Eur J Cardiothorac Surg 2005;27:32-34
© 2005 Elsevier Science NL
Continuous pleural lavage may decrease postoperative morbidity in patients undergoing thoracotomy for stage 2 thoracic empyema
Ari Mennander*,
Jari Laurikka,
Pekka Kuukasjärvi,
Matti Tarkka
Heart Center, Tampere University Hospital, Tampere University, 33521 Tampere, Finland
Received 21 June 2004;
received in revised form 30 September 2004;
accepted 4 October 2004.
* Corresponding author. Tel.: +358 3 3116 4945; fax: +358 3 2475756. (E-mail: ari.mennander{at}pshp.fi).
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Abstract
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Objective: To assess the impact of postoperative continuous pleural lavage (PCPL) after thoracotomy for the treatment of stage 2 pleural empyema in relation to postoperative length of stay and morbidity. Methods: Stage 2 pleural empyema was diagnosed with computer tomography. Conservative treatment including antibiotics and pleural aspiration was introduced. 89 patients treated for stage 2 pleural empyema by thoracotomy, pleural discharge evacuation and irrigation after pleural decortication were identified after unsuccessful conservative treatment for 10 days. Whenever pleural discharge remained opaque after operation, PCPL was administered daily through the cranial chest tube and discharge evacuated through the caudal pleural suction (10–15mmHg) tube. Risk factors related to pleural pus and patient outcome were sought for. Results: Seventy-seven out of 89 patients (86.5%) had clear empyema discharge immediately after pleural decortication and irrigation. Pleural discharge remained opaque despite surgery in 12 out of 89 patients (13.5%) and PCPL was introduced. Presence of a combination of risk factors for pleural empyema, such as dental caries, alcohol abuse or previous inflammatory reaction, was predictive for persistence of opaque pleural discharge after operation (P<0.05). Need for re-thoracotomies (in 11 cases, P=ns) and postoperative deaths (P<0.05) were related with patients who did not have PCPL. The length of the hospital treatment was 20.1±3.1 (days±SEM) among patients with PCPL and 19.2±1.8 without PCPL before possible re-thoracotomy, respectively (P=ns). Conclusions: Early postoperative (1 day–11 months) mortality was statistically associated with patients having fibrinopurulent empyema but no PCPL. PCPL is a feasible method to clear pleural pus discharge without prolongation of hospitalization and may be recommended after thoracotomy for patients with fibrinopurulent stage 2 empyema.
Key Words: Pleural empyema • Lavage • Morbidity
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1. Introduction
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Complicated pleural empyema is a medical challenge, as preoperative diagnosis is often inadequate in identifying accurately possible pleural pus [1]. Computed tomography (CT) may reveal pleural fluid and inflammatory adhesions, but occasionally infection per se remains unrevealed until surgical opening of pleural cavity is performed [2–5]. However, presence of infective pleural pus, often characterized with bacteria and thick pleural discharge, determines patient morbidity and occasionally mortality [5,6].
Various treatment methods are introduced to compensate unawareness of best strategy to deal with complicated pleural empyema [4,5,7,8]. In addition, it has been suspected that most of these patients may be too ill to bear thoracotomy and minimal surgical methods have gained popularity [9]. However, thorough debridement of pleural cavity from devastating infection supplemented with pleurectomy is mandatory for recovery [5,6]. Thoracoscopic interventions for treatment of complicated pleural empyema have remained as an adjunct method before final open pleurectomy.
An irrigation method for the treatment of contaminated pleural space has been successfully used earlier in a high-risk patient after pneumonectomy [10]. We speculate whether continuous irrigation with physiological saline to clear pleural discharge after chest tube drainage and open pleurectomy may enhance patient recovery after complicated pleural empyema with persistent opaque pleural discharge. We therefore compared our results of novel lavage technique to our standard procedures without postoperative irrigation.
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2. Patients and methods
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During 1996–2003 we identified 89 patients treated surgically for stage 2 pleural empyema in Tampere University hospital. Pleural empyema was diagnosed clinically according to patient symptoms and related pathogen. Stage 2 pleural empyema was defined, as described earlier [11]. Briefly, stage 2 consisted of patients with fibrinopurulent stage empyema characterized by a thickening of the exudate and dense fibrin deposition forming occasionally distinct abscess and pertinent pus discharge. All patients were evaluated with CT and initially treated with antibiotics and chest tube drainage. Thoracotomy, pleural fluid evacuation and decortication were performed in the usual open fashion to patients with pleural empyema that were not clinically recovering within ten days of conservative treatment and simple thoracostomy pleural tubing alone. After thoracotomy, 2 large (28 Ch) chest tubes were inserted into pleural cavity and pleural suction (10–15mmHg) introduced. In 12 patients, an active pleural lavage was performed postoperatively with continuous Ringer solution (2000ml inserted in one hour, 3 times per day for 2–4 days) through the cranial chest tube and pleural discharge evacuated by the caudal chest tube under active 10–15mmHg suction. This postoperative continuous pleural lavage (PCPL) was introduced if pleural discharge remained opaque after thorough pleural irrigation during operation and pleural decortication.
