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Lichtenstein D, Smolyakov V, Refaely Y, Mashni I, Lazar LO, Pines G. Empyema Secondary to Pneumonia: Whom Should We Operate? J Laparoendosc Adv Surg Tech A 2024; 34:214-218. [PMID: 38301148 DOI: 10.1089/lap.2023.0387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Introduction: Empyema secondary to pneumonia is a common condition. A significant number of patients will require surgical intervention for drainage and decortication. The aim of this study was to identify predictive factors for surgical intervention. Materials and Methods: The medical records of patients who were diagnosed with empyema secondary to pneumonia between the years 2010 and 2019 in a university hospital were included in the study. Patients who underwent surgical intervention were defined as group A and nonoperative treatment as group B. Clinical and laboratory data were collected from medical records and patients' chest computerized tomography (CT) scans were reviewed. Results: A total of 194 patients were included in the study-86 patients were included in group A and 108 patients in group B. Several parameters on admission were found to have a statistically significant correlation with surgical intervention: younger age, higher systolic blood pressure, and elevated white blood count. Multivariant analysis showed that younger age was found to have a statistically significant correlation with operative intervention (adjusted odds ratio = 0.971, P = .023). A statistically significant correlation between surgical intervention and survival (adjusted hazard ratio [HR] = 1.762, P = .046) and an inverse correlation between age and survival (adjusted HR = 0.050, P < .001) were found. Surgical intervention was associated with increased survival irrespective of age. A total of 42 CT scans were available for review. The mean density of the empyema fluid in group A was higher by 4.3 hounsfield units compared to group B (P < .067). Conclusions: Younger age was found to be associated with surgical intervention among patients suffering from empyema secondary to pneumonia. Surgical intervention was associated with increased long-term survival, irrespective of patients' age. Several radiologic characteristics were associated with the need for surgery in this study: empyema fluid density, pleural thickening, and fluid loculations. Additional prospective studies are required to ascertain these results.
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Affiliation(s)
- Daniel Lichtenstein
- Department of Thoracic Surgery, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Rehovot, Israel
| | - Vadim Smolyakov
- Department of Radiology, Kaplan Medical Center, Rehovot, Israel
| | - Yael Refaely
- Department of Thoracic Surgery, Soroka Medical Center, Faculty of Medicine, Ben Gurion University, Beer Sheva, Israel
| | - Ibrahim Mashni
- Department of Thoracic Surgery, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Rehovot, Israel
| | - Li Or Lazar
- Department of Thoracic Surgery, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Rehovot, Israel
| | - Guy Pines
- Department of Thoracic Surgery, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Rehovot, Israel
- Department of Surgery, Kaplan Medical Center, Rehovot, Israel
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Mandal KC, Mandal G, Halder P, Mitra D, Debnath B, Bhattacharya M. Empyema Thoracis in Children: A 5-Year Experience in a Tertiary Care Institute. J Indian Assoc Pediatr Surg 2019; 24:197-202. [PMID: 31258270 PMCID: PMC6568155 DOI: 10.4103/jiaps.jiaps_112_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: Empyema thoracis (ET) in children is a disease of significant morbidity and mortality. In the event of failure to resolute following intercostal chest tube drainage (ICD), thoracotomy decortication (TDC) remains the treatment of choice. We have reviewed the outcome of management of 96 cases of ET with the intent to establish the scope of ICD as primary form of the management. Materials and Methods: This is a retrospective study of 96 patients of ET who were managed in pediatric surgery department over a period of 5 years (April 2013 – March 2018). Ninety-six patients at a single center met inclusion criteria for having ET and underwent ICD. We excluded the cases where video-assisted thoracoscopic surgery was provided as primary treatment. The patients were categorized into complicated and uncomplicated groups. Those with pyopneumothorax, encysted empyema, multiloculated empyema, and bilateral ET were assigned as complicated group. There were two treatment groups: (I) those responded with ICD alone (II) those with ICD followed by TDC. Results: All 96 cases received ICD as primary management. There were 54 uncomplicated cases and 42 complicated cases. Out of 42 complicated cases, 26 patients recovered with ICD alone and 16 patients needed TDC. A total of 80 (83.33%) patients (54 uncomplicated ± 26 complicated) recovered with ICD alone. Significant complications were encountered in follow-up of patients who underwent delayed thoracotomy in the form of overriding of the ribs (n = 3) and postoperative air leak (n = 4). There was no mortality in our series. Conclusion: Early initiation of management of ET with intercostal tube drainage is simple, safe, effective even in complicated cases, and has less complications. Thoracotomy with decortication should be reserved for ICD failure cases.
