World J Surg (2011) 35:981–984 DOI 10.1007/s00268-011-1035-5
Approach to Empyema Necessitatis ¨ rki • Tu¨lay O ¨ rki Asli Gu¨l Akgu¨l • Alpay O • Mustafa Yu¨ksel Bu¨lent Arman
•
Published online: 15 March 2011 Ó Socie´te´ Internationale de Chirurgie 2011
Abstract Background Thoracic empyema is a collection of pus in the pleural space. Empyema necessitatis is a rare complication of empyema, characterized by the dissection of pus through the soft tissues of the chest wall and eventually through the skin. We present nine cases of empyema necessitatis, including etiology, duration, and characteristics of clinical history, kind of surgery used, and treatment choices. Methods In a 4-year period nine patients were treated for empyema necessitatis. Six were male and 3 female with an age range of 13–89 years (median = 40 years). Results Empyema necessitatis was treated with drainage and antibiotherapy or antituberculosis therapy in three patients with the diagnosis of tuberculosis or nonspecific pleuritis. Decortication of the thoracic cavity was used in three patients successfully. Others were treated with open drainage. Final diagnoses were tuberculous empyema in five patients, chronic fibrinous pleuritis in three, and squamous cell carcinoma in one. Except for two patients, one with
A. G. Akgu¨l (&) Thoracic Surgery, Kocaeli University Faculty of Medicine, Kocaeli, Turkey e-mail:
[email protected] ¨ rki B. Arman A. O Thoracic Surgery, Maltepe University Faculty of Medicine, Istanbul, Turkey ¨ rki T. O Anesthesia and Reanimation, Kartal Kosuyolu Heart and Research Hospital, Istanbul, Turkey M. Yu¨ksel Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
multisystem failure and one with squamous cell carcinoma, all were discharged with no complications. Conclusion Surgery plays a critical role in the management of empyema necessitatis in selected patients. Tube drainage, open drainage, and decortication are the choices in variable conditions for obliterating the cavity and regenerating pulmonary function. Introduction An empyema is a collection of pus in a natural body cavity. One of the most common varieties of empyema is empyema thoracis, which can be localized at or involve the entire pleural space [1]. There has been little change in the management of suppurative lung and pleural disease in the last two decades. The number of cases of tuberculous empyema has decreased over the past few decades, but it has not been eradicated. Although the problem is better managed now with the development of potent antituberculous medication, especially in third-world countries, the increasing number of immunosuppressed patients with HIV and transplantations and the increasing use of postchemotherapy for cancer have led to the development of more cases of tuberculosis. Empyema necessitatis is a rare complication of empyema that is characterized by the dissection of pus through the soft tissues of the chest wall and eventually through the skin [1–5]. We present nine cases of empyema necessitatis, including etiology, time and characteristics of clinical history, kind of surgery used, and treatment choices. Materials and methods In a 4-year period nine patients with the diagnosis of empyema necessitatis were treated (Table 1). Six were
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Table 1 Patients’ characteristics Patient
Sex
Age
Side
CH
1
M
37
R
10
Radiology
Final procedure
Diagnosis
DD
Parenchymal infiltration
Decortication
Tuberculous pleuritis
7
[10 mm pleural thickness 2
M
26
R
5
\10 mm pleural thickness
Tube drainage
Chronic pleuritis
9
3
M
75
R
60
[20 mm pleural thickness
Open drainage
Tuberculous pleuritis
–
Decortication
Chronic pleuritis
8
Open drainage
Chronic pleuritis
–
Decortication
Tuberculous pleuritis
10
Tube drainage
Tuberculous pleuritis
11
Tube drainage
Tuberculous pleuritis
–
Open drainage
Squamous cell carcinoma
–
Calcification Volume loss Parenchymal infiltration Atelectasis 4
M
17
R
11
[10 mm pleural thickness
5
F
89
L
36
[20 mm pleural thickness Volume loss
6
F
40
L
12
[10 mm pleural thickness
Atelectasis
Atelectasis Parenchymal infiltration Loculated area 7
M
13
R
1
\10 mm pleural thickness Parenchymal infiltration
8
M
85
L
6
\10 mm pleural thickness
9
F
55
L
5
[20 mm pleural thickness
Parenchymal infiltration Atelectasis CH clinical history (months); DD duration of drainage (days)
and pulmonary tuberculosis 50 years ago. One patient was treated for pleuritis 5 months prior, and one patient was treated for pleural effusion 20 years ago. One patient had undergone a pneumonectomy because of a destroyed lung due to tuberculosis 25 years ago. Finally, one patient had a history of spontaneous pneumothorax treated with tube drainage 6 years ago.
Results
Fig. 1 Physical view of empyema necessitatis (subcutaneus bump)
male and 3 female with an age range of 13–89 years (median = 40 years). They were admitted to the hospital with complaints of a subcutaneous bump (Fig. 1) (n = 9), cough (n = 6), pain (n = 3), sputum (n = 3), fatigue (n = 2), fever (n = 1), and dyspnea (n = 2). Two patients had a history of pulmonary infection that was treated with nonspecific therapy 5 years before presentation. Two patients had a history of pleural thickness
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All patients were evaluated carefully and diagnosed clinically, radiologically, and with needle aspiration. Physical examination, clinical history, blood and sputum tests, chest X-rays at the posteroanterior and lateral positions, spirometry, and thorax computed tomography (CT) were examined carefully. Chest roentgenograms showed opacity of varying degrees on the affected side. Thorax CTs demonstrated atelectasis, parenchymal infiltrates, pleural thickness of varying size, and volume loss in some cases, and a thick, well-encapsulated, calcified pleural rind and loculated fluid with a fistula connecting the thoracic cavity and empyema with subcutaneous tissue in all (Fig. 2). Fine-needle aspiration was used in all patients and aspirated material was taken from the cavity filled with the
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Fig. 2 Thoracic CT of empyema necessitatis
loculated fluid. Empyema was demonstrated macroscopically. Cytological and bacteriological examinations were done using a routine procedure to determine etiological factors. We could not identify the specific tuberculosis agent from the thoracentesis results. Chest tube drainage was first applied to all patients. Empyema necessitatis was successfully treated with only tube drainage and antibiotherapy in two young patients. Duration of drainage was 9 and 11 days, respectively. Surgical treatment of three patients consisted of partial decortication of the thoracic cavity. This was successful when the expