Empiema 2007 Full

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DOI: 10.1016/j.ejcts.2007.05.0282007;32:422-430Eur J Cardiothorac Surg

Thomas F. MolnarCurrent surgical treatment of thoracic empyema in adults

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Review

Current surgical treatment of thoracic empyema in adultsThomas F. Molnar *

Department of Surgery, Medical School, University of Pecs, Pecs, Hungary

Received 19 March 2007; received in revised form 24 May 2007; accepted 31 May 2007

Summary

A review of the recent literature on treatment modalities of adult thoracic empyema was conducted in order to expose the controversies andverify where consensus exists. Critical reading filtered through clinical experience was the method followed. The roles of surgical drainage,lavage techniques, debridement via VATS, decortication, thoracoplasty and open window thoracostomy were considered using the Oxford Centerof Evidence Based Medicine criteria. The roles of the different therapeutical modalities were interpreted in the light of the triphasic nature ofempyema thoracis. The randomised controlled trials came up with conflicting results. With two exceptions all of the papers reviewed provide

level (2b) or below evidences. The lack of a single ideal treatment modality or policy reflects the complexity of the diagnosis and staging of thisheterogeneous disease. Basic elements of intervention drainage, different evacuation techniques, decortication, thoracoplasty and openwindow thoracostomy are well-established technical modalities; however, neither a universally acceptable primary modality nor the goldstandard of their sequence is available. Drainage remains to be the initial treatment modality in Phase I disease. Debridement via VATS is a safe,reliable andefficientmethod in thefibrinopurulentphase. Organised pleural callusrequiresformaldecortication.Open windowthoracostomyis asimple and safe procedure for high-risk patients and results in quick detoxication. Thoracoplasty kept its final role in pleural space management.Acute postoperative bronchial stump insufficiency requires immediate surgery. Evacuation of toxic material is mandatory. No single-stageprocedure offers a solution.An optimised agressivity treatmentmodality shouldbe tailored to thecondition of thepatient and to the potential ofthepersisting cavity. Decision-making involves a triad consisting of theaetiology of empyema (i.e. primary vs secondary), general conditionof thepatient and stage of disease, while considering the triphasic nature of development of thoracic empyema. The current attitudes show that thepresent concepts are based mainly on expert opinion. Flexibility and patience on behalf of the surgeon and nursing staff, the patient and thehospital management, as well as a good understanding of the complexity of this condition are the cornerstones of the treatment. No exclusivesequence of procedures leading to a uniformly predictable successful outcome is available. Individualised approaches can be recommended basedon institutional practice and local protocols. Thoracic empyema in general seems to remain resilient to fit completely into the categories ofevidence-based medical approach.# 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Keywords: Empyema thoracis; Percutaneous thoracostomy; Open thoracic window; Fibrinolysis; Decortication; Thoracoplasty; Video-assisted surgery; Surgical

decision-making

1. Introduction

Thoracic empyema, the inflammatory process in apreformed anatomical space defined by the visceral andparietal pleura, was one of the first recognised thoracicpathological entities that had been a therapeutic challenge.Since then it seems to resist proper evidence-based

approaches so far. As a paradoxical result of increased lifeexpectancy, improved survival of malignant diseases andextended operability criteria within and outside the scope ofthoracic surgery, the pool of potential candidates forempyema thoracis is expanding. Antibiotic abuse led toincreased numbers of therapy-resistant cases and the

tuberculosis did not cease to be a permanent threat either.Immunocompromised conditions either iatrogenic (trans-plantation and cancer therapy) or the result of drug abuseand HIV [1] impose further risk in developing thoracicempyema. The utmost need of commonly accepted defini-tions, and consensus in the categories is highlighted by thefact that thoracic empyema is located on the interface

between thoracic surgery and pneumonology on the one handand trauma surgery on the other.

The protean face of the disease, diabolically masquerad-ing its own clinical manifestation, is not helpful either. Thisnature of the condition is exposed by Grahams comment onthe paradigm shifting work of Samson and Burford on theefficacy of decortication of thoracic empyema, adding:

You men who have been working in World War II havenot been seeing empyema. Empyema is an abscess ofthe pleural cavity. It is a word that was used by

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* Corresponding author. Address: H-7633 Pecs, Ifjusagu 13, Hungary.

Tel.: +36 30 6403362; fax: +36 72 536 496.

E-mail address: [email protected].

1010-7940/$ see front matter # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

doi:10.1016/j.ejcts.2007.05.028

mailto:[email protected]://dx.doi.org/10.1016/j.ejcts.2007.05.028http://ejcts.ctsnetjournals.org/http://ejcts.ctsnetjournals.org/http://ejcts.ctsnetjournals.org/http://ejcts.ctsnetjournals.org/http://dx.doi.org/10.1016/j.ejcts.2007.05.028mailto:[email protected]


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Hippocrates to mean abscess. . .You have been seeinginfections attenuated by drugs which were not knownin 1941 . . .and much less known to Hippocrates . . .ifyou had talked to Hippocrates about this as empyema,he would have said: I dont understand what you aretalking about[2].