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Affiliation(s)
- Kartik Chandra Mandal
- Department of Pediatric Surgery, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Gobinda Mandal
- Department of Pediatric Medicine, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Pankaj Halder
- Department of Pediatric Surgery, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Dipanwita Mitra
- Department of Anesthesiology, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Bidyut Debnath
- Department of Pediatric Surgery, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Mala Bhattacharya
- Department of Pediatric Medicine, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
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Angurana SK, Kumar R, Singh M, Verma S, Samujh R, Singhi S. Pediatric empyema thoracis: What has changed over a decade? J Trop Pediatr 2019; 65:231-239. [PMID: 30053189 DOI: 10.1093/tropej/fmy040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES The purposes of this paper are to study clinicobacteriological profile, treatment modalities and outcome of pediatric empyema thoracis and to identify changes over a decade. DESIGN This is a retrospective study. SETTING Department of Pediatrics of a tertiary care hospital in North India. PATIENTS We enrolled 205 patients (1 month-12 years) of empyema thoracis admitted over 5 years (2007-11) and compared the profile with that of a previous study from our institute (1989-98). RESULTS Pleural fluid cultures were positive in 40% (n = 82) cases from whom 87 isolates were obtained. Staphylococcus aureus was the most common isolate (66.7%). Methicillin-sensitive S. aureus accounted for 56%, Methicillin-resistant S. aureus (MRSA) 10% and gram-negative organisms 18.3% of isolates. Intercostal drainage tube (ICDT) was inserted in 97.5%, intrapleural streptokinase was administered in 33.6%, and decortication performed in 27.8% cases. Duration of hospital stay was 17.2 (±6.3) days, duration of antibiotic (intravenous and oral) administration was 23.8 (±7.2) days and mortality rate was 4%. In the index study (compared with a previous study), higher proportion of cases received parenteral antibiotics (51.7% vs. 23.4%) and ICDT insertion (20.5% vs. 7%) before referral and had disseminated disease (20.5% vs. 14%) and septic shock (11.2% vs. 1.6%), less culture positivity (40% vs. 48%), more MRSA (10.3% vs. 2.5%) and gram-negative organisms (18.4% vs. 11.6%), increased use of intrapleural streptokinase and surgical interventions (27.8% vs. 19.7%), shorter hospital stay (17 vs. 25 days) and higher mortality (3.9% vs. 1.6%). CONCLUSIONS Over a decade, an increase in the incidence of empyema caused by MRSA has been noticed, with increased use of intrapleural streptokinase and higher number of surgical interventions.
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Affiliation(s)
- Suresh Kumar Angurana
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kumar
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Meenu Singh
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Verma
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ram Samujh
- Pediatric Surgery, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunit Singhi
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Wu J, Liu C, Lee S, Kuo Y, Hsieh T. Assessment of the charlson comorbidity index score, CHADS2 and CHA2DS2-VASc scores in predicting death in patients with thoracic empyema. Heart Lung 2018; 47:157-161. [PMID: 29370933 DOI: 10.1016/j.hrtlng.2017.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/18/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with thoracic empyema have an increased risk of mortality, but their absolute rate of mortality depends on age and comorbidities. OBJECTIVE This study seeks to assess the predictive value of the Charlson Comorbidity Index score (CCIS), CHADS2 and CHA2DS2-VASc scores for mortality risk in patients with empyema thoracis. METHODS From Taiwan's National Health Insurance Research Database we identified a total of 484 participants diagnosed with thoracic empyema. The CCIS, CHADS2 and CHA2DS2-VASc scores were used to stratify mortality risk. RESULTS The incidence rate of mortality in the present study was 20.39 per 1000 person-months. A strong correlation was found between thoracic empyema and CCIS score. CONCLUSIONS Our results show that patients with thoracic empyema have a significantly high incidence rate of mortality and that CCIS can be used as an indicator of risk for mortality.
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Affiliation(s)
- Jengyuan Wu
- Department of Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Chienming Liu
- School of Medicine, Tzu Chi University, Hualian, Taiwan; Department of Chest Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Shangsen Lee
- Department of Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Yuhung Kuo
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Tengfu Hsieh
- Department of Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; School of Medicine, Tzu Chi University, Hualian, Taiwan.
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Abstract
Aim and Objective This study aims to report 100 pediatric patients of empyema thoracis treated by open decortication, highlighting the presentation, delay in referral, operative findings, the response to surgical intervention, and follow-up. Materials and Methods All the children who underwent open decortication for stage III empyema thoracis during the study period January 2015-December 2016 were included. Preoperative workup included hemogram, serum protein, chest radiographs, and contrast-enhanced computed tomographic (CECT) scan of the chest. Results One hundred (65 males, 35 females) (age 2 months-13 years, mean 4.5 years) were operated during a 2-year period. Among them, 90% patients were referred 3 weeks after the onset of disease. Intercostal chest drainage (ICD) had been inserted in (95) 95% cases. Thickened pleura, multiloculated pus, and lung involvement were invariably seen on CECT scan. Bronchopleural fistula was present in five patients. Decortication and removal of necrotic tissue were performed in all the patients. Mean duration of postoperative ICD was 4 days. Follow-up ranged from 1 month to 2 years (mean 12 months). There was no mortality. Five patients had proven tuberculosis. Only 10% presented within the early period of the disease. Conclusion The duration of the disease had a direct relationship with the thickness of the pleura and injury to the underlying lung. Delayed referral causes irreversible changes in the lung prolonging recovery. Meticulous open surgical debridement gives gratifying results. The status of the lung at the end of surgery is a major prognostic factor.
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Affiliation(s)
- Aditya Pratap Singh
- Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India
| | - Arvind Kumar Shukla
- Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India
| | - Pramila Sharma
- Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India
| | - Jyotsna Shukla
- Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India
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Ahmed S, Azam H, Basheer I. Is open decortication superior to fibrinolytic therapy as a first line treatment in the management of pleural empyema? Pak J Med Sci 2016; 32:329-32. [PMID: 27182233 PMCID: PMC4859016 DOI: 10.12669/pjms.322.9676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: To confirm that either Fibrinolytic therapy or open decortication which of the two is an effective First line treatment of pleural empyema. Methods: This prospective comparative study was conducted in the department of surgery Sheikh Zayed Medical College and Hospital, Rahim Yaar Khan. Seventy eight (78) patients were included in this study. There were two groups of patients; Group I (n=35) patients treated with fibrinolytic therapy, Group II (n=43) patients treated with open decortication. Data was entered and analyzed in SPSS v16. Student’s t-test was used for comparison of quantitative variables. Chi-square and Fisher’s Exact test were used for comparison of qualitative variables. P-value ≤ 0.05 was taken as significant difference. Results: There was no significant difference in base baseline characteristics of patients of Group I and II. Incidence of comorbidities was also same between the groups. Most of the patients in Group I and II were in empyema stage III. Fluid cultures was positive in 33 (94.3%) patients in group I and 39 (90.7%) patients in group II. 30 (85.7%) was successfully treated using fibrinolytic therapy but this therapy failed in five (14.3%) patients, two of these patients expired within the hospital. There was only one (2.3%) treatment failure in open decortication Group that patient expired within the hospital (p-value 0.04). Overall duration of hospitalization was significantly high in fibrinolytic group, this was 17.6± 1.95 days versus 12.09± 2.18 days in open decortication group (p-value<0.0001). There was no significant difference regarding operative mortality within the two groups. Conclusion: Open Drainage is associated with better outcomes as compared to fibrinolytic therapy when used as a First line treatment of empyema.
