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Empyema thoracis: a role for open thoracotomy and decortication


BACKGROUND Thoracentesis and antibiotics remain the cornerstones of treatment in stage I empyema. The management of disease progression or late presentation is controversial. Open thoracotomy and decortication is perceived to be synonymous with protracted recovery and prolonged hospitalisation. Advocates of thoracoscopic adhesiolysis cite earlier chest drain removal and hospital discharge. This paper challenges traditional prejudice towards open surgery.

METHODS A five year audit of empyema cases referred to a regional cardiothoracic surgical unit analysing previous clinical course, surgical management, and outcome.

RESULTS Between February 1992 and February 1997, the number of referrals to this centre increased dramatically. Twenty two children were referred for surgery (15 boys, seven girls; age range, 0.5–16 years). Before referral, patients had been unwell for 6–50 days (median, 15), had been treated with several antibiotics, and had undergone chest ultrasound (15 patients), computed tomography (five patients), pleural aspiration attempts (13 patients), and intercostal drainage (seven patients). The organism responsible was identified in only two cases (Streptococcus pneumoniae). Three patients had intraparenchymal abscess formation. Eighteen patients underwent open thoracotomy and decortication. Drain removal was performed on the first or second day. Fever resolved within 48 hours. Median hospital stay was four days. All patients had complete clinical and radiological resolution.

CONCLUSIONS Treatment must be tailored to the disease stage. In stage II and III diseases, open decortication followed by early drain removal results in rapid symptomatic recovery, early hospital discharge, and complete resolution. In the early fibrinopurulent phase, alternative strategies should be considered. However, even in ideal cases, neither fibrinolysis nor thoracoscopic adhesiolysis can achieve more rapid resolution at lower risk.

  • Management principles: treatment must be based on radiological staging and clinical status

  • Antibiotics and drainage are usually successful in stage I disease

  • Factors contributing to development of stage II and stage III disease: late presentation, failure to identify responsible organisms, inadequate antibiotic treatment, reluctance to drain, suboptimal drain placement, under use of ultrasound imaging for initial staging and assessment of treatment response, and late surgical referral

  • Surgical results: in stage II and stage III empyema, open thoracotomy and decortication is followed by drain removal within 48 hours, prompt hospital discharge, and complete resolution. Using these results as a benchmark, alternative treatments should only be undertaken in carefully selected patients

  • empyema
  • decortication

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