Thoracic empyema might be considered too complex todiscuss as a unique clinical picture. However, the commonand dominating inflammatory nature of the disease, theuniform pathological changes and the shared treatmentmodalities (the armamentarium available) to correct themprovide a rationale for treating thoracic empyema as anentity.

Attempts to obtain data using DynaMed (http://search.-ebscohost.com) clinical reference tool failed to find any itemfor empyema thoracis clinical evidence. The CochraneDatabase of Systematic Reviews [3]reveals serious limita-tions as far as thoracic surgical aspects are concerned.Conclusions of a previous small RCT[4]had to be revaluatedby a recent report with a diagonally opposite outcome [5],which makes thoracic empyema an eminent example of thecomplexities Tom Treasure detailed in our speciality[6].

The method of the present systemic review applies to thecategories (Table 1) developed by the Oxford Centre forEvidence Based Medicine (OCEBM) (http://www.cebm.net/levels_of_evidence.asp.2001) and previously used in thespeciality[7].

Medline through PubMed was used for the primary articlesearch, limiting the time frame from 1 January 2000 to 1October 2006, employing the following terms: empyemathoracis (n= 81), thoracic empyema (n= 764), postoperativeempyema (n= 355) and postpneumonic empyema (n= 19).Using additional keywords such as intercostal catheter/

drain, decortication, thoracostomy, thoracoplasty and VATSfailed to present other than duplicate titles. The extra-ordinary healing potential of paediatric patients puts thembeyond the scope of the present review as they are moreresponsive to more conservative treatment regimes [8].Consequently in this article only the treatment modalities ofadults (over 16 years) andthe usual upper limit for admissionsto a paediatric profile department are discussed.

Of the 1219 articles found when searching, 92 wereconsidered relevant following a quick two-step (title/abstract) evaluation. The following specific predeterminedexclusion criteria: non-adult patients, lackof clear definition/stage of empyema, complete outcome/complication/conver-sion data list, left 51 eligible papers. Unfortunately, non-

English articles had to be excluded. Case reports, otherwiserelevant, were not excluded. Subjectively selected papers

from the pre-2000 era were also incorporated where thereview required it. The selected papers were then reviewedand filtered through the clinical experience of the reviewer inthethirdstep.ThelevelofOCEBMevidenceappearsinthetextin semicircular brackets where it is relevant.

2. Basics

2.1. Definition

Thoracic empyema is a dynamic process, inflammatory inorigin and taking place within a preformed space bordered byboth the visceral and parietal pleura. It is a complex clinicalentity, neither a sole clinical, laboratory, nor a radiologicaldiagnosis. A significant lack of detectable causative organ-isms (frank sterile pus) reported between 47% and 56% [911]complicates further definition. In this paper, the entities arediscussed according to Lights classification of the para-pneumonic effusions from 4 to 7 (i.e. simple complicated tocomplex empyema)[12].

The following criteria [13] were accepted for the diagnosisof thoracic empyema, irrespective of their origin:

1. Frank pus at tapping or organisms demonstrated on Gramstain (direct) or culture (indirect), or all of the testspositive for:

2. pH below 7.2, glucose level of fluid less than 400 mg/l,LDH above 1000 IU/ml, protein level above 3 g/ml andWBC over 15 000 cells/mm3.

3. Physical, radiological and laboratory signs accompaniedthe relevant clinical picture.

Imaging techniques like chest X-ray, fluoroscopy, chestultrasound and CT have their own role, but the basic methodsof anamnesis, physical examination and (guided) tapping andanalysis of the specimen are of eminent importance [13,14].

2.2. Origin and taxonomy

The most common form of empyema thoracis is post- orparapneumonic, representing 4060% [15,16] of all cases.From 5% to 20% all post- or parapneumonic effusions becomethoracic empyema [9,17]. Thirty percent or less of all theadult cases originate in thoracic surgical procedures (lung,oesophageal, mediastinal or other intrathoracic procedures)[18]. About 1.64.2% of thoracic trauma develops empyemathoracis[19,20]. Other sources like non-operative oesopha-

geal, subdiaphragmatic and infected malignant pleuraleffusions are occasionally mentioned[21].