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Affiliation(s)
- Sultan Ahmed
- Sultan Ahmed (FCPS General Surgery), Assistant Professor of General Surgery, Sheikh Zayed Medical College & Hospital, Rahim Yaar Khan, Pakistan
| | - Hammad Azam
- Hammad Azam (FCPS General Surgery), Assistant Professor of Cardiac Surgery, Sheikh Zayed Medical College & Hospital, Rahim Yaar Khan, Pakistan
| | - Imran Basheer
- Imran Basheer (FCPS Pulmonology), Assistant Professor of Pulmonology, Sheikh Zayed Medical College & Hospital, Rahim Yaar Khan, Pakistan
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Clinical outcome of parapneumonic empyema in children treated according to a standardized medical treatment. Eur J Pediatr 2014; 173:1339-45. [PMID: 24838799 DOI: 10.1007/s00431-014-2319-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 04/04/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED Treatment of parapneumonic empyema (PE) consists of intravenous antibiotics and, in case of large effusions and persisting fever, pleural chest drain (±intrapleural fibrinolytics) or video-assisted surgical intervention. We standardized the treatment for PE in our tertiary care center choosing a first-step nonsurgical approach. The aim was to evaluate the need for surgery and to collect data on disease course, outcome, and microbiology. For all children treated for PE between 2006 and 2013, data were prospectively collected concerning treatment, length of stay, duration of fever, complications, and causative agent. Of 132 children treated for PE, 20 % needed surgical intervention. Analyzed per year, the need for surgery decreased from almost 40 % in 2007 to 0 % in 2010 again increasing to 40 % although this did not reach statistical significance (p = 0.115). Median duration of "in-hospital fever" was 5 days (IQR, 3-8). The duration of fever correlated with pleural LDH (r = 0.324; p = 0.002) and pleural glucose (r = -0.248; p = 0.021) and was inversely correlated with pleural pH (r = -0.249; p = 0.046). Based on pleural PCR data, 85 % of PE were caused by Streptococcus pneumoniae (40 % serotype 1). CONCLUSION After introduction of a standardized primary medical approach (chest drain ± fibrinolysis) for PE in our institution, the need for surgical rescue interventions overall remained at 20 %, which is higher than in some other reports. Difference in microbiology or disease severity could not be proven.
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Islam S, Calkins CM, Goldin AB, Chen C, Downard CD, Huang EY, Cassidy L, Saito J, Blakely ML, Rangel SJ, Arca MJ, Abdullah F, St Peter SD. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Pediatr Surg 2012; 47:2101-10. [PMID: 23164006 DOI: 10.1016/j.jpedsurg.2012.07.047] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 07/23/2012] [Accepted: 07/25/2012] [Indexed: 11/16/2022]
Abstract
The aim of this study is to review the current evidence on the diagnosis and management of empyema. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee compiled 8 questions to address. A comprehensive review was performed on each topic. Topics included the distinction between parapneumonic effusion and empyema, the optimal imaging modality in evaluating pleural space disease, when and how pleural fluid should be managed, the first treatment option and optimal timing in the management of empyema, the optimal chemical debridement agent for empyema, therapeutic options if chemical debridement fails, therapy for parenchymal abscess or necrotizing pneumonia and duration of antibiotic therapy after an intervention. The evidence was graded for each topic to provide grade of recommendation where appropriate.
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Affiliation(s)
- Saleem Islam
- University of Florida College of Medicine, Gainesville, FL, USA
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Development of posttraumatic empyema in patients with retained hemothorax. J Trauma Acute Care Surg 2012; 73:752-7. [DOI: 10.1097/ta.0b013e31825c1616] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Shin JA, Chang YS, Kim TH, Haam SJ, Kim HJ, Ahn CM, Byun MK. Surgical decortication as the first-line treatment for pleural empyema. J Thorac Cardiovasc Surg 2012; 145:933-939.e1. [PMID: 22929218 DOI: 10.1016/j.jtcvs.2012.07.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 06/13/2012] [Accepted: 07/25/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study objective was to evaluate the clinical outcomes of surgical decortication as the first line of treatment for pleural empyema. METHODS We analyzed the medical records of 111 patients who presented with empyema and were treated with simple drainage or surgical decortication as the first line of treatment at Gangnam Severance Hospital, a tertiary referral medical center in Seoul, Korea. RESULTS Of 111 patients with empyema, 27 underwent surgical decortication as the first intervention. Surgical decortication showed a better treatment success rate in all study subjects (96.3%, 26/27 patients) compared with simple drainage (58.3%, 49/84 patients; P < .0001 for method comparison). After propensity-scored matching, decortication resulted in a better outcome (95.0%, 19/20 patients) versus drainage (56.7%, 17/30 patients; P = .003). Surgical decortication as the first line of treatment for empyema was the best predictor of treatment success after adjustment for compounding factors (odds ratio, 14.529; 95% confidence interval, 1.715-123.074; P = .014). CONCLUSIONS The first treatment choice for pleural empyema is a critical determinant of ultimate therapeutic success. After adjusting for confounding variables, surgical decortication is the optimal first treatment choice for advanced empyema.
