Eur J Cardiothorac Surg 2004;26:498-502
© 2004 Elsevier Science NL
Causes and management of postpneumonectomy empyemas: our experience
Grzegorz Kacprzak*,
Marek Marciniak,
Emanuel Addae-Boateng,
Jerzy Kolodziej,
Konrad Pawelczyk
Department of Thoracic Surgery of the Medical University, Department of Thoracic Surgery of the Lower Silesian Centre of Lung Diseases, Thoracic Surgery Centre in Wroclaw, Grabiszynska 105 st., 53-439 Wroclaw, Poland
Received 13 January 2004;
received in revised form 8 May 2004;
accepted 14 May 2004.
* Corresponding author. Address: Powstancow Slaskich St., 46/16, 53-333 Worclaw, Poland. Tel.: +48-71-33-49-419; +48-0608-29-57-70 (Mobile); fax: +48-71-33-49-603
e-mail: grzegorzkacprzak{at}interia.pl
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Abstract
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Objective: Infection of the pleural cavity and development of empyema are potential dangers after pneumonectomy. In spite of decrease in frequency of postpneumonectomy empyemas (PPE) formation, this is still a serious complication. The aim of this study was: analysis the mechanisms of postpneumonectomy empyema formation and attempt the elaboration of the optimal management of these patients. Methods: 1148 pneumonectomies were performed at the Thoracic Surgery Centre between 1984 and 2002. PPE occurred in 76 (6.6%) patients between the ages of 25–77. For statistical purposes the 
2 test was used. Results: The causes of PPE showed that in 56/76 (73.7%) patients its formation was due to a postoperative complications. In 4/76 (5.3%) cases the cause of empyema was associated with intraoperative infection during the operation. In 3/76 (3.9%) patients a long period of treatment at the intensive care unit due to postoperative shock predisposed to the infection. In 13/76 (17.1%) patients the cause was not established. Statistically significant PPE was associated with postoperative complication (P=0). Postoperative complication caused by one factor was more frequent than those caused by 2 or 3 factors (P=0). PPE was the most often diagnosed in the second postoperative week (P=0.0001). 13 (17.1%) patients died during the 30 days after beginning of the treatment of PPE. The course of complication was more impetuous and more deaths were noted in patients diagnosed during the first week after operation. Only 8 patients from 34, who were selected for thoracentesis and lavage with deposition of antibiotics into the pleural cavity recovered. Jointly 68 (89.5%) patients underwent chest tube drainage. After 2-3 weeks the tube was removed in 16 patients. 17 (22.4%) patients were not qualified for operation. 35 (46.1%) patients underwent different operative procedures: 20 fenestrations, 12 fenestrations with myoplasty and 3 thoracoplastic operations with myoplasty. Conclusions: The most common causes of PPE were postoperative complications, mainly bronchopleural fistula. The scheme of therapeutic management in PPE was elaborated as a result of our experience.
Key Words: Postpneumonectomy empyema • Thoracocentesis • Drainage • Therapeutic management
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1. Introduction
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Infection of the pleural cavity and the development of empyema are potential dangers after lung tissue resection procedures, mostly after pneumonectomy. In spite of the decrease in frequency of postpneumonectomy empyema (PPE) formation, this is still a serious complication. This complication may cause a great danger, especially if it combines together with bronchopleural fistula [1,2]. Course of the disease may be different. Some patients are in good condition, but in some the respiratory and circulatory insufficiency may appear. General status of patient determinates therapeutic management. The aim of this paper was: analysis the mechanisms of postpneumonectomy empyema (PPE) formation and attempt the elaboration optimal management of these patients. To this end potential factors, which may cause PPE, the bacterial flora and clinical course of this complication were analyzed. This analysis may be helpful in intra and postoperative management of the patients to avoid a PPE formation. Work out an appropriate therapeutic management may alleviate the course of the disease, allow both to apply an appropriate scheme of therapeutic management and to decrease amount of deaths.
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2. Clinical material and methods
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Between 1984 and 2002 at the Thoracic Surgery Centre in Wroclaw 1148 pneumonectomies were performed in patients between the ages of 25–77. PPE occurred in 76 (6.6%) patients. The causes of pneumonectomies in 68 (89.5%) patients were lung cancer, in 6 (7.9%) posttuberculosis cirrhosis of the lung tissue and in 2 (2.6%) benign tumor. In perioperative period the patients received routine prophylactic antibiotic therapy. Between 1984–1989 aminoglicosid (Gentamycin, Amikin), between 1990 and 1995 II generation cephalosporine (Biocefal) were administered, and at the beginning of 1996 Mandol has been used. In I and IV or V day routinely the chest X-ray and in some cases ultrasonography were performed.
Between 1984–1995 drain in postpneumonectomy cavity was maintained II or III days depending to quantity of pleural fluid outflow. Since 1996 drain has been maintained maximum I or II days. Before 1996 thoracocentesis of postpneumonectomy cavity was made routinely in IV or V day after operation. Pleural fluid was sent to bacteriological examination and biochemical investigation (blood cell count, specific weight, Rivalty test, protein and glucose levels, pH of fluid). Since 1996 thoracocentesis has been made if the patient demonstrated alarming symptoms like: dyspnoea, fever or if we suspected haematoma of postpneumonectomy cavity basing on X-ray, chest ultrasonography or biochemical investigation (blood cell count decreasing). If contents of pleural cavity was not organized (only blood stained fluid) we did not perform treatment procedures.
Hand stitching of the stump, using Overholt or Sweet method was performed, in all patients. Only in 3 (3.9%) patients the stump was involved by neoplastic process. Patients with bronchopleural fistula (BPF) diagnosed within 24 h after operation were not analyzed, because they were reoperated immediately. The results those operations were good.
For statistical purposes the 2 test was used. The value of P<0.05 was defined as statistically significant.
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3. Results
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Analysis of our experience showed that the number of operations without complications increased in the ensuing 5 years periods. The differences are statistically significant (P=0) (Fig. 1)
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Analysis of the potential causes of PPE showed that in 56/76 (73.7%) patients its formation was due to a postoperative complications. In 38/56 (67.9%) patients only one causative factor was identified. In 10 cases it was a result of postresectional cavity haematoma, in 8 due to wound suppuration and in 20 bronchopleural fistula (BPF) was noticed. In 13/56 (23.2%) cases two causative factors were isolated. In 5 cases it was a result of cavity haematoma and wound suppuration, in 4 cases haematoma and BPF and in 4 cases BPF and wound suppuration. In the remaining 5/56 (8.9%) patients three etiologic factors were identified like a wound suppuration, postresectional cavity haematoma and BPF. Other causes of PPE formation, defined as intraoperative, were observed in 4/76 (5.3%) patients. In all of these cases there was a spill of necrotic tumour mass material into the operative field. Another group of factors that predisposed to the formation of PPE involved in 3/76 (3.9%) patients who were treated at the intensive care unit after operation. Two of them, because of a shock which ensued a massive intraoperative blood loss and third one with ARCI (acute respiratory and circulatory insufficiency). In the rest of 13/76 (17.1%) patients no specific predisposing factors were established. PPE is statistically significant associated with postoperative complications than with other factors (P=0) (Fig. 2)
. Moreover it was observed that complications associated with one causative factor occurred statistically significant more often than those caused by 2 or 3 factors (P=0) (Fig. 3)
. In the group with only one causative factor, BPF occurred more frequent than other factors (P=0.0376) (Fig. 4)
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In the group of 76 patients BPF was diagnosed in 33 (43.4%) cases. The BPF was responsible for PPE formation more frequently than other factors and the difference was statistically significant (P<0.05).
Incubation of the flora from infected pleural cavity, showed a predominance of cocci (50%) such as Staphylococcus aureus in 31 patients and G(–) rods (40.6%) including Pseudomonas aeruginosa in 16 cases and Proteus mirabillis in 9 patients (Table 1). In 20 (26.3%) patients infection was caused by one bacterial strain and in 56 (73.7%) patients by 2 or 3 strains. In the group of cocci Staphylococcus aureus was isolated more often than other bacteria and the difference was statistically significant (P<0.05) (Fig. 5)
. In the group of rods Pseudomonas, Proteus and unspecific G negative bacteria appeared more frequently than others (P=0).
PPE was diagnosed in the first week in 12 (15.8%), in the second week in 24 (31.6%), in the third week in 5 (6.6%) and in the fourth week in 8 (10.5%) patients. Between 5 and 8 weeks PPE was diagnosed in 15 (19.7%), between 2–9 months in 9 (11.8%) patients and after 1 year in 3 (4.0%) patients. Statistical analysis showed that PPE was the most often diagnosed in the second postoperative week and it was statistically significant (P=0.0001) (Fig. 6)
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In analysis period 30 days at the beginning of the treatment of PPE we noted 13 (17.1%) deaths. 7 patients died due to sepsis. In 6 of them it was a result of ARCI (acute respiratory and circulatory insufficiency). 5 deaths which accounted for 41.7% (5/12) of deaths in this group were observed in patients who were diagnosed with PPE in the first postoperative week. In 4 of them the cause of death was sepsis and in 1 ARCI. 6 deaths were noted in the group of patients who were diagnosed with PPE in second week. This accounted 25% (6/24) in this group. 5 patients died as a result of ARCI and 1 due to sepsis. One death due to sepsis was noted in the group of patients who were diagnosed with PPE in third week after operation. This accounted 20% (1/5) in this group. In patients who were diagnosed with PPE in fourth week 1 death due to sepsis was observed. This accounted 12.5% (1/8) deaths in this group. No deaths were recorded in patients who were diagnosed with PPE between 5 and 8 weeks, between 2 and 9 months and one year after operation. The course of complication was more impetuous and more deaths were noted in patients diagnosed during the first week after operation.