Registry databases, medical notes and charts were studied for preoperative and postoperative data. The following preoperative characteristics were compared: age, gender, body mass index (weight in kg divided by the square of the length in meters), blood group, alcohol use, presence of cerebral insult, reflux esophagitis, dental caries, acute inflammation, tuberculosis, carcinoma, mesothelioma and serum CRP. Patients that had an empyema that was associated with trauma or previous thoracic surgery were excluded from the study. Hospital data included preoperative time before thoracotomy, total hospitalization time for treatment of empyema, need for PCPL, need for rethoracotomy, drainage time, presence of bacteria and antibiotics. Nine patients died during follow-up. Eight patients who survived to discharge were reexamined in our institution for recovery at least 1month (1–19 months) after hospitalization.
2.1. Statistical methods
All data were collected prospectively on standard forms and entered into a computerized database (SPSS 11.5). Numerical variables are presented as the mean±SE of mean for groups and compared with each other using the Mann–Whitney test where appropriate. Preoperative data and postoperative outcome are compared using the 
2 test where appropriate. Values of P less than 0.05 were considered as significant.
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3. Results
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Demographic results of the patients are summarized in Table 1. Of the 89 patients 73 were men and the remaining 16 women. Blood group, body mass index, previous illness, status of teeth, presence of malignancy, CRP value and antibiotics did not statistically differ among groups. Presence of a combination of risk factors, such as dental caries, alcoholism, reflux esophagitis, cerebral insult or acute inflammation, was predictive for persistence of opaque pleural discharge and subsequent PCPL. Instead, these risk factors alone were not statistically predictive for subsequent PCPL (Table 1). Bacteria culture was positive in 44% of patients (Table 2). Neither the positive culture of bacteria nor antibiotics differed statistically among patients.
Average hospital treatment lasted 19.3±1.6 days. Neither preoperative nor postoperative lengths of hospitalization differed among groups. Interestingly, PCPL after surgery did not statistically enhance length of hospitalization (Table 3). There were 11 reoperations for recurrent empyema, all performed in patients in whom PCLP was not used, though discharge was initially clear until relapse of empyema after hospitalization, as observed by deterioration of clinical status and pus. All 9 empyema-related deaths occurred early after operation in patients without PCPL (P<0.05).
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4. Discussion
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Presence of infected pleural pus after thoracotomy for complicated stage 2 empyema did not prolong patient recovery in our study. This was due to aggressive surgical protocol, which included not only traditional thoracotomy, pleural discharge evacuation and decortication, but also thorough PCPL after surgery until evacuation discharge changed to clear and running fluid.
Only 12 patients (13.5%) required PCPL after the first postoperative days, though in all of our 89 patients with infected pleural cavity, the rinsing with Ringer solution was used during surgery. This indicates that though patients are at high risk for infections, the need for PCPL for clearness of pleural discharge after radical surgical debridement is only occasional. PCPL with normal saline may well be accomplished whenever needed, for simplicity. Though an unusual electrocardiographic acute ST segment increase was reported secondary to warm saline thoracic cavity irrigation earlier [12], we did not observe any of the earlier reported side-effects in our patients [7,13,14]. Indeed, our patients were often severely ill with concomitant illnesses and occasional sepsis, but tolerated the treatment protocol. It would be most valuable to study in future the effect of PCPL after thoracotomy on restoration of pulmonary function.
The timing of surgery was dependent on failure of adequate conservative treatment with antibiotics and pleural tubing. Obviously, it may be speculated that earlier surgical intervention would have prevented vast thoracotomy and decreased postoperative hospitalization. However, as chest tube drainage is required for all cases, only a minority of patients with empyema is in need of other surgical procedures. As the majority of patients may well recover definitely without surgery, some clinics including our own have adopted a staged approach for the treatment of pleural empyema [8,11,15,16].
