We read with great interest the paper entitled 'Surgery should be the first line of treatment for empyema'. 1 As clearly reported in this publication the gold standard for empyema treatment is still debated. Several approaches have been proposed: chest tube insertion with subsequent instillation of fibrinolytic agents, minimally invasive surgery with debridement and coagulation of pleural adhesions, and open surgical toilette of the pleural cavity with extended decortication of a trapped lung. The therapeutic strategy depends on several factors like stage (exudative, fibrinopurulent, organized) and type of empyema (uni-or multilocular), surgeon's preference and skills and clinical status of the patient.Our experience includes all of these treatment modalities and our therapeutic strategy is taken on a case by case basis. Recently, we have concentrated our attention on a group of patients that overcomes the standard treatment criteria. Six high cardiac risk patients (mean age 73 Ϯ 6.7 years) with a very low cardiac ejection fraction (<25%) developed empyema; in three cases the effusion was multiloculated. The deranged clinical status was at high risk also for minimally invasive procedure under local anaesthesia. As patients were pyretic and septic, we decided to perform an evacuative thoracentesis with an 8 Ch in diameter Argyle Safety Thoracentesis System (Tyco Healthcare UK Ltd, Gosport, Hampshire, UK); the procedure was performed at the bed of patients and the small-bore flexible catheter was left in place and secured with a zero skin stitch. This 'soft' approach allowed to gently and repeatedly drain the effusion and wash the pleural cavity without stress; in fact through the catheter we were also able to irrigate the pleural space with povidone-diluted solution twice a day until the complete resolution. No fibrinolytic agents were instillated. The catheter was washed after irrigation with eparinized solution to avoid clotting. All patients were at early fibrinopurulent stage and in four out of six the pus was sterile; in two cases a Streptococcus pneumoniae was detected and an i.v. specific antibiotic therapy was started. In the other patients a broad spectrum antibiotic therapy was administered. In five cases we have observed a complete resolution with restitutio ad integrum (mean 7 days; range 4-11). In one case we had a partial response and the patient died because of cardiac failure 2 weeks later.We strongly believe that this very minimally invasive approach should be considered for high-risk patients contraindicating the standard therapeutic options. The complete success rate in our experience exceeds 80% with no complications, no catheter clotting and a good patient's compliance. REFERENCE 1 Petrakis IE, Heffner JE, Klein JS. Surgery should be the first line of treatment for empyema. Respirology 2010; 15: 202-7.
Recurrent respiratory papillomatosis with malignant transformationr esp_1763 726..••
Dear Editor:We have read with great interest the case reported by Ruan et al. 1 that describes a 29-year-old ...