Successful surgical management of a pyothorax in a Guinea baboon (Papio papio)

A 16-year-old male Guinea baboon (Papio papio) was evaluated for weakness and focal wet fur of 1-week duration. A pyothorax caused by Streptococcus anginosus was diagnosed. A surgical approach was chosen, combined with a systemic antibiotic therapy. Medical imaging and C-reactive protein follow-up revealed the resolution of the pyothorax.

Pyothorax and Constrictive Pericarditis after Chemoradiotherapy for Esophageal Cancer

A 75-year-old man underwent chemoradiotherapy for advanced esophageal cancer. After nine years, he was hospitalized for left pyothorax. Consequently, the patient underwent drainage and window opening surgery. He experienced cardiopulmonary arrest but was resuscitated. Based on cardiac catheterization data, the patient was diagnosed with constrictive pericarditis. Unfortunately, extracorporeal circulation did not improve his condition, and he ultimately died. An autopsy revealed adhesion between the pericardium and pleura, especially the pericardium in contact with the left thoracic cavity, which was markedly thickened. This suggests that constrictive pericarditis, a latent complication of chemoradiotherapy, is aggravated by pyothorax.

Thoracic empyema: aetiology, diagnosis, treatment, and prevention

PURPOSE OF REVIEW

The aim of this study was to review current key points in the aetiology, diagnosis, treatment, and prevention of empyema thoracis. Early postpandemic trends have seen an increasing global incidence and evolution in the aetiology of empyema. Due to varied aetiology and typically lengthy treatment, empyema will be disproportionately affected by the rising tide of antimicrobial resistance (AMR), thus warranting attention and further research.

RECENT FINDINGS

Multiple novel biomarkers (e.g. IL-36γ) are under investigation to aid diagnosis, while oral health assessment tools are now available for prognosticating and risk-stratifying patients with thoracic empyema. There exists an ongoing lack of evidence-based guidance surrounding antibiotic treatment duration, surgical intervention indication, and prognostic scoring utility.

SUMMARY

Understanding aetiologies in different global regions and settings is pivotal for guiding empirical treatment. Antimicrobial resistance will make thoracic empyema increasingly challenging to treat and should prompt increased awareness of prescribing practices. Novel biomarkers are under investigation which may speed up differentiation of pleural effusion types, allowing faster cohorting of patients.Although newly identified predictors of morbidity and mortality have been suggested to be beneficial for incorporation into clinical practice, further work is required to prognosticate, risk-stratify, and standardize treatment.

Surgery-related outcomes from a close-knit surgeons' team in thoracic oncology

Reducing morbidity, length of hospital stay, and readmission rate are of paramount importance to improve patients' care. In the present paper, we aim to describe our experience in managing major oncologic thoracic surgery in clinical practice. This is a retrospective experience over the last 7 years. Data from 215 consecutive patients (performed by a single-team of two surgeon) undergoing thoracic surgery were reviewed and evaluated. The total hospital mean stay was 3,3 days. Complications were represented by 4 hemothorax, 1 pleural empyema without fistula, 3 arrhythmias (atrial fibrillation), 2 pnuemonias and 1 chylotorax. No 30-day severe surgery-related complication occurred, no mortality. In 169 Vats procedures, no convertion was necessary. We conclude that a united team work represented by two close-knit surgeons, with similar clinical background, propensity to share problems, no competitive behavior, allow to do faster surgery, to standardize the procedure improving the post-operative outcomes of cancer patients.

Risk factors influencing postoperative pleural empyema in patients with pleural mesothelioma: a retrospective single-centre analysis

OBJECTIVES

Postoperative empyema is a severe, potentially lethal complication also present, but poorly studied in patients undergoing surgery for pleural mesothelioma. We aimed to analyse which perioperative characteristics might be associated with an increased risk for postoperative empyema.

METHODS

From September 1999 to February 2023 a retrospective analysis of consecutive patients undergoing surgery for pleural mesothelioma at the University Hospital of Zurich was performed. Uni- and multivariable logistic regression was used to identify associated risk factors of postoperative empyema after surgery.

RESULTS

A total of 400 PM patients were included in the analysis, of which n = 50 patients developed empyema after surgery (12.5%). Baseline demographics were comparable between patients with (Eyes) and without empyema (Eno). 39% (n = 156) patients underwent extrapleural pneumonectomy (EPP), of whom 22% (n = 35) developed postoperative pleural empyema; 6% (n = 15) of the remaining 244 patients undergoing pleurectomy and decortication (n = 46), extended pleurectomy and decortication (n = 114), partial pleurectomy (n = 54) or explorative thoracotomy (n = 30) resulted in postoperative empyema. In multivariable logistic regression analysis, EPP (odds ratio 2.8, 95% confidence interval 1.5-5.4, P = 0.002) emerged as the only risk factor associated with postoperative empyema when controlled for smoking status. Median overall survival was significantly worse for Eyes (16 months, interquartile range 5-27 months) than for Eno (18 months, interquartile range 8-35 months).

CONCLUSIONS

Patients undergoing EPP had a significantly higher risk of developing postoperative pleural empyema compared to patients undergoing other surgery types. Survival of patients with empyema was significantly shorter.

Empyema Secondary to Pneumonia: Whom Should We Operate?

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.

Development of organized pleural empyema as a result of occult foreign body aspiration

Foreign body (FB) aspiration is a rare incident in adults. Many patients cannot recall the episode of aspiration and are hospitalized with complications of an endobronchial FB.

Rapidly progressive empyema in the setting of vaping in an otherwise healthy patient

Vaping is defined as inhaling and exhaling vapour that is a product of heating a liquid or wax-like material. Electronic cigarettes (e-cigarettes) have become a popular method of smoking in the last decade and are advertised as an alternative to conventional smoking. Since the increase in e-cigarette use, various lung injury patterns have started to appear among users. Recent studies have shown an increased susceptibility to respiratory tract infections among e-cigarette/vaping product users. We present a case of pneumonia caused by Pseudomonas fluorescens complicated by rapidly developing empyema in an otherwise healthy patient.

Aspiration Pneumonia Caused by Prevotella Causing Prothorax after Pulmonary Puncture: a Case Report

BACKGROUND

Aspiration pneumonia in patients in immunocompetent populations is rare, and secondary pyothorax due to puncture operations during treatment has been reported rarely.

METHODS

We report a confirmed case of aspiration pneumonia caused by Prevotella. The pathogen was detected and confirmed using percutaneous lung puncture and high-throughput next-generation sequencing (NGS).

RESULTS

The patient developed secondary pyothorax, severe rash, and exacerbation of symptoms following the lung puncture. Finally, after adjusting the antibiotic regimen and performing chest drainage and washout, the patient's lesions were absorbed, symptoms improved, and the rash disappeared.

CONCLUSIONS

Prevotella aspiration pneumonia can occur in immunocompetent individuals, and invasive bronchoscopic alveolar lavage may be considered as an option to reduce the risk of infectious organism translocation.

Clostridioides difficile recovered in pleural fluid: Contamination or infection? A case report of a proven empyema and a literature review

INTRODUCTION

Pleural empyema is an infrequent manifestation of extraintestinal Clostridioidesdifficile infection, with just eight cases reported in literature.

METHODS

We report a new case in a 70-year-old male without comorbidities or evidence of concomitant gastrointestinal disease, and review the previous cases reported in the literature.

RESULTS

The isolate was susceptible to all antimicrobial tested and was negative for A+B toxins. The patient fully recovered after drainages and antimicrobial therapy with amoxicillin-clavulanate and doxycycline.

CONCLUSION

As in the previously reported cases, aspiration was the most plausible hypothesis of mechanism of infection in our patient. Empyema by Clostridioidesdifficile is a diagnostic challenge, since it is necessary to rule out that the isolation of this microorganism in pleural fluid is not a contamination. Furthermore, more evidence is needed for its treatment since data regarding this entity are still scarce.

[Uniportal thoracoscopic thorough debridement for tubercular empyema with abscess of the chest wall]

Objective: To examine the feasibility and technical considerations of thorough debridement using uniportal thoracoscopic surgery for tuberculous empyema complicated by chest wall tuberculosis. Methods: A retrospective analysis was conducted on 38 patients who underwent comprehensive uniportal thoracoscopy debridement for empyema complicated by chest wall tuberculosis in the Department of Thoracic Surgery, Shanghai Pulmonary Hospital, from March 2019 to August 2021. There were 23 males and 15 females, aged (M(IQR)) 30 (25) years (range: 18 to 78 years). The patients were cleared of chest wall tuberculosis under general anesthesia and underwent an incision through the intercostal sinus, followed by the whole fiberboard decortication method. Chest tube drainage was used for pleural cavity disease and negative pressure drainage for chest wall tuberculosis with SB tube, and without muscle flap filling and pressure bandaging. If there was no air leakage, the chest tube was removed first, followed by the removal of the SB tube after 2 to 7 days if there was no obvious residual cavity on the CT scan. The patients were followed up in outpatient clinics and by telephone until October 2022. Results: The operation time was 2.0 (1.5) h (range: 1 to 5 h), and blood loss during the operation was 100 (175) ml (range: 100 to 1 200 ml). The most common postoperative complication was prolonged air leak, with an incidence rate of 81.6% (31/38). The postoperative drainage time of the chest tube was 14 (12) days (range: 2 to 31 days) and the postoperative drainage time of the SB tube was 21 (14) days (range: 4 to 40 days). The follow-up time was 25 (11) months (range: 13 to 42 months). All patients had primary healing of their incisions and there was no tuberculosis recurrence during the follow-up period. Conclusion: Uniportal thoracoscopic thorough debridement combined with postoperative standardized antituberculosis treatment is safe and feasible for the treatment of tuberculous empyema with chest wall tuberculosis, which could achieve a good long-term recovery effect.

Operative versus percutaneous drainage with fibrinolysis for complicated pediatric pleural effusions: A nationwide analysis

PURPOSE

Management of complicated pleural effusions and empyema using tube thoracostomy with intrapleural fibrinolysis versus surgical drainage has been debated for decades. However, there remains considerable variation in management with these approaches in the pediatric population. This study aims to compare the nationwide outcomes of pediatric patients with complicated pleural effusions.

METHODS

Patients <18 years old with a diagnosis of pleural effusion or empyema associated with pneumonia were identified from the Nationwide Readmissions Database (2016-2018). Demographics, hospital characteristics, and complications were compared among patients undergoing isolated percutaneous drainage (PD), percutaneous drainage with intrapleural fibrinolysis (PDF), or operative drainage (OD) using standard statistical tests.

RESULTS

5424 patients (age 4 [IQR 1-11] years) were identified with a pleural effusion or empyema who underwent percutaneous or surgical intervention. PD (22%) and OD (24%) were utilized more frequently than PDF (3%). Index complications, including bleeding and postprocedural air leak, were similar between groups. Those receiving PDF had lower index length of stay (LOS) and admission costs. Thirty-day and overall readmission rates were highest in patients receiving PD (15% and 24%) and OD (12% and 23%) versus PDF, all p < 0.001. Those receiving OD had fewer readmission complications including recurrent effusion or empyema, pneumonia, and bleeding. Overall readmission cost was highest in those receiving PD (p = 0.005).

CONCLUSION

In this nationwide cohort, PDF was associated with lower index admission cost, shorter LOS and lower rates of readmissions compared to OD. This knowledge should be used to improve selection of these treatments in this patient population.

TYPE OF STUDY

Retrospective Comparative LEVEL OF EVIDENCE: III.

Massive pleural empyema secondary to amoebic liver abscess in a child

BACKGROUND

Pleural empyema secondary to a ruptured amoebic liver abscess is a rare complication in the pediatric population.

CASE REPORT

We report the case of a 13-year-old male with right flank abdominal pain, productive cough with foul-smelling sputum, fever, and respiratory distress. Physical examination revealed breathlessness, decreased vesicular murmur in the right hemithorax, abdominal distension, hepatomegaly, and lower limb edema. Laboratory tests revealed mild anemia, leukocytosis without eosinophilia, elevated alkaline phosphatase, hypoalbuminemia, and positive immunoglobulin G antibodies against Entamoeba histolytica in pleural fluid. He required a chest tube and treatment with metronidazole. After 2 months of follow-up, the abscesses disappeared, and the empyema decreased.

CONCLUSIONS

Massive pleural empyema secondary to a ruptured liver abscess is a rare complication. The epidemiological link associated with the symptoms and serological tests can help in the diagnosis.

Vertical musculocutaneous trapezius flap for the closure of postpneumonectomy empyema

OBJECTIVE

The aim of the study was to present our experience with the vertical musculocutaneous trapezius (VMCT) flap and highlight its utility in the thoracic wall reconstruction in patients with bronchopleural fistula (BPF).

MATERIALS AND METHODS

We present a five case series of patients with long-standing cavities and BPF. The VMCT flap was used, and a direct pathway into the defect was made through a separate posterior thoracotomy shortening the distance between the flap and the defect.

RESULTS

In 80% of the cases, the flap succeeded in solving the fistula and filling the defect, quality of life improved, and the need for oxygen decreased.

CONCLUSIONS

Management of open window thoracostomy is challenging. Debridement, thoracoplasty, and flap coverage are the mainstream of their treatment, but these patients have scarce available muscle. The VMCT flap represents the major non-affected musculocutaneous unit in the thoracic area after lung surgery. Its dermal component offers a rigid matrix to form a seal over the bronchial stump. Its muscular component adds a good amount of vascularized tissue. No functional impairment has been described after its use.

The Association of Vacuum-Assisted Closure Therapy with Dynamic Volume Change of a Muscle Flap Transposed in an Empyema Cavity for Chronic Empyema: A Case Report

A 62-year-old woman with a history of lung resection for lung cancer was admitted to our hospital due to cough, which became progressively more severe. She was diagnosed with chronic empyema with bronchopleural fistula (BPF) of the right upper bronchial stump. Although a pedicled muscle flap was transposed to the empyema cavity, the fistula remained. We used a vacuum-assisted closure system after open-window thoracotomy and observed the cavity reduction with expansion of the transposed muscle flap. We quantitatively evaluated the dynamics of the cavity change using a three-dimensional image analysis system. A reduction of the volume of the muscle flap by prolonged empyema and expansion of the muscle flap was observed immediately after vacuum-assisted management. However, expansion of the right residual lung was not recognized. Pedicled muscle flap transposition followed by vacuum-assisted management after open-window thoracotomy may be effective for treating chronic empyema caused by BPF.

[A Case of Pleural Empyema with Fistula Caused by Endobronchial Metastasis of Renal Cell Carcinoma]

A 52-year-old man complained of asymptomatic gross hematuria and cough. Chest and abdominal computed tomography (CT) revealed a right renal tumor, mediastinal lymph node metastasis, and right endobronchial metastasis. The right endobronchial metastasis was causing obstructive atelectasis in the lower lobe of the right lung. After tumor biopsy, the pathological diagnosis was clear cell renal cell carcinoma. Combination immunotherapy with ipilimumab and nivolumab was initiated, but CT showed enlargement of the metastatic lesion and lung abscess after two courses of treatment. The therapy was then switched to axitinib. Six days after initiation of axitinib, the lung abscess perforated into the pleural cavity, which resulted in the formation of pleural empyema with fistula. Ten days after initiation of axitinib, obstruction of the bronchus was relieved due to shrinkage of the right endobronchial metastasis, which resulted in development of a pneumothorax. Placement of a thoracic drainage tube and administration of an antimicrobial agent improved the pneumothorax and inflammatory response, but the drainage tube could not be removed. Long-term insertion of the thoracic drainage tube considerably diminished the patient's quality of life, and after 4 months, he was transferred to another hospital to receive the best supportive care.

[Effective Treatment for Empyema with Fistula by Negative Pressure Wound Therapy:Report of a Case]

A 54-year-old male with alcoholic cirrhosis and diabetes mellitus was referred to our hospital for the treatment of right pleural empyema with fistula. Despite performing a simple suture closure of the pulmonary fistula, air leakage occurred one week after surgery. Hence, we covered the fistula with a pediculed muscle flap associated with an open window thoracostomy. After 32 days of gauze drainage, negative pressure wound therapy( NPWT) was introduced for reducing the residual pleural space. A chest computed tomography( CT) scan showed almost the full expansion of the lung after undergoing 98 days of NPWT. The patient was discharged from the hospital four months after thoracostomy.

Management of pleural empyema in a 12-year-old obese patient with COVID-19: a pediatric case report

BACKGROUND

With the ongoing coronavirus disease (COVID-19) pandemic, along with the development of new mutations of the virus and an increase in the number of cases among pediatrics, physicians should be aware and alerted on the atypical presentations of the disease, especially in less expected individuals.

CASE PRESENTATION

Here we present a 12-year-old obese boy (BMI = 37.5 kg/m2) who presented with empyema, which was following SARS-CoV-2 infection. The patient had no history of fever. Due to the onset of dyspnea, a chest tube was inserted for him which was later altered to a pleural drainage needle catheter.

CONCLUSION

Our case is the first report of COVID-19 presenting as empyema among pediatrics. Pleural empyema should be considered as a rare complication of COVID-19. Since there is still no guideline in the management of empyema in the context of COVID-19, delay in diagnosis and intervention may cause morbidity and mortality in children.

Sepsis in the Postpneumonectomy Space: Pathogenesis, Recognition, and Management

Empyema may occur in the pleural space after pulmonary resection. Subsequent bacterial contamination results in infection and development of frank empyema. Pneumonectomy-surgical removal of the entire lung-is the treatment of choice for centrally located bronchogenic carcinoma, diffuse malignant mesothelioma, and chronic inflammatory lung diseases with destroyed lung from pulmonary tuberculosis, fungal infections, and bronchiectasis. In the uncomplicated case, on the pneumonectomy side, the diaphragm becomes elevated as the air-fluid level decreases with chest wall deformation and gradual disappearance of hydrothorax. The pneumonectomy space is at potential risk for getting infected from bacterial contamination and developing empyema.

Outcomes in patients with fractured ribs: middle aged at same risk of complications as the elderly

AIMS

Rib fractures occur in up to 10% of hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax. There is strong evidence that elderly patients have worse outcomes compared with younger patients. Evolving evidence suggests adverse outcomes start at a younger age. The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

METHOD

A two-year retrospective study of patients admitted to any Northland District Health Board hospital with one or more radiologically proven rib fracture was performed. Patients with an abbreviated injury scale score >2 in the head or abdomen were excluded. The study population was stratified by age into three groups: >65, 45 to 65 and <45 years old.

RESULTS

170 patients met study inclusion criteria. Patients <45 had a significantly shorter length of stay (LOS) and lower rates of pneumonia compared to patients 45 and older, despite a higher Injury Severity Score and pulmonary contusion rate. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome.

CONCLUSION

This study found higher rates of pneumonia and an increased LOS in patients 45 and older despite their lower overall injury severity when compared to patients under 45. Patients aged 45-64 had outcomes similar to patients >65. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Sarcomatoid carcinoma associated with chronic empyema and early lung and pleural metastases: A case report

INTRODUCTION

The relationship between chronic empyema and malignant tumors, most of which are lymphoma, has been recognized for many decades. Sarcomatoid carcinoma associated with chronic empyema is extremely rare, may metastasize to other organs in the early stage, and rapidly progresses to death. As far as we know, this was the first case report on sarcomatoid carcinoma associated chronic empyema.

THE PATIENTS MAIN CONCERNS AND IMPORTANT CLINICAL FINDINGS

A 59-year-old man presented to our hospital with a 9-year history of chronic empyema and a chief complaint of left chest wall pain for 5 months. The diagnostic contrast-enhanced computed tomography (CT) showed a large irregular soft tissue mass located on the left lower hemithorax at the margin of the empyema cavity extending to the adjacent chest wall and lung parenchyma. In addition, CT revealed pleural and pulmonary metastases surrounded by ground glass opacity.

THE MAIN DIAGNOSIS, THERAPEUTICS INTERVENTIONS, AND OUTCOMES

The patient underwent CT guided percutaneous core needle biopsy (PCNB). The histopathological evaluation showed carcinomatous proliferation of pleomorphic spindle cells with extensive necrosis. Immunohistochemically, tumor cells were positive for cytokeratin and vimentin. The final histopathological diagnosis was sarcomatoid carcinoma underlying chronic empyema. The tumors showed rapid progression on serial simple radiography. Palliative treatments were performed, but the patient still developed severe dyspnea and died shortly after on day 16.

CONCLUSION

Sarcomatoid carcinoma can occur very rarely as a complication of chronic empyema, and is more aggressive than usual. Early detection of developing malignancy during the follow-up of chronic empyema is an important factor for patient prognosis.

Postpneumonectomy MRSA empyema treated with vacuum therapy - case report and literature review

INTRODUCTION

Postpneumonectomy empyema is one of serious complications with high mortality and lethality. In this paper, the authors describe the treatment of methicillin-resistant Staphylococcus aureus-induced postpneumonectomy empyema by vacuum therapy in a patient operated on for malignant pleural mesothelioma.

CASE REPORT

A 64-year-old patient was operated on at our clinic for epithelioid mesothelioma of the right pleural cavity. We performed extrapleural pneumonectomy with intraoperative hyperthermic intrathoracic chemotherapy. Seven weeks after surgery the patient was readmitted for right pleural cavity empyema caused by methicillin-resistant Staphylococcus aureus (MRSA). Following pleural cavity debridement and mesh explantation we applied vacuum therapy. In total, we performed 4 dressing changes with final application of an antibiotic solution into the pleural cavity and wound closure. The patient showed no evidence of recurrent empyema during subsequent 12-month follow-up and underwent chemotherapy.

CONCLUSION

Vacuum therapy is an effective treatment of postpneumonectomy empyema in patients without a bronchopleural fistula; nevertheless, specific postpneumonectomy patient care is required.

Effective treatment of bronchopleural fistula with empyema by pedicled latissimus dorsi muscle flap transfer: Two case report

RATIONALE

Bronchopleural fistula (BPF) is a dreaded complication after lobectomy or pneumonectomy and is associated with high morbidity and mortality. Successful management remains challenging when this condition is combined with empyema, and the initial treatment is usually conservative and endoscopic, but operative intervention may be required in refractory cases.

PATIENT CONCERNS

Two patients diagnosed with BPF with empyema were selected to undergo surgery in our hospital because they could not be cured by conservative and endoscopic therapy for 1 or more years. One was a 70-year-old man who had a 1-year history of fever and cough after he received a minimally invasive right lower lobectomy for intermediate lung adenocarcinoma and chemotherapy 2 years ago; the other was a 73-year-old man who had a 2-year history of cough and fever after he underwent a minimally invasive right upper lobectomy for early lung adenocarcinoma 3 years earlier.

DIAGNOSIS

Both patients were diagnosed with BPF with empyema.

INTERVENTIONS

After receiving conservative and endoscopic therapies, both patients underwent pedicled latissimus dorsi muscle flap transfers for complete filling of the empyema cavity.

OUTCOMES

The patients recovered very well, with no recurrence of BPF and empyema during postoperative follow-up.

LESSONS

It is crucial to not only completely control infection and occlude BPFs, but also obliterate the empyema cavity. Thus, pedicled latissimus dorsi muscle flap transfer associated with conservative and endoscopic therapies for BPF with empyema is a useful treatment option, offering feasible and efficient management with promising results.

[Aspergillus Empyema with Bronchopleural Fistula due to Destroyed Lung after Postoperative Radiotherapy for Thymoma]

A 35-year-old man underwent adjuvant chemoradiation therapy to the surgical margin of the thymoma. Five years after the therapy, an area of the right upper lung lobe, which was included in the irradiation field, developed destroyed lung, resulting in Aspergillus empyema with bronchopleural fistula. To control the infection, an open window thoracostomy was performed. As the bronchopleural fistula resulted in pneumonia, bronchial embolization was performed with an Endobronchial Watanabe Spigot. After the empyema cavity was cleaned, the empyema space was closed with omental and muscular flap, thoracoplasty. Negative pressure wound therapy was carried out because of poor wound healing. The patient is doing well without relapse 15 months after the thoracoplasty.

[Empyema Secondary to Percutaneous Liver Drainage via Thoracic Cavity for Hepatic Abscess]

Percutaneous liver drainage is associated with few complications. We report a case of empyema secondary to passage of a drain through the chest cavity in a patient treated with percutaneous liver drainage for hepatic abscess. A 72-year-old man was diagnosed with a liver abscess and underwent percutaneous liver drainage via the 7th intercostal space. He developed fever 7 days after the drainage procedure and was diagnosed with empyema on chest computed tomography and underwent video-assisted thoracoscopic curettage. Intraoperatively, we observed the liver drainage tube penetrated the thoracic cavity and the diaphragm, and he was diagnosed with iatrogenic empyema. The patient's postoperative course was uneventful, and the chest drain was removed on the 3rd postoperative day. Percutaneous liver drainage is associated with the risk of penetration of the thoracic cavity and the diaphragm.

High Occurrence of Thrombo-Embolic Complications During Long-Term Follow-up After Pleural Infections-A Single-Center Experience with 536 Consecutive Patients Over 17 Years

Purpose

Pleural infections are associated with significant inflammation, long hospitalizations, frequent comorbidities, and are often treated operatively—all of which are consequential risk factors for thrombo-embolic complications. However, their occurrence following the treatment of pleural infection is still unknown. The aim of the study was to ascertain the early and long-term occurrence of thrombo-embolic events in patients treated for pleural infections.

Methods

The study included all patients that were treated for pleural infections in Tampere University Hospital between January 2000 and December 2016. Data regarding later treatment episodes due to pulmonary embolisms and/or deep vein thromboses as well as survival data were requested from national registries. The rates were also compared to a demographically matched reference population adjusted for age, sex, and the location of residence.

Results

The final study population comprised 536 patients and 5318 controls (median age 60, 78% men). The most common etiology for pleural infection was pneumonia (73%) and 85% underwent surgical treatment for pleural infection. The occurrence of thrombo-embolic complications in patients and controls was 3.8% vs 0.1% at three months, 5.0% vs 0.4% at one year, 8.8% vs 1.0% at three years, and 12.4% vs 1.8% at five years, respectively, p < 0.001 each. Female sex, advanced age, chronic lung disease, immunosuppression, video-assisted surgery, and non-pneumonic etiology were associated with a higher incidence of thrombo-embolism.

Conclusions

The occurrence of thrombo-embolic events—particularly pulmonary embolism but also deep vein thrombosis—was significant in patients treated for pleural infections, both initially and during long-term follow-up.

A CARE-compliant article: a case report of pleural empyema secondary to Klebsiella pneumoniae liver abscess with a hepatopleural fistula

INTRODUCTION

Klebsiella pneumoniae liver abscess (KPLA) is often associated with accompanying metastatic complications such as septic pulmonary embolism, brain abscess, and endophthalmitis. Pleural empyema secondary to a KPLA is a very unusual finding, made even more rare with the presence of a hepatopleural fistula.

PATIENT CONCERNS

An 81-year-old woman presented with aggravated dyspnea.

DIAGNOSIS

The patient was diagnosed with KPLA with empyema through computed tomography (CT) scan findings and pleural fluid culture.

INTERVENTIONS

The empyema was drained by thoracostomy, and treatment with empirical antibiotics was initiated. After early removal of the chest tube, the liver abscess as well as the empyema increased. An additional liver abscess drainage procedure was performed.

OUTCOMES

The fever resolved and dyspnea improved following drainage of effusion. Three days later, the follow-up chest radiograph showed decreased pleural effusion.

CONCLUSION

Pleural empyema is a rare but fatal complication secondary to KPLA. Additionally, the discovery of a hepatopleural fistula on a CT scan (multiplanar reconstruction image) made this case even more rare. Both, the liver abscess and pleural empyema, were effectively drained through the fistula tract with drainage procedure, thoracostomy, and additional liver abscess drainage. Prompt diagnostic evaluation, using an imaging modality such as CT, and early drainage management with intravenous antibiotics can improve clinical outcome.

A case report on the effect of rituximab on pyothorax-associated lymphoma

RATIONALE

Pyothorax-associated lymphoma (PAL) is a rare type of malignant pleural lymphoma. Most lymphomas are normally discovered around 20 to 50 years after tuberculosis infection. In China, there have been few reports about PAL cases so far. We report a case of a patient, whose tuberculosis and lymphoma were diagnosed concurrently.

PATIENT CONCERNS

The patient, a 76-year-old male, was reported to our hospital on March 13, 2015. He had recurrent shortness of breath during the previous 2 years of routine activities solely. His symptoms became more serious which was manifested by edema of lower limbs 1 day before his admission to our hospital.

DIAGNOSES

Doctors reached the diagnosis of PAL based on the patient's pathologic cell morphology and immunohistochemistry. The chest computed tomography examination revealed that there were pleural effusions on both sides, and some extent of compressive atelectasis in the lower parts of the inflamed lungs yet without space-occupying lesions. There were multiple small nodules which may be benign in the right upper lung.

INTERVENTIONS

The current first-line treatment for diffuse large B-cell lymphoma is the cyclophosphamide, adriamycin, vincristine, prednisone (CHOP) protocol. Given that the patient had cardiac diseases and cardiotoxicity of anthracyclines, doctors decided to adopt rituximab with cyclophosphamide, vincristine, and prednisone chemotherapy without anthracyclines.

OUTCOMES

The treatment effect was obvious after one cycle of chemotherapy. The patient's pleural and pericardial effusions were significantly reduced. With the chemotherapy protocol above continuously adopted, pleural and pericardial effusions did not increase in multiple reexaminations on October 25, 2015, February 15, 2016, and August 10, 2016.

LESSONS

Analytical research revealed that chemotherapy with rituximab can increase the complete remission rate of non-Hodgkin lymphoma, reduce the possibility of failure and relapse, and prolong disease-free and overall survival. Moreover, there is no significant increase in adverse drug reactions compared with the effect of chemotherapy with CHOP alone. In the case of this patient, chemotherapy with rituximab was safe and efficacious.

REPORT-Pleural lavage of amphotericin B for treatment of empyema caused by Candida albicans infections: A case report

Chest fungal infection is a rarely seen lethal disease with rapid progression. Sufficient residence time of antifungal agent with therapeutic concentration in the chest is an essential point during anti-infection therapy, which is hard to achieve via conventional systemic drug delivery. We here by describe a case of successful treatment of fungal Chest infection via local pleural lavage. A 59 years old male was hospitalized due to chest pain. X-ray of chest and bacterial culture of thoracic drainage fluid and blood indicated severe chest infection of Candida albicans. The patient was initially administered intravenously with amphotericin B (25mg/day). However, the symptoms were not significantly improved after 5 days of treatment. Then one-hour pleural lavage of 5mg amphotericin B in volume of 50ml 5% glucose solution was added once daily. On day 12, bacterial cultures showed negative, and chest X-ray exhibited apparent decrease of shadow area, also other examinations such as body temperature and white blood cell count suggested significant improvement of infection. The therapeutic strategy of amphotericin B was maintained until two consecutive bacterial cultures were negative, then was switched back to intravenous drip alone for another one month found. No significant adverse effects were observed during the treatment. In conclusion, this case demonstrates a new local pleural lavage method of amphotericin B for chest fungal infection, which may provide a reference for the treatment of such cases.

[Surgical Treatment for Pneumopyothorax Secondary to Pancreatic Fistula]

A 46-year-old woman with cervical cancer with multiorgan metastasis visited our hospital. She underwent a total gastrectomy, splenectomy, distal pancreatectomy, left adrenalectomy, and left partial diaphragmatic resection. Postoperatively, she developed pleural effusion with high level of amylase secondary to a pancreatic fistula, consequently causing left-sided empyema. She developed acute respiratory distress syndrome. Urgent surgical treatment was scheduled, and left lower lobectomy, with diaphragmatic partial resection were performed under the venovenous extracorporeal membrane oxygenation. After surgery, intensive care for 45 days was necessary and she was discharged home 6 months post operatively.

The first experience of the use of hydro-surgical technologies in the treatment of children with pulmatic-pleural complications of destructive pneumonia

Drainage and endoscopic methods of sanitation of the pleural cavity do not always allow to achieve effective debridement of pathological contents.

AIM

To development and introduction into clinical practice of hydrosurgical technologies for debridement of the pleural cavity.

MATERIAL AND METHODS

From 423 children with acute community-acquired pneumonia 88 (20.80%) children destructive pneumonia were diagnosed. Of the 88 patients with destructive pneumonia, 28 patients did not have pleural complications and were excluded from the study. 60 patients were divided into 2 groups depending on the method of surgical treatment. In the first group (n=30), two additional subgroups were formed: IA group (main n=15) - they carried out drainage and washing the pleural cavity with saline; IB group (control n=15) - only drainage of the pleural cavity. The second group (n=30) were also divided into 2 subgroups; Group IIA (main n=15) children operated according to the method of video-assisted thoracoscopic sanitations of the pleural cavity developed by us using hydrosurgical technologies; Group IIB (control n=15) - children are operated on by the method of traditional video-assisted thoracoscopic sanitations of the pleural cavity. A prospective, non-randomized, single-center study was conducted to evaluate the effectiveness of various treatments. The treatment plan was determined on the basis of a combination of anamnesis, clinical and instrumental studies and laboratory parameters.

RESULTS

All studied in the comparison groups were homogeneous by sex, weight and height. The results of applying the Kruskal-Wallis test revealed statistically significant differences between the groups for the periods of relief of the intoxication syndrome (p<0.001) and the periods of relief of the pain syndrome (p=0.012) in favor of the main group. Summarizing all analyzing the parameters in the comparison groups allowed us to prove the advantage of the proposed treatment methods over the treatment methods used in the control groups.

CONCLUSION

Hydrosurgical methods of treatment demonstrate obvious clinical and economic efficacy, which leads to the rapid reexpantion of the affected lung.

Distal duodenectomy: a new option of surgical treatment for duodenal tumors

OBJECTIVE

To assess severity, safety and functional advisability of distal pancreatectomy using original surgical technique developed in the Blokhin National Medical Research Centre of Oncology.

MATERIAL AND METHODS

There were 10 patients with duodenal malignancies who have undergone distal pancreatectomy in the Blokhin National Medical Research Centre of Oncology for the period 2006-2018. Distal pancreatectomy for primary duodenal tumors was performed in 8 patients, 2 patients underwent surgery for external invasion of the duodenum.

RESULTS

Postoperative complications Clavien-Dindo grade 1 and 2 occurred in 4 (40%) patients. Surgical complication grade 2 occurred in 1 (10%) patient (pancreatic fistula with effective conservative management). There were no cases of leakage of duodenal stump and duodenojejunostomy, impaired bile flow and stenosis of anastomosis with delayed stomach emptying.

CONCLUSION

Distal duodenectomyis associated with low postoperative morbidity, good functionality and quality of life. This procedure is preferred for non-epithelial and neuroendocrine tumors, as well as with secondary malignant duodenal invasion.

