Postpneumonectomy empyema. CT findings in six patients

Spontaneous Rupture of Empyema Necessitans in the Emergency Department

An empyema necessitans is a rare complication of a collection of purulent material in the pleural space that spreads outside of the pleural cavity and involves the soft tissues of the chest wall. Due to compression forces created by the size of the collection of empyema in the chest cavity, patients are usually symptomatic and present with severe dyspnea. Chest X-ray or ultrasound of the chest cavity are the ideal screening tools to visualize the empyema and followed by computerized tomography scan of the chest to confirm the presence and extent of the pathology. In rare occasions, the empyema can rupture spontaneously, which may lead to critical situation requiring emergent intervention. We report the case of a 72-year-old male who presented to the emergency department with severe dyspnea and was diagnosed with empyema necesitans. During the initial management of the case, the empyema necessitans ruptured spontaneously and required emergent interventions to stabilize the patient.

Imaging findings of complications after thoracic surgery

Many surgical procedures are used for the treatment of lung, heart, and mediastinal diseases. The techniques can result in postoperative complications. The nature of these complications differs according to the duration of thoracic surgery and the onset of the complication. The complications occurring within 1 month and more than 1 month generally considered as early and late complications, respectively. Chest radiographs and CT scans obtained in patients who have undergone thoracic surgery show normal changes during the surgical procedure and diverse postsurgical complications. Familiarity with the clinical and radiologic findings of the normal alterations and possible complications after thoracic surgery is crucial in minimizing the increased morbidity and mortality.

Postoperative complications after thoracic surgery for lung cancer

Lung cancer is the leading cause of cancer-related deaths in the United States. Several surgical techniques are currently used as part of the standard of care for early-stage lung cancer. Differentiating normal postoperative changes from complications is essential in the management of these patients. This article will review the various surgical approaches used, ranging from wedge resection to pneumonectomy, and will outline their expected postsurgical changes. Early and late postsurgical complications will be described, some of which are unique to the type of surgery performed. In addition, local tumor recurrence is a form of postoperative complication and must be distinguished from typical postoperative or postradiation change. Knowledge of both common and uncommon postoperative complications is crucial in the follow-up of lung cancer patients.

SUMMARY STATEMENT

Familiarity with the appearance of postoperative complications in lung cancer patients is vital to distinguish it from the normal postoperative or postradiation appearance in follow-up imaging.

Radiographic and CT Findings of Thoracic Complications after Pneumonectomy

Pneumonectomy is the treatment of choice for bronchogenic carcinoma and intractable end-stage lung diseases such as tuberculosis and bronchiectasis, but it is often followed by postoperative complications, which account for significant morbidity and mortality. Knowledge of the radiologic features of such complications is of critical importance for their early detection and prompt management. Complications of pneumonectomy are classified as early or late, depending on when they occur in relation to the hospitalization period. Early complications of pneumonectomy include pulmonary edema, bronchopleural fistula, pneumonia of the contralateral lung, empyema, and adult respiratory distress syndrome, which may occur separately or in combination. Late postpneumonectomy complications include recurrent disease, infection, effects of radiation therapy or chemotherapy, and surgical complications such as late-onset bronchopleural fistula, postpneumonectomy syndrome, and esophagopleural fistula. Sequential examinations with chest radiography after pneumonectomy are an invaluable method of screening for these complications, especially in the early postoperative period. When the radiographic findings are inconclusive, computed tomography is helpful for establishing a diagnosis and obtaining detailed information about the disease process.

Volume-expanding complications after pneumonectomy: comparison of CT findings

The purpose of this study was to assess and characterize the computed tomographic (CT) findings of various volume-expanding complications occurring in the postpneumonectomy space. Chest CT scans, obtained in 17 patients in whom plain chest radiographs had revealed shift of the mediastinum away from the surgical side after pneumonectomy for lung cancer, were retrospectively reviewed. Recurrent neoplasm (n=6) appeared as soft-tissue mass projecting into the postpneumonectomy space and/or enlarged mediastinal lymph nodes. Empyema (n=4) was manifested by smooth thickening of the residual pleura with or without thickening of the extrapleural tissues. Hemothorax (n=4) was characterized by amorphous material of high attenuation contained within the postpneumonectomy space. Chylothorax (n=2) presented no abnormal finding except for expansion of the postpneumonectomy space. The remaining one case showed only expansion of the postpneumonectomy space and it was normalized without any treatment, which was supposed to be transient pleural fluid collection of uncertain cause. When mediastinal shift away from the surgical side occurs on plain chest radiography following pneumonectomy, CT can be helpful in differentiating various volume-expanding complications providing characteristic features.

Prevalence and clinical significance of pleural microbubbles in computed tomography of thoracic empyema

AIM

To determine the prevalence and clinical significance of pleural microbubbles in thoracic empyema.

MATERIALS AND METHODS

The charts of 71 consecutive patients with empyema were retrospectively reviewed for relevant demographic, laboratory, microbiological, therapeutic and outcome data. Computed tomography (CT) images were reviewed for various signs of empyema as well as pleural microbubbles. Two patient groups, with and without microbubbles were compared.

RESULTS

Mean patient age was 49 years and 72% were males. Microbubbles were detected in 58% of patients. There were no significant differences between patients with and without microbubbles in regard to pleural fluid chemistry. A causative organism was identified in about 75% of cases in both. There was no difference in the rates of pleural thickening and enhancement, increased extra-pleural fat attenuation, air-fluid levels or loculations. Microbubbles were diagnosed after a mean of 7.8 days from admission. Thoracentesis before CT was performed in 90 and 57% of patients with and without microbubbles (p=0.0015), respectively. Patients with microbubbles were more likely to require repeated drainage (65.9 versus 36.7%, p=0.015) and surgical decortication (31.7 versus 6.7%, p=0.011). Mortalities were 9.8 and 6.6% respectively (p=0.53).

CONCLUSION

Pleural microbubbles are commonly encountered in CT imaging of empyema but have not been systematically studied to date. Microbubbles may be associated with adverse outcome such as repeated drainage or surgical decortication. The sensitivity and specificity of this finding and its prognostic implications need further assessment.

Post-pneumonectomy empyema: Current management strategies

Post-pneumonectomy empyema is an uncommon but potentially life-threatening complication. It has a strong association with bronchopleural fistula, which acts as a continued source of infection into the thoracic cavity. Numerous risk factors have been identified and strategies formulated to minimize its occurrence. When bronchopleural fistula occurs, its treatment depends on several factors including extent of dehiscence, degree of pleural contamination and general condition of the patient. Early diagnosis and assessment with appropriate investigations, and aggressive therapeutic strategies are paramount in controlling sepsis, facilitating closure of fistula, and sterilization of the closed pleural space. Recent success with repeat debridement has made routine space obliteration not mandatory in management. The development of minimal-access interventions including video-assisted thoracic surgery, endoscopic application of tissue glue and stenting may be additional tools to complement conventional surgery in post-pneumonectomy empyema management.

Postpneumonectomy empyema

Empyema is a serious complication after pneumonectomy. It is often associated with a bronchopleural fistula. Several risk factors have been associated with an increased incidence of these two challenging complications. Therapy aims at simultaneously treating the infected pleural space and the fistula. The authors describe their favorite methods which include repeated open debridements of the pleural space, primary closure of the fistula, and covering of the bronchial stump using intrathoracic transposition of extrathoracic skeletal muscle followed by delayed closure of the chest wall after instillation of an antibiotic solution (Clagett and modified Clagett procedures). The goals of treatment remain a healthy patient with a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients. Failure is often associated with a persistent or recurrent bronchopleural fistula.