Taxonomy of thoracic empyema (Table 2) offers thedidactic advantage of exposing the relations among origin,

T.F. Molnar / European Journal of Cardio-thoracic Surgery 32 (2007) 422430 423

Table 1

Levels of sources of evidence according to the OCEBM

1. Randomised controlled trials (RCT)

2. Cohort studies (longitudinal follow-up or prospective studies)

3. Small cohort studies/case controlled studies (cases with specific outcome:retrospective studies)

4. Experimental papers

5. Expert opinion without explicit critical appraisal

In addition, papers can be sub-categorised with Suffix a: meta-analysis or

systemic review or Suffix b: individual paper.

Table 2

Classification of thoracic empyema

Primary( post-/parapneumonic) thoracic empyema

Secondary to lung resection

without BPF

with minor/moderate/significant BPFSecondary to other surgical trauma

Secondary to non-medical trauma

http://search.ebscohost.com/http://search.ebscohost.com/http://www.cebm.net/levels_of_evidence.asp.2001http://www.cebm.net/levels_of_evidence.asp.2001http://ejcts.ctsnetjournals.org/http://ejcts.ctsnetjournals.org/http://ejcts.ctsnetjournals.org/http://ejcts.ctsnetjournals.org/http://www.cebm.net/levels_of_evidence.asp.2001http://www.cebm.net/levels_of_evidence.asp.2001http://search.ebscohost.com/http://search.ebscohost.com/


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stage and therapeutical options. Decision-making rests uponthese three pillars. The question is, how and to what extentshould the individual elements be weighted in the particularcase. An empyema was designated primary (PTE) if therewere no previous surgical interventions involving the chest orno data of other mechanic insult (trauma). Pneumonia-related (post- or parapneumonic effusion) complicated

effusion and fibrinopurulent-stage empyema are the mostfrequent forms. Tuberculotic (specific) empyema, infectedmalignant pleural effusion and empyema of unknown originor idiopathic are less frequent [4,5,811,15,17].

A thoracic empyema is secondary (STE) if it follows a chesttrauma. Most frequently it is a surgical trauma, in themajority of the cases a lung resection [18]. Penetrating orblunt chest trauma (direct contamination or superinfectionof a retained clot) is another cause of secondary thoracicempyema [19,20]. The distinction between primary andsecondary thoracic empyema may sound artificial and yet thetag reflects the basic difference in their optimal approaches.

2.3. Pathology

The complete unintervened process of development ofthoracic empyema takes about 56 weeks, if a full-blownsepsis does not kill the patient earlier, but the length of theindividual stages is not clearly defined(Fig. 1). While the dateof the diagnosis is usually well documented, the origin of thewhole process, especially in primary thoracic empyema, toofrequently disappears in the haziness of the personalanamnesis.

The triphasic nature of the disease is well established[2123]. In Stage I (exudative phase) the visceral pleuraremains elastic and dimensions of the thoracic cavity aremaintained. Stage II (transitional or fibrinopurulent) is

typified by turbid and infected fluid, which becomes thickand purulent. The fibrin deposits construct bridges whichseptate the effusions creating multiple loculations. In StageIII (organising or consolidative phase) this is replaced byformal granulation tissue[24]. A sheet of inflammatory tissuewould gradually compress the underlying tissue, causingcontraction of the affected hemithorax. Finally, themediastinum is shifted ipsilaterally, the diaphragm iselevated and the spaces between the ribs are narrowed.

3. Array of methods

The primary therapeutic aim: ubi pus evacua if you find

pusremove it hasnot changed sincethe age ofCelsus.Only ina short period of hope, at the advent of penicillin and its

derivates, the thought flared up of the needlessnessof surgicalmethods. This mirage reappears again and again. The aim ofthe surgical therapy is local infection control if possible, butwithout elimination of the pleural dead space with impending

colonisation it is hardly achievable. The combinations andsequence of surgical methods listed in Table 3 are summarisedin the empyema diamond diagram (Fig. 2).

3.1. Tube/closed thoracostomy/intercostal catheter

(ICC)/intercostal drain (ICD)

Thoracocentesis (tapping) with a large bore needle [9]isfor diagnosis and (3b) or below evidences support itsusefulness in early empyema cases [9,10,25]. Drainageperformed as a single procedure is usually a first-lineintervention with a success rate for PTE between 67% and

T.F. Molnar / European Journal of Cardio-thoracic Surgery 32 (2007) 422430424

Table 3

Array of treatment modalities coping with empyema thoracis

Thoracocentesis (tapping)

Drainage

Simple

Empyema tube (von Petzers drain)

Negative passive drain (underwater drain/von Bulaus system/Heimlichs

valve)Active

Intermittent suctionContinuous suction

Irrigation

Cyclic (tidal) one tube ore more

Continuous suctionirrigation (two or more tubes)

Chemical decortication (fibrinolysis)

Debridement

Open

VATS

Decortication (Fowler-Delorme procedure)

Thoracoplasty without plomb

With plomb

Muscle

Omentum

Other

Open window thoracostomy

Eloesser flap and modificationsWithout flap (fenestration)

Combined procedures

Clagett procedure

Weder procedure

Fig. 1. Time-scale and overlapping of stages of thoracic empyema. The fog

function of an uncertain prehistory is intended as a fine adjusting element

helping to approach the theoretical origin of clinical events.

Fig. 2. Treatment modalities according to the therapeutic pathways: the

empyema diamond (Source: Molnar TF, Benko I: Management of primary

empyema thoracis. 4th European Conference on General Thoracic Surgery,

Cordoba, Spain, 1996, Abstract Book 059).

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74%[2628]. Common sense dictates that the more Stage Icases included in a series, the better the success rate. Seriesfocusing on subsequent surgeries report a 3665% failure rateof simple tube drainage [9,17]. The lower efficacy of themethod in trauma-related empyema thoracis reflects thehigh proportion of Stage III cases and low-risk youngerpatients[19]. The mortality of thoracic empyema treated by

drainage ranges is at 1124% [3,9,10,28,29].Improving the efficacy of the drainage by irrigation is a

well-established technique[30], either by cyclic (alternativeor tidal) or continuous (two or more tubes, suctionirrigationsystems) irrigation[31,32]. Only anecdotal reports exist withregard to the solution. Saline is the more widely usedsubstance to dilute the causative organisms and to evacuatethe debris by washing out. Iodine and derivates areextensively used on the continent but not approved in thisapplication in the British National Formulary [33]. Strictlyspeaking, the practice is based on historical observations likethe Carrell-Dakin method [30] and personal conviction.Efficacy of local antibacterial treatment lacks firm evidence,but again there are no reliable arguments against those

positive anecdotal observations based on plausible assump-tions. It is agreed that a positive culture and antibiogram arethe sine qua non of this sort of therapy[34].

Personal experiences, conventions, training, schooling,conviction and accessibility of technicalities, manpower(nursing) are the variables of the details of this technique. Inthis rich field of individual approaches with firm convictions,controlled data are scarce. It is obvious that the moresophisticated an empyema treating system is, the higher thechance for a successful outcome. It may be related to theamount of devotion to the patient and the system rather thanthe real difference in efficacy of the methods.

Site of drainage (dependent point) and number and size of

drains are empiric. Where numbers are available, Ch28 seemsto be the accepted lower gauge, but Ch32 or over is notuncommon either. Neither question of pain control nor ofphysiotherapy as factors influencing the quality of life andoutcome was raised specifically in any of the referredmaterial[2534]. The force and the type of the suction, thetube setting and specification of systems used are among theunexplored details. According to (2b) level evidences [20]drainage is usually a first-line therapeutic modality. On rareoccasions permanent tube thoracostomy can provide a finalsolution when others failed[35].

3.2. Fibrinolysis, enzymatic/chemical decortication

Breaking the septa of the empyema cavity and degradingthe devitalised, necrotic mass covering the inner surface byintrapleural instillation of streptokinase in order to make itaccessible for drainage was initially described by Tillet et al.in 1951[36].

Contrary to previous convincing reports [4] recent (1a)level evidence did not find enzymatic decortication [5]superior to tube thoracostomy treatment. On the other handat (2a) level the success rate with ICC alone versus ICC andstreptokinase were 67.1% versus 87.7%. Multiple regressionanalysis has proven fibrinolysis as a sole independent factorfor better outcome [37]. Where Stage III empyema caseswere excluded, similar results were reported[9]. All of the

above listed procedures share the advantage of localanaesthesia. They are considered to be minor surgeries,despite presenting the maximum of agressivity the individualpatient can cope with in a non-negligible portion of thecohorts.

3.3. Video-assisted empyema surgery (debridement/

evacuation)

In this group of procedures misnomers flourish. Evacuationof necrotic material from the cavity, essentially from theparietal wall, is, by definition, debridement. Decortication, aprocedure known since 1885[30,38,39] the peeling of theorganised coat of the visceral pleura is the very essence ofthe operation. Papers heralding VATS decortication [40,41]uniformly fail to demonstrate in their Methods section that astandard Fowler-Delorme procedure was performed. Thismanoeuvre is a technically demanding procedure even underdirect tactile and full visual control. Therefore, it seems tobe reasonable to discuss all video-assisted clearings hereunder the title of evacuation in which debridement [42] is the

core of the procedure, irrespective of their own usage ofterminology. Pathoanatomy offers the evidence, as there isno distinctive and, therefore, removable cortex prior to atleast the first 4 weeks [24,40].