Risk of developing pleural empyema in patients with stroke: a propensity-matched cohort study

Pleural empyema is an important complication of pneumonia. Patients with stroke are at a higher risk developing pneumonia; however, the association between stroke and pleural empyema risk is largely unknown. We used the data from the National Health Insurance Research Database of Taiwan to establish a stroke group consisting of 466,170 patients diagnosed between 2000 and 2010, and a non-stroke group consisting of the same number of individuals matched by the propensity score. Incident pleural empyema was monitored toward the end of 2011. Adjusted hazard ratios (aHRs) of pleural empyema in the stroke group, compared to the non-stroke group, were estimated using the Cox proportional hazards model. We found that the incidence of pleural empyema is 2.69-fold higher in the stroke group than in the non-stroke group (15.2 vs. 5.59/10,000 person-years, p < 0.001), with an aHR of 2.89 [95% confidence interval (CI) = 2.72-3.08]. Further analysis reveals the aHRs of pleural empyema to be 2.62 (95% CI = 2.45-2.79) in patients with ischemic stroke and 4.53 (95% CI = 4.14-4.95) in patients with hemorrhagic stroke compared with those without stroke. In addition, we observe that stroke patients with ventriculoperitoneal (VP) shunt implantation exhibit more than sevenfold risk for developing of pleural empyema. In conclusion, patients with stroke are at an elevated risk of developing pleural empyema. The risk is greater for those with hemorrhagic stroke than for those with ischemic stroke. The risk increases further for patients who undergo VP shunt implantation.

Pleural Empyema Following Liver Resection: A Rare But Serious Complication

BACKGROUND

Postoperative pleural empyema following liver resection has not been thoroughly described in the literature yet. Hence, we aimed to describe characteristics of patients experiencing this complication.

METHODS

Characteristics and outcomes of 21 patients who developed pleural empyema after hepatectomy, defined as a bacteriologically proven pleural infection with clinical and biological inflammatory signs requiring antibiotherapy and thoracic drainage, from 2001 to 2014, were retrospectively analyzed.

RESULTS

Overall incidence of pleural empyema was 1 %. Nineteen (90.5 %) patients underwent right or extended right hepatectomy. All 21 patients developed postoperatively pleural effusion and 13 (62 %) infected abdominal collection. They had significantly more bile leakage and intra-abdominal abscesses compared to a matched control group of patients undergoing a right hepatectomy. Accidental diaphragmatic opening was observed in six patients (intra-operatively n = 4, transdiaphragmatic abdominal drainage n = 2). Treatment included percutaneous pleural drainage and in six (29 %) patients a thoracotomy for surgical drainage. Three patients (14 %) died due to sepsis and multiorgan failure. No patient treated by thoracotomy died postoperatively.

CONCLUSION

Postoperative pleural empyema is a rare but serious complication occurring mostly after right hepatectomy complicated with intraabdominal sepsis. Pleural paracentesis for diagnosis and treatment should be rapidly considered. Early thoracotomy for optimal drainage would reduce postoperative mortality.

[Pyopneumothorax in rheumatoid arthritis]

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting the joints but which frequently includes extra articular effects, including pulmonary nodules, which grow faster under immunosuppressive treatment.

CASE REPORT

A 74 years old man, with mild asbestosis, underwent treatment with methotrexate then leflunomide (LEF) for seropositive RA. In February 2014, during monitoring of his asbestosis, chest CT scan showed the appearance of thick-walled cavitating lung nodules, with a central and sub pleural distribution. The patient was asymptomatic. Bronchoalveolar lavage excluded infection and tumor. LEF was stopped but in May 2014, the patient was admitted with respiratory infection and a pyopneumothorax which required surgical management. The postoperative course was complicated with a persistent pneumothorax.

CONCLUSIONS

We describe a case of RA complicated by a pyopneumothorax after treatment with LEF. The risk of this complication could be reduced by regular chest imaging.

Empyema caused by a colopleural fistula: A case report

RATINALE

Empyema is a condition in which pus gathers in the area between the lungs and the inner surface of the chest wall. An empyema caused by colo-pleural fistula is a rare but potentially life-threatening condition.

PATIENT CONCERNS

We describe a case of 42-year-old man was brought to our Emergency Department for chest pain with dyspnea and fever.

DIAGNOSES

The final diagnoses are empyema caused by colo-pleural fistula and colon cancer.

INTERVENTIONS

The patient underwent laparotomy surgery, during which a tumor was found in the splenic flexure of the descending colon. The tumor penetrated the colonic serosa and invaded the left side of the diaphragm. A left hemicolectomy was performed.

OUTCOMES

After the operation, the patient recovered smoothly and was discharged on postoperative day 14. It's been over 3 years now, CT and colonoscopy assessments show no recurrence or metastasis.

LESSONS

This case serves as a reminder to test for pathogens in patients with an unexplained empyema. If normal intestinal bacteria are detected, the empyema may be derived from intestinal disease. In addition, an abdominal examination should be performed in patients with an empyema of unknown origin.

[Successful Treatment of Acute Empyema Due to Rupture of Pyogenic Liver Abscess]

Cases of rescue after rupture of pyogenic liver abscess into the thorax are rare. Here, we report 2 cases of rescue in patients with acute empyema due to rupture of a suppurative abscess into the thorax. Case 1:A 61-year-old male had high fever of 39 °C and right abdominal pain. Thoracic computed tomography(CT) showed encapsulated pleural effusion in the right thorax and ring-like enhancement in the right liver. The diagnosis was acute empyema caused by rupture of liver abscess. The pathogenic bacteria were Streptococcus group. The drain was removed after 6 days and the patient was discharged 32 days after surgery without reefing the diaphragm. Case 2:A 74-year-old male had a high fever of 39 °C and right chest pain. CT showed encapsulated pleural effusion in the right thorax, but not in the lung, and a low density area in the posterior segment of the liver. The diagnosis was acute empyema caused by rupture of liver abscess. The pathogenic bacteria were Streptococcus group and Bacteroides. The drain was removed after 8 days and the patient was discharged 32 days after surgery without reefing the diaphragm.