Patients with confirmation of pleural cavity infection after pneumonectomy were qualified for treatment according to the following criteria: macroscopic purulent aspirate during thoracocentesis, infected haematoma and positive microbiologic incubations of the pleural aspirates. 34/76 (44.7%) patients, were selected for thoracocentesis and lavage with the deposition into pleural cavity the appropriate antibiotics. In 8/76 (10.5%) cases this procedure led to complete recovery. The remaining 26 patients who responded poorly to such a treatment added up to 42 (55.3%) others who were in a poorer clinical condition initially and were treated with chest tube drainage. Together, they constituted a group of 68/76 (89.5%) patients who underwent chest tube drainage with daily pleural cavity lavage as part of their treatment. This helped to decide after 2–3 weeks of treatment whether to remove the tube or qualify the patient for operation. The possibility of operation was considered in 52/76 (68.4%) patients. 17/76 (22.4%) patients were disqualified from the operation as a result of poor general condition or lack of consent. Those patients were discharged as permanent carriers of drain. 35/76 (46.1%) patients underwent different surgical procedures like: 20 fenestrations, 12 fenestrations with myoplasty and 3 thoracoplastic operations with myoplasty. Those procedures allowed us to achieve a success rate of 91.4% (32/35) This analysis showed that drainage more frequently led to the resolution of PPE than thoracocentesis. The difference was statistically significant (P=0). Since 5 years mainly chest drainage has been performed. Our experience let us to elaborate a scheme of therapeutic management of PPE in dependence of patient's general condition and clinical course of the disease (Fig. 7)
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4. Discussion
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The sources of infection of the postpneumonectomy cavity are diverse. An incidental infection of the pleural cavity may ensue during the operation as result of spilling of secretions from the respiratory tree or after operation because of a leaking bronchial stump into the postpneumonectomy cavity. In our material we observed BPF in 33 (43.4%) patients. The source of infection can be a cavity due to tuberculosis or fungal infection, pulmonary abscess or neoplastic tumours, which are ruptured during operation [2]. In three cases we noted a spillage of necrotic tumour material during the operation. Postoperative haematoma is a conducive medium for bacterial growth. It was a causative factor of PPE in 24 (31.6%) patients in our material. Geha and Goldstraw observed that during the period of 1970–1980 there was a domination of one bacterial strain with the predominance of Gram(+) especially Staphyllococcus aureus as the cause of pleural cavity infection [3,4]. In our material we observed a similar situation during 1984–1988. In the ensuing years we observed an increase of mixed infections with 2 or 3 strains of bacteria and an increase of Gram(–) bacteria including Pseudomonas aeruginosa. Pairolero published a similar observation [5]. Analysis of bacterial culture allowed us to take an appropriate decision of changing antibiotic, which was used in perioperative prophylaxis. Besides this allowed us to apply an appropriate antibiotic in early phase of PPE treatment, when the antibiograms were prepared.
Schueckler reported 2 cases of PPE diagnosed 4,5 and 12 years, respectively, after operation and define them as ‘late empyemas’. He postulated that the possible source of infection was a haematogenous flow of bacteria from foci elsewhere in the body [6]. In our material 3 cases diagnosed 1 year after operation. The severity of the infection is determined by the extent of the purulent process. The concomitant appearance of complication like wound infection, postresectional haematoma and BPF is a factor of poor prognosis. We observed such a situation in 4 patients, two (50%) of them died. Most of the patients in our material 68 (89.5%) needed a chest tube drainage of the postresectional cavity. Thoracocentesis made in our Department were not enough effective, therefore we use them now sporadically in special cases. Besides the removal empyema from postpneumonectomy cavity, administration of the appropriate antibiotics during septic period is necessary. When detoxification was achieved and the general condition of the patient has improved the patients should be prepare for surgical repair [7,8]. In our material the operation was investigated in 52 (68.4%) patients. PPE are often observed in patients who undergo lung resection as result of cancer, whose general conditions are average, poorly tolerate the extensive operative procedures and have limited respiratory and circulatory reserves. Fenestration, which is a shorter procedure, seems to be the most appropriate method of treatment in such patients [4,7,9–14]. In 1915, Robinson as the first performed open drainage of the pleural cavity together with transposition of the latissimus dorsi muscle. Since then Pairolero has propagated this method reporting a success rate of 85.7% in the treatment of BPF and almost 100% in pleural empyema [5,15–17]. In 1937 Alexander said that thoracoplasty should be used to close the pleural cavity only when other methods will not give a similar result. The disadvantage of this method is the significant deformation of the chest. However, the junction of the thoracoplasty and myoplasty according Pairolero and Jaduczk allow to achieve up to 95% success in the treatment of PPE [5,14,18,19]. In our experience various procedures allowed to achieve a success rate of 91.4% (32/35) in PPE.
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5. Conclusions
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(1) The most common causes of PPE were postoperative complications, mainly bronchopleural fistula. (2) The cause of PPE infection was mixed bacterial flora with the predominance of Staphylococcus aureus and Pseudomonas aeruginosa. (3) PPE was the most often diagnosed in the second postoperative week. (4) The course of complication was more impetuous and more deaths were noted in patients diagnosed during the first week after operation. (5) Analysis of our experience let us to elaborate a therapeutic management in dependence of general condition of patient and clinical course of the disease.
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Abstract
1. Introduction