From the mid-1990s, thoracoscopic evacuation ofempyema sac has gained popularity[42]. Subsequent papershave supported the original observations and notes onlimitations[40]. Success rate ranges from 68% to 93% (from(2b) to (3b)) [17,21,4043], and seems to be in closecorrelation with the composition of the investigated patientgroup. The more the Stage III empyema or in general, thelonger the anamnesis the higher the failure rate[17,44],necessitating further surgery such as decortication, open

window thoracostomy and thoracoplasty, in order offrequency. The conversion rate is 58%[40,42], and is 1025% of a second-stage, open decortication [40,41]. Patientswith a history shorter than 4 weeks had a good chance to becured by VATS alone [40,42] while histories over 5 weeks(presumed Stage III) tended to necessitate a decortication[17,21,42] (3b). Preselection bias interferes with theoutcome rather than treatment modalities themselves.

There seems to be an undisputed superiority of VATSprocedures as far as early posttraumatic cases are concerned[41,43]. Evidence (3b) suggests that following a failed tubethoracostomy a VATS evacuation is more beneficial than afteran interim attempted fibrinolysis [21]. An ultrasonic devicewas recently published[44], which can improve the efficacy

of the breakdown manoeuvres during VATS debridement.The quality of the underlying lung is a decisive factor in

outcome. Potential for restitutio ad integrum restoringthe original parenchyma volume in order to fill the space isthe key element. Evacuation of infected posttraumaticeffusion facilitates quick re-expansion of the healthyunderlying lung, a significantly different situation from alung recovering from a lobar pneumonia. Underlying diseasessuch as cancer and tuberculosis, either debilitating the recoilcapacity of the lung tissue or destroying the barrier functionof the pleural surface, leading to bronchopleural fistula likeemphysema and other conditions resulting in honeycomblung, are the main factors responsible for failure. The 30-day




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mortality of the patients treated by this modality is 3.44.2%[17,21,27,31,40] .

3.4. Open surgical methods for empyema

3.4.1. Decortication

Decortication is the method of choice when the underlying

lung is unable to expand(trapped lung) due to theestablishedthick inflammatory coat and the patient is fit enough formajor intervention. Decortication, a procedure originallyused for the treatment of tuberculotic and posttraumatic-trapped lung [2,30], relies on lung elasticity in order to fill thecavity, freeing the encased parenchyma from the compres-sing inflammatory coat. Where the case history is longer than6 weeks, which is equivalent to a Stage III disease, therecommendations are concordant, if the patient is fit forsurgery [10,26]. The majority of the Fowler-Delormeprocedures are performed for Stage III postpneumonicempyema [21,45] or following trauma [19,26]. Stage IIIempyema reduces lung perfusion to 2025% on the involvedside. Decortication can double this value and improve vital

capacity from 62% up to 80% and FEV1 from 50% to 69%. Inspite of improvement in values, the function of the affectedlung remains impaired [46]. The remaining ventilation/perfusion mismatch is due to multilevel functional lungdamage [47]. In patients with a longstanding posttubercu-lotic collapsed lung with minimal perfusion, decorticationcan be attempted but the outcome is unpredictable [48]. Asfar as the patient is symptomatic, the benefit of theprocedure is proven (2b) [4549]. However, decorticationis not indicated and observation is warranted for asympto-matic patients[50].

Patients undergoing VATS for empyema are likely to beconverted to open procedure (i.e. decortication) in 3.840%

depending on the delay in decision even as early as in Stage II[17,51]. There is a recent shift to muscle-sparing (axillary)thoracotomy, narrowing the agressivity gap between VATSand open surgery. Bronchopleural, pleurocutaneous fistulamight necessitate additional parenchyma sparing lungresection in up to 10.1% of the cases [21].

With respect to the aetiology, up to 80% of posttraumaticempyema requires formal decortication [19,41]. Reoperationrate after failed decortication is half of that following VATSprocedure. The mortality of decortication is 1.36.6%[26,29,50].

3.4.2. Thoracoplasty

Collapse therapy remodelling the osteomuscular wall of

the thoracic cage in order to control the underlyinginflammatory process was among the first effectivethoracic surgical procedures [52]. In modern times, theaim of the procedure is space filling: either by diminishing thedistance between the lung parenchyma by collapsing the roofof the chest and/or filling the space with viable tissue(omentum, muscle transposition). This procedure can beperformed alone or in combination with other modalities,like re-do stump closure. In spite of modern prosthesistechnology, no recent reports [53] are available oncontemporary usage of non-biological plombage. Propersurgical technique and planning are needed to avoiddeformities like scoliosis and other related consequences

[54]. Unresponsive cases to less aggressive multiple treat-ments may obviate the need for thoracoplasty [52,55].Thoracoplasty with or without myoplasty is a viableconsolidating step in sequential empyema surgery. Previousprocedures include fenestration in 1772% to sterilise thecavity [5658]. Postpneumonectomy traction diverticulumcaused oesophagopleural fistula was treated by fenestration

followed by thoracoplasty [56]. Thoracomyoplasty wassuccessfully applied in simultaneous bronchopleural andoesophagopleural fistulas after pneumonectomy [59]. Theusual problem of the plombage, the too small volume offilling material, can be solved by plastic surgical methods[60,61]. Combination of thoracoplasty and omental pedicledflap for chronic empyema due to bronchopleural fistula (BPF)can achieve an 82.6% success[57](3b). In selected cases it isa first-line procedure rather than being a last resort whenevery previous attempts failed[52](3b). The 11% failure rateincludes those who will carry on with permanent thoracost-omy [55]. The overall mortality in these low case numberseries is about 4.35% [55,57,62].

3.4.3. Open window thoracostomy (OWT)/fenestration/empyema marsupialisation

For debilitated patients with thoracic empyema, thor-acoplasty is not a viable alternative and as tube thoracost-omy with or without VATS debridement would fail to controlthe disease, open window thoracostomy should be offered[12]. Marsupialisation of the cavity via rib(s) resection andopen drainage is a well-established [62,63] method of lowrisk. Consequences concerning quality of life in patients withOWTremain unexplored so far. It is the choice of treatment ifthere is a permanent supply of causative organisms due tobronchopleural fistula (BPF). It can be applied either as adefinite treatment with intent to cure, a preliminary

procedure prior to definite treatment [58,64] or as a lastresort procedure when others have failed to achieve arelatively stable disease [35,65]. Muscle transposition isproposed as the space becomes sterile-cleansed [61,66].Recurrent cancer, poor function and persisting local infec-tions are common causes of open window failure [67].

In contemporary thoracic surgical practice the post-operative empyema, usually with BPF, is the main indication[13,34]of the procedure, and is relatively rare (even as lowas 3%) in postpneumonic, primary thoracic empyema cases[21,17]. This is an externalisation via unroofing the empyemacavity at the dependent point. The originally intended valvemechanism of the Eloesser flap, introduced in 1935 [63],went through several modifications, reaching the present

form, where the inverted flap attached to the floor of thecavity gets daily packings[68].

Altogether, 210% of pneumonectomies [35,68] arefollowed by development of a bronchopleural fistula.Postpneumonectomy thoracic empyema is a result ofbronchopleural fistula in 80100% of the cases [56,69,70],with a mortality ranging between 5% and 25% on average[66]with up to 40% if pleuropneumonectomy is performed [71]with a maximum value of 75% [35].

The (3b) level evidences are uniform in differentiating anddecision-making according to the acuteness of the clinicalpicture. Half of the BPFs develop within 4 weeks followingsurgery [69]. Right- sided BPF develops in 75100%




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[64,66,67,70,72] of the cases. The closer the onset of thestump insufficiency is to the time of surgery, the worst theprognosis [64,70]. Immediate postoperative bronchopleuralfistula (within 1 week), resulting in acute empyema thoracis,usually presents as a fulminant Stage II disease. This dramaticclinical picture of impending sepsis necessitates a promptdecision. Removal of toxic material and control of supply line

of the infected agents are the aims to be achieved by thesurgical interventions.

Clagetts procedure [69,70,72,73] is the best-evidenced(3b) method for historical reasons. The complex procedureconsists of open pleural drainage, serial operative debride-ment and eventual chest closure after filling the pleuralcavity with antibiotic solution [70]. Window making,fenestration, is part two of the procedure [34]. Dailyirrigation with antibiotics [69] or regular open packingscomplete the procedures. Observational studies prove thattiming of initiation of therapy is crucial. When reoperationwas within 12 h even 100% success rate was reported.Realistically, a one-in-four mortality [64]can be expected.The temptation to not use thoracostomy was proven to be a

risk factor [64]. Early thoracostomy allows time forimprovement of nutritional status increasing the chancesof a successful operative closure. Muscle flap coverage of thestump or filling the resulted space is performed in 87% of thecases[70], leading up to a complete healing in 7581% of thecases [58,68,70].

As an alternative to the staged and time-consumingClagett procedures, Weder applies the repetitive thoracot-omy and debridement policy [74]. Stuffing the cleansedcavity with antiseptic packages and changing them regularlyare the essence of the method. This standardised concept ofrepeated debridement is applied equally to early and latepostoperative empyema in a sequential, pre-planned stan-

dardised way[75]. The premeditative repetitive pattern haspreviously proven its value in non-thoracic suppurative-necrotic processes like pancreatitis. This technique seems tobe applicable not only to treat but also to prevent empyemain high-risk procedures like completion pneumonectomy forinfective diseases[76].