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Affiliation(s)
- Jung Ar Shin
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Yoon Soo Chang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Tae Hoon Kim
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Seok Jin Haam
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Gangnam Severance Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Hyung Jung Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Chul Min Ahn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Min Kwang Byun
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea.
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Goldin AB, Parimi C, LaRiviere C, Garrison MM, Larison CL, Sawin RS. Outcomes associated with type of intervention and timing in complex pediatric empyema. Am J Surg 2012; 203:665-673. [DOI: 10.1016/j.amjsurg.2012.01.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/12/2012] [Accepted: 01/12/2012] [Indexed: 10/28/2022]
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Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study. J Trauma Acute Care Surg 2012; 72:11-22; discussion 22-4; quiz 316. [PMID: 22310111 DOI: 10.1097/ta.0b013e318242e368] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy. METHODS An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 hours of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications. RESULTS RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH ≤300 cc (odds ratio [OR], 3.7 [2.0-7.0]; p < 0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6-13.7]; p = 0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2-9.0]; p = 0.023), and volume of RH ≤900 cc (OR, 3.9 [1.4-13.2]; p = 0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4-9.9]; p < 0.001), RH >900 cc (OR, 3.2 [1.4-7.5]; p = 0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2-4.6]; p = 0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively. CONCLUSION RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.
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Meier AH, Hess CB, Cilley RE. Complications and treatment failures of video-assisted thoracoscopic debridement for pediatric empyema. Pediatr Surg Int 2010; 26:367-71. [PMID: 20148253 DOI: 10.1007/s00383-010-2562-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE Video-assisted thoracoscopic debridement (VATD) is a well-established intervention to treat pediatric empyema. There is ongoing controversy at what stage in the treatment algorithm it should be utilized. To shed further light onto this debate, we reviewed our institutional experience looking for factors predicting treatment failure or complications of VATD. METHODS We retrospectively analyzed data on patients that had undergone VATD for empyema from 1995 to 2008. We used independent sample t tests and Chi-square tests (SPSS) for statistical analysis. RESULTS One hundred and fifty-two procedures in 151 patients [81 male (53.6%)] were identified. In 146 (96.7%) the etiology of the empyema was pulmonary, in 3 (1.98%) due to an infectious abdominal process and in 2 (1.3%) due to abdominal trauma. 118 patients (78.1%) were transferred from outside hospitals. 107 (70.1%) underwent VATD primarily, 44 (29.1%) following another procedure. The overall complication rate was 13.8%, most of which were minor. Treatment failures occurred in seven patients, resulting in three reoperations; two patients died. The average length of stay was 10.1 days, but was significantly longer if VATD followed another procedure or if a complication occurred. The risk for complications correlated with older age (6.2 vs. 8.8 years, p = 0.023) and lower hematocrit on admission (31.1 vs. 27.9%, p = 0.006). CONCLUSIONS VATD provided effective treatment for pediatric empyema. Complications were mostly minor, occurring more frequently in older patients and those with a lower admission hematocrit. Early VATD decreased the length of hospitalization.
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Affiliation(s)
- Andreas H Meier
- Division of Pediatric Surgery, Department of Surgery, School of Medicine, Southern Illinois University, PO Box 19665, Springfield, IL 62794-9665, USA.
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Antibiothérapie des pleuropneumopathies de l’enfant : quelles leçons tirer des études cliniques publiées et propositions thérapeutiques. Arch Pediatr 2008; 15 Suppl 2:S84-92. [DOI: 10.1016/s0929-693x(08)74222-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Thoracoscopy was initially described for use in children to obtain pulmonary biopsy samples in the immunocompromised patient. With refinements in technique, development of better instrumentation, and advances in pediatric anesthesia, there are now many diagnostic and therapeutic indications for the use of thoracoscopy in children. One of the most common indications includes pleural debridement for empyema. Many centers consider this the optimal approach for biopsy of mediastinal lesions and excision of bronchogenic or duplication cysts. The technique is useful for pleural disorders, such as spontaneous pneumothorax and chylothorax. Thoracoscopy has been used to achieve exposure for spinal diskectomy in children with thoracic scoliosis, and newer techniques are being developed in performing anatomic lobectomies, repair of esophageal atesias, and closure of diaphragmatic hernias. The role of the robot in pediatric thoracoscopy is still in the early stages of definition.
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Affiliation(s)
- Scott A Engum
- Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana 46202, USA.
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