Interestingly, in our study neither other immunosuppressive states, such as malignancies or previous infections, nor reflux esophagitis alone were predictive for continuation of pus formation. However, presence of a combination of such risk factors was statistically more often present in patients with persistent opaque pleural discharge group. This may reflect the changing pattern of patients suffering of complicated empyema and pleural discharge. Nevertheless, all re-thoracotomies were needed to patients without PCPL. Mortality was smaller in patients who had PCPL as compared with patients devoid of PCPL. As unfortunately other treatment modalities were not taken into consideration, we cannot specify whether one-year mortality after thoracotomy without PCPL in our patients would have been smaller after, e.g. thoracoscopy. Discovery of various risk factor combinations related to pleural pus formation may encourage a more liberal use of PCPL after thoracotomy in stage 2 pleural empyema.
Taken together, thoracotomy, pleural debridement and subsequent PCPL for complicated stage 2 pleural empyema may determine patient recovery. A randomized study is highly necessary to clarify whether PCPL is recommended in stage 2 pleural empyema despite continuation of pleural pus.
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Acknowledgments
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We thank the Tampere Tuberculosis Foundation for support.
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References
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- Hoffer FA, Bloom DA, Colin AA, Fishman SJ. Lung abscess versus necrotizing pneumonia: implications for interventional therapy. Pediatr Radiol 1999;29:87-91.[CrossRef][Medline]
- Renner H, Gabor S, Maier A, Friehs G, Smolle-Juettner FM. Is aggressive surgery in pleural empyema justified?. Eur J Cardiothoracic Surg 1998;14:117-122.
- Roberts JR. Minimally invasive surgery in the treatment of empyema: intraoperative decision making. Ann Thorac Surg 2003;76:225-230.[Abstract/Free Full Text]
- de Souza A, Offner PJ, Moore EE, Biffi WL, Haenel JB, Franciose RJ, Burch JM. Optimal management of complicated empyema. Am J Surg 2000;180:507-511.[CrossRef][Medline]
- Striffeler H, Gugger M, Im Hof V, Cerny A, Furrer M, Ris H-B. Video-assisted thoracoscopic surgery for fibrinopurulent pleural empyma in 67 patients. Ann Thorac Surg 1998;65:319-323.[Abstract/Free Full Text]
- Duan M, Chen G, Wang T, Zhang Y, Dong J, Li Z, Sui T. One-stage pedicled omentum majus transplantation into thoracic cavity for treatment of chronic persistent empyema with or without bronchopleural fistula. Eur J Cardiothoracic Surg 1999;16:636-638.[Abstract/Free Full Text]
- LeMense GP, Strange C, Sahn S. Empyema thoracis. Therapeutic management and outcome. Chest 1995;107:1532-1537.[Abstract/Free Full Text]
- Waller DA, Rengarajan A. Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema. Ann Thorac Surg 2001;71:1813-1816.[Abstract/Free Full Text]
- Karmy-Jones R, Sorenson V, Horst M, Lewis JW, Rubinfeld I. Rigid thoracoscopic debridement and continuous pleural irrigation in the management of empyema. Chest 1997;111:272-274.[Abstract/Free Full Text]
- Katz NM, McElvein RB. A method of early irrigation of the contaminated postpneumonectomy space. Ann Thorac Surg 1981;31(5):464-468.[Abstract]
- Cassina PC, Hauser M, Hillejan L, Greschuchna D, Stamatis G. Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome. J Thorac Cardiovasc Surg 1999;117:234-238.[Abstract/Free Full Text]
- Brown MJ, Brown DR. Thoracic cavity irrigation: an unusual cause of acute ST segment increase. Anesth Analg 2002;95(3):552-554.[Abstract/Free Full Text]
- Athanassiadi K, Gerazounis M, Kalantz N. Treatment of post-pneumonic empyema thoracic. Thorac Cardiovasc Surg 2003;51:338-341.[CrossRef][Medline]
- Huang H-C, Chang H-Y, Chen C-W, Lee C-H, Hsiue T-R. Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion or empyema. Chest 1999;115:751-756.[Abstract/Free Full Text]
- Al-Kattan KM. Management of tuberculous empyema. Eur J Cardio-thoracic Surg 2000;17:251-254.[Abstract/Free Full Text]
- Tseng Y-L, Wu M-H, Lin M-Y, Lai W-W, Liu C-C. Surgery for lung abscess in immunocompetent and immunocompromised children. J Pediatr Surg 2001;36:470-473.[Medline]
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Abstract
1. Introduction