Solution of chronic or late postoperative empyema alsoconsists of drainage, debridement, closure of BPF whenpresent and space obliteration[76,77]. Onset of BPF laterthan 15 weeks is an independent predictor of a positiveoutcome [70]. BPF smaller than 3 mm may respond tothoracoscopic debridement alone or in combination withopen window thoracostomy [76]. Operative closure of thebronchial stump can be performed via the previous

thoracotomy or transsternally using a transpericardialapproach[64,77]. Re-amputation of the stump or, on rareoccasions, carinal resection is anecdotally reported. Remo-delling the osteomuscular chest wall and/or facilitation ofgranulation, further on external tissue plombage, are themethods of space management as were discussed above.Chronic fistulas frequently require two or more procedures[58,66,67]. Decision-making can hardly be overselective. Onthe lower end of surgical agressivity with regard to BPFtreatment, local filling of the hole is reported in cases oflimited dehiscences measuring maximum 35 mm. Theselimited case series consist of manoeuvres relying on localtissue healing potentials with time-gain for scar formation.

Transbronchial methods include glueing [78] or chemicalcauterisation [79]. The logical solution of expandablecovered metallic stents [80,81] is anecdotally reported.Unfortunately, no recent evidence is available with Millspositivenegative pressure balance bottle-system[82].

4. Discussion

In the present review [83] of the observed outcomesfollowing different treatment modalities, patient selection,cohort size, methods of randomisation and so on were notscrutinised in the study, which definitely weaken the powerof the conclusions. Generally, the information available fromthe publications does not allow a clear differentiation in howmuch of the treatment effect is due to actual treatmentdifferences and how much is due to the assignment of thepatients to selective treatment modalities.

The very few controlled trials on this topic came up withconflicting results[4,5]. The relative lack of RCTs, reportsconsidered as basics for clinical standard, does not mean that

the mass clinical experience collected on this topic [1,5,982] would not be able to serve as a proper guideline. Thereports reviewed, providing usually level (3b) or belowevidences, still fit into a harmonious picture. The lack of asingle ideal treatment modality or policy reflects thecomplexity of the diagnosis and staging of this heterogeneousdisease. Decision-making protocols cannot function withoutclear and unmistakable categories. Basic elements ofintervention drainage, different evacuation techniques,decortication, thoracoplasty, open window thoracostomy are well-established technical modalities; however, neither auniversal primary modality nor the gold standard of theirsequence is available.

The optimally aggressive treatment modality should betailored to the condition of patients and to the healingpotential of the persisting cavity. Decision-making relies onthe triad of the aetiology of empyema (PTE vs STE), generalcondition of the patient and actual stage of disease,considering the triphasic nature of it. The basic differencesin the behaviour of naturally developing empyema cavity(i.e. postpneumonic) and of those infected spaces that havefollowed the removal of lung parenchyma dictate the choiceof procedure (Fig. 3). Existence or lack of dead space withinthe pleural cavity is the definite distinction and decisivefactor influencing outcomes following different therapeu-tical attempts. No effective infection control can beexpected in the presence of an active cavity. The law of

Nature horror vacui rules on these fields, too.


Fig. 3. Connection between the stages of thoracic empyema and the best-

evidenced methods of choice. The theoretical time-scale is not necessarily

identical to the documented duration of the disease of the individual patient.

The graphical representation is not intended to be considered as an absolute

and exclusive scheme.



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There are two main sources of the bias limiting the dailyroutine applicability of the (3b) reports. Preselection ofpatients into different modality groups a priori influencesoutcomes: the results are mirroring the attitude of thesurgeon/team rather than the distance of the investigatedmethod from the ideal treatment. In postpneumonicempyema, the surgeons problem starts with the timing

and circumstances of referral: called to see the empyemapatient only when other (i.e. conservative) methods failed;only not to mention the case, when the typical empyemapatient is referred to surgical care on a Friday afternoon,preferably on a long weekend. The highly selected cohort ofpatients with unreliable information on the origin of theprocess explains the uncertainties around the value of theindividual procedures on the surgical pathway. In the averagepaper, a hierarchy of methods is evaluated and with rareexceptions, the actually presented method is proven to bethe best.

The problem with postresectional thoracic empyemapatients is similar. The higher the risk they have prior to theoriginal operation, the higher their failure rates for less

aggressive modalities when thoracic empyema develops. Thefragility of these patients means that rather than operability,resectability is their burden.

Drainage remains to be the initial treatment modality inStage I disease. The weight of additional elements in success/failure such as suction tactics, physiotherapy and nutritionalstatus needs further clarification. There is no territory in ourtopic, where the devil in the details rule would be stronger.The number of drains, their size, location, details ofmanagement and caring at multilevel, i.e. doctoral, nursingand physiotherapeutic, and of timing, frequency andduration of the exact manoeuvres are neglected aspects ofstudies. Debridement via VATS is a safe, reliable and efficient

method in Stage II cases. VATS is not limited exclusively toStage II disease. Video techniques have a role in Stage IIIthoracic empyema, too, as far as evacuation is concerned.

