EACTS expert consensus statement for surgical management of pleural empyema

Abstract

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preference.

Management for Pediatric Pleural Empyema in Resource-Poor Country: Is Chest Tube Drainage with Antiseptic Lavage-Irrigation Better than Tube Thoracostomy Alone?

“…Treatment failure in all groups using antiseptic lavage irrigation or not represented patient with late stage disease (stage 2 or 3) and patients undergoing operative therapy presumed to have advanced disease. Chronic cases and complications such as broncho-pleural fistula, a lesion of the lung, recurrent severe hemoptysis, fibrothorax may requires aggressive intervention like wedge resection or decortications [14]. In this study a few patients of stage 2 or 3 pleural empyema with multiloculated empyema, broncho pleural fistula or pathological state of underlying lung who fail to the measures need complex surgical procedures.…”

Current understanding in source control management in septic shock patients: a review

“…It is a safe, fast and effective tool to determine volume and accessibility in order to drain abscesses or pleural infected effusions. Recent recommendations on this matter (29,30) suggested as first approach the use of thoracic ecography, following diagnostic sampling thoracocentesis, and if necessary the placement of a chest tube. The role of video assisted thoracoscopy and open thoracotomy can be reserved for those chronic or loculated cases.…”

Differentiation of Lung Cancer, Empyema, and Abscess Through the Investigation of a Dry Cough

“…If the patient fails treatment or is experiencing symptoms of fever, tachycardia, hypotension, or tachypnea, then pleural drainage is required [3]. The least aggressive method of pleural drainage is CT-guided tube thoracostomy with small bore catheter placement [8-10]. Any fluid drained from the mass should be cultured and assessed for pH, lactate dehydrogenase, glucose level, and cell count [10].…”

“…The least aggressive method of pleural drainage is CT-guided tube thoracostomy with small bore catheter placement [8-10]. Any fluid drained from the mass should be cultured and assessed for pH, lactate dehydrogenase, glucose level, and cell count [10]. If the chest tube is placed and the mass persists, then another method of pleural drainage must be used [8, 10].…”

“…Any fluid drained from the mass should be cultured and assessed for pH, lactate dehydrogenase, glucose level, and cell count [10]. If the chest tube is placed and the mass persists, then another method of pleural drainage must be used [8, 10]. Masses that are solid or loculated often resist drainage [8, 10].…”