insertion.

Empyema severity score (ESS) was used to determine the severity of disease with the aim of objectively comparing the results of urokinase and decortication procedures. Only peel, scoliosis, pleural culture of atypical pathogens including gram-negative organisms or anaerobes, and low pH (<7.2) and glucose content (<40 mg/dl) of pleural fluid have been found to be correlated with severe disease [6]. A severity score was assigned to each case according to Hoff et al.'s study [6], giving one point for the presence of each of the aforementioned five variables. All variables were determined in each case except for pleural pH, which was occasionally obtained. Pleural peel was evaluated by pre- and postprocedure CT in all. Scoliosis was examined on posteroanterior X-rays. Patients with an ESS2 were classified as having severe disease, an ESS equal to 1 identified patients with moderate disease, and the absence of these factors (ESS=0) indicated mild disease.

Forty-three children with ME in the OG and another 28 children with ME in the fibrinolytic group (FG) were analyzed retrospectively. Data was collected from patients' archive files. The blood and urine tests of all patients were studied. No coagulation anomaly was present. The Wilcoxon test was used to compare ESS values.

Mean age was 10.2 (range: 3–14 years); the boy/girl ratio was 1:2. The two groups of patients had similar characteristics (Table 1). All had undergone medical treatment and tube thoracostomy. Patients were regularly seen in the policlinic 10 days, 1 and 3 months after discharge. Mean long-term follow-up was 3.8 years (6 months to 11 years).

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions References

In the thoracotomy group (n=43), all patients recovered completely. No deaths occurred. Postoperative complications consisted of incisional infection in two patients, atelectasis in one and reoperation due to hemorrhage in one. Wound infection was manifested by seropurulent fluid. Complete resolution was achieved by antibiotics according to culture (Staphylococcus aureus) and dressing twice a day. Atelectasis was treated with respiratory exercise and nasotracheal aspiration; no bronchoscopy was needed. Reoperation indication was oozing of 300 ml a day through the chest tube in a 7-year-old child. Intercostal artery ligation was performed. Mean hospital stay after surgery was 8.7 (5–19) days. No deaths occurred.

Before intervention, there was no difference between mean ESS scores of the OG and FG. Both surgery and fibrinolytic treatment decreased or eliminated the severity of empyema. After intervention, the mean ESS of the OG was less than that of the FG (P<0.05). Among the previously five given factors, in the postoperative period only scoliosis (1 point) was present in the OG. Low glucose (1 point) and low pH (1 point) were present in the FG.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions References

 
Experience of the use of intrapleural fibrinolytics in children is limited and the safety and efficiency of these agents are not well described [4]. It was not possible to conclude that urokinase instillation for loculated empyema thoracis would decrease the need for surgery or shorten the hospital stay [4]. The present study can be helpful for assessing the timing of administration and ideal dosing of intrapleural urokinase and determining its potential side effects. In multiloculated cases, urokinase instillation had a success rate of 67.8% while this rate was 100% with open thoracotomy and decortication. In a similar study, with urokinase instillation for empyema drainage, two patients died of sepsis with incomplete drainage and five patients underwent decortication (three recovered and two died postoperatively); 45% of patients required placement of more than one drain. Mean hospital stay was 20 days [6]. In another study, fibrinolytic treatment was associated with complete resolution of empyema in 62%, partial relief of symptoms in eight and 30% failed to improve [2]. Bleeding occurred in one patient as a complication and one death occurred [2]. In our study, one child died of sepsis (5%). The rate of partial response was 10.7%. No deaths occurred among decorticated patients after urokinase instillation.

The duration of hospital treatment of patients with empyema is longer than in those with parapneumonic effusion. If untreated empyema gains a fibro-purulent nature in a short time, leading to more fibrin accumulation in the pleural area, decortication is the treatment of choice [7]. Aspiration mostly failed to treat empyema, as in the present study [7]. Our patients generally receive no or insufficient pneumonia treatment during the pre-hospitalization period. Thus most of them are advanced pleural effusion cases, including viscous pus. Therefore, the success rate of aspiration treatment was extremely low. Obtaining pleural effusion by thoracentesis may sometimes be difficult even using a large needle. Mean hospital stay prior to decortication, including time for other treatment, was 17.7 days, and, after decortication, 8.7 days. Total hospital stay was 26.4 days in those who underwent decortication [8].

It has been reported that mean duration before initiating urokinase therapy was 7 days and the chest tube was removed a mean of 3.7 days after urokinase instillation. Patients were discharged a mean of 5 days after urokinase instillation and mean hospital stay was 15.5 days [4]. Mean hospital stay of our patients was longer than those in the literature. This may be related to the need for longer preparation and observation as well as the relatively high mean number of multiloculated chronic cases.

Some studies have reported that conservative treatments failed and more patients required decortication [6,9]. Recent discussions have emphasized the importance of early and aggressive treatment of empyema prior to the development of stage 3 (organizing phase), after which effective treatment is more difficult [10,6]. Video-assisted thoracoscopic surgery (VATS) can be performed safely and effectively in children with stage II empyema, thus avoiding the morbidity of open thoracotomy and decortication [11]. Especially in phase III, the open operative revision of a pleural empyema is the method of choice; if the empyema cavity is divided then VATS is recommended [12]. However, little benefit from VATS has been also observed [13]. All our patients were in the organizing phase (stage III).

Early decortication had beneficial effects on pulmonary perfusion [14]. Fibrinolytic use should be advocated in potential decortication candidates in an effort to avoid surgery with attendant morbidity [4]. However, surgical morbidity is low and mortality rate is extremely rare. On the other hand, surgery gave a low mean ESS and complete resolution in 100% of patients. Contrary to studies that favor intrapleural fibrinolytic therapy, in an experimental animal model streptokinase and urokinase were not found to be effective for liquefaction of thick pleural exudates [15].

	5. Conclusions

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions References

 
In our opinion, fibrinolytic therapy is not an alternative to surgery, especially in loculated empyemas in children. Continued conservative therapy may risk the morbidity of a protracted febrile illness requiring prolonged hospitalization and/or antibiotic treatment. Open thoracotomy and complete lung decortication, in loculated cases, must remain the preferred treatment method. Fibrinolytic therapy may be beneficial when used in the early stage of loculation and fibrosis (fibrinopurulent stage).

	Footnotes

 
Presented at the World Society of Cardio-thoracic Surgeons-ISCTS, 12th World Congress, Luzern, Switzerland, March 3–6, 2002.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions References

 

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