Organised pleural callus or cortex (Stage III) requires opensurgery: formal decortication. A persisting cavity is achallenge without a single and uniform solution (Fig. 4).Open window thoracostomy, either through limited thor-acotomy or VATS, represents a simpler and, therefore, saferprocedure than thoracoplasty.

It is a valuable procedure as an initial step in cavitymanagement and a unique and definite one for high-riskpatients, too. Thoracoplasty, the conventional collapseprocedure, lost its popularity against the alternativetechniques, i.e. decortication and thoracostomy, but it has

its final step role in pleural space management when othermethods failed. Using aggressive methods in space sterilisa-tion and obliterative techniques (pedicled muscle oromentum plombs) with preservation of the first rib in caseof destroyed lung seems to be worthwhile to consider it as areal alternative.

Acute postoperative bronchial stump insufficiencyrequires immediate surgery, but to what extent? Evacuationof toxic material is mandatory. Closed drainage, openwindow thoracostomy, repetitive thoracotomies and cavitypacking are equally viable options. Stabilised patientsbenefit from the attempts of surgical closure of the dehiscentstump. No single-stage procedure offers solution.

Irrespective of the above detailed differences in specificfeatures of thoracic empyema, the basic rules for treatmentremain the same:

(1) complete evacuation of the content of infected space(2) elimination of cavity(3) control of causative organisms/sterilisation(4) forced auxiliary treatment such as aggressive physiother-

apy, nutritional support in every phase of treatment.

5. Conclusion

Summarising the current divergent attitudes towards thiswell-known entity of a sinister natural history one can saythat thoracic empyema shows that present concepts arebased mainly on the somehow paternalised OCEBM categoriesof level (3b) and expert opinion in the family of theevidences. Attempts of applicable risk stratification havefailed so far; therefore, no other option than highlyindividualised approaches can be recommended. The thor-

acic surgeon should command all the possible techniqueswithin their limitations to adjust it to his/her individualpatient [84]. Flexibility and patience on behalf of thesurgeon, nursing staff and the patient furthering theendeavour of hospital management to understand thecomplexity of this condition are the cornerstones of thetreatment. Thoracic empyema is an eminent example, thatno established method can be neglected by putting oursurgical heritage on the dusty shelves of a distant corner.

Thoracic empyema, a wolf in a sheepskin, does not allowrecommending a clear single sequence of procedures leadingto a uniformly predictable successful outcome. Institutionalpractice, local protocols based on past experience and


Fig. 4. Approaches of the persisting space problem: (1) internal closure of BPF

(endoscopic methods); (2) external closure of BPF (re-amputation, coverage);

(3) diminishing the remaining space by de-roofing the musculoskeletal struc-

tures (thoracoplasty); (4) space occupying by muscle/omentum transposition

(plombage); (5) establishing a persistent orifice (window/tube).



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individual case management with a flexibly optimisedsequence of procedures may offer the best outcome.

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DOI: 10.1016/j.ejcts.2007.05.0282007;32:422-430Eur J Cardiothorac Surg

Thomas F. MolnarCurrent surgical treatment of thoracic empyema in adults

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http://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422http://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422http://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422http://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422#BIBLhttp://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422#BIBLhttp://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422#otherarticleshttp://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422#otherarticleshttp://ejcts.ctsnetjournals.org/cgi/collection/pleurahttp://ejcts.ctsnetjournals.org/cgi/collection/pleurahttp://ejcts.ctsnetjournals.org/cgi/collection/pleurahttp://ejcts.ctsnetjournals.org/cgi/collection/lung_otherhttp://ejcts.ctsnetjournals.org/cgi/collection/lung_otherhttp://ejcts.ctsnetjournals.org/cgi/collection/lung_otherhttp://ejcts.ctsnetjournals.org/misc/Permissions.shtmlhttp://ejcts.ctsnetjournals.org/misc/Permissions.shtmlhttp://ejcts.ctsnetjournals.org/misc/Permissions.shtmlhttp://ejcts.ctsnetjournals.org/misc/reprints.shtmlhttp://ejcts.ctsnetjournals.org/misc/reprints.shtmlhttp://ejcts.ctsnetjournals.org/http://ejcts.ctsnetjournals.org/http://ejcts.ctsnetjournals.org/http://ejcts.ctsnetjournals.org/misc/reprints.shtmlhttp://ejcts.ctsnetjournals.org/misc/Permissions.shtmlhttp://ejcts.ctsnetjournals.org/cgi/collection/pleurahttp://ejcts.ctsnetjournals.org/cgi/collection/lung_otherhttp://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422#otherarticleshttp://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422#BIBLhttp://ejcts.ctsnetjournals.org/cgi/content/full/32/3/422

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