CONCLUSION

Pathogenic bacteria in a pyogenic liver abscess are usually Gram-negative rods, but recently have also been reported to be Streptococcus anginosus group( SAG). Coinfection with SAG and anaerobic bacteria occurs in elderly patients, compromised hosts, and patients with a severe malignant disease. Therefore, early drainage using surgical treatment regardless of reefing the diaphragm should be considered to control severe infection due to liver abscess rupture.

A Case of Incarcerated and Perforated Stomach in Delayed Traumatic Diaphragmatic Hernia

The patient was an emergency transported, 57-year-old man complaining of left thoraco-lateroabdominal pain, with a history of blunt chest trauma 3 months prior. Thoracoabdominal computed tomography (CT) resulted in a diagnosis of diaphragmatic hernia with incarceration and perforation of the stomach, and same-day emergency surgery was performed. The surgery was performed via an abdominal approach, and after manually repositioning the stomach incarceration, the perforated region was resected and the diaphragm sutured closed. Diaphragmatic hernia can be occasionally difficult to diagnose at the time of initial treatment, and may have been overlooked at the initial presentation, 3 months earlier in the present case. When examining a case of blunt force thoracoabdominal trauma, it is important to keep in mind the possibility of diaphragmatic injury. Additionally, during surgery for traumatic diaphragmatic hernia, in cases where manipulation of the abdominal organs is thought necessary, commencing the surgery with an abdominal approach is desirable.

[Not Available]

Immediate and late results of the combined gastrectomy (CG) performance in 719 patients, suffering locally—spread gastric cancer (LSGC), were analyzed. Additional resection of adjacent оrgans was performed in 165 observations. In early postoperative period complications in 116 (16.1%) patients have had occurred, including surgical complications — in 77.7%, and nonsurgical — in 22.3%. Lethality in 30 postoperative days have constituted 11.1%. Тhe patients' postoperative life time was at average (22.9 ± 1.67) mo, mediana— 9.3 mo; indices of 3—year and 5—year survival — (18.9 ± 1.72) and (12.9 ± 1.51)%,accordingly. Essential difference in favor of subtotal distal gastric resection was established, basing on comparison data between this procedure and CG. The data obtained witnessed the expediency of combined operative interventions, what have had widened possibilities of the patients' radical treatment for LSGC.

Paraspinous muscle flap for the treatment of an empyema cavity: three case reports

A surgical option is commonly chosen when conservative medical therapy for empyema is impossible. The muscles used include the latissimus dorsi, trapezius, and pectoris major, based on the size and location of the empyema cavity. However, these volumes are decreased in patients suffering from malnutrition, and flap dissection and elevation are sometimes invasive. Therefore, we developed an alternative method, and present three successful cases in which we used a pedicled paraspinous muscle flap to fill the dead space caused by empyema fenestration in the medial region of the back. The paraspinous muscle flap remains an important tool in reconstruction. However, such flaps should be created only in selected cases, such as those with empyema in the posterior region. Also, if the pleural space is large, additional muscle flaps will be required.

[Vacuum-assisted Closure Therapy for Residual Space after Open Window Thoracotomy for Pleural Empyema due to Bronchopleural Fistula]

A 73-year-old man underwent right middle-lower bilobectomy for lung adenocarcinoma. He suffered from pneumonia followed by empyema due to bronchopleural fistula. On day 19 after the operation, an open window thoracostomy was created. Then the pleural space was treated conservatively with saline irrigation and petrolatum gauze packing. Progressive formation of healthy granulation tissue was observed around the bronchopleural fistula and the adjacent pulmonary artery, resulting in a complete closure of the bronchopleural fistula. And then we applied vacuum-assisted closure (VAC) therapy to the residual pleural cavity. At 4 weeks after the initiation of VAC therapy, the pleural cavity was completely filled with granulation tissue and re-expanded residual lung. In conclusion, VAC therapy is a safe and effective treatment for residual space after open window thoracostomy for empyema due to bronchopleural fistula, if it is applied after closure of bronchopleural fistula and adequate granulation tissue formation on the great vessels.

EARLY COMPLICATIONS FOLLOWING ANATOMIC LUNG RESECTIONS--EXPERIENCE OF A THORACIC SURGICAL ONCOLOGY UNIT

AIM

To analyze the medical and socioeconomic impact of the complications of anatomic lung resections performed at the Thoracic Surgery Unit of the Iasi Regional Cancer Institute.

METHODS

This retrospective study included patients who underwent anatomic lung resections between January 2013 and August 2015.

RESULTS

Over this interval a total of 172 major lung resections were performed: 31 (18.02%) pneumonectomies, 5 (2.91%) bilobectomies, and 136 (79.06%) lobectomies. Complications occurred in 36 patients, including bronchial stump fistula in 7 patients (4.06%), bronchopneumonia (9/5.23%), pleural empyema without bronchoscopically documented bronchial stump fistula (1/0.58%), chylothorax (1/0.58%), postoperative arrhythmia (3/1.74%), early postoperative stroke (1/0.58%), prolonged air leak (requiring hospital stay longer than 14 days) (11/6.38%), and postoperative hemothorax requiring reintervention (3/1.74%). Secondary to complications, a number of 3 (1.74%) patients died early postoperatively.

CONCLUSIONS

The incidence of immediate and early postoperative complications is comparable to those reported by other authors.

[Successful Case of Coil Embolization for Repeated Pulmonary Arterial Bleeding in Postoperative Empyema with Bronchopleural Fistula]

A 78-year-old woman underwent right S6 segmentectomy and upper lobe partial resection for adenocarcinoma. About 11 months after the operation, she was diagnosed as having empyema with bronchopleural fistula and open thoracotomy was performed. From the following day, active hemorrhage from the pulmonary artery into the thoracic cavity(500~800 ml) repeated. Tamponade, surgical treatment such as putting hemostasis sheet, or covering with a pedicled latissimus dorsi muscle flap could not prevent rebleeding. Therefore selective pulmonary artery coil embolization was performed, after that the rebleeding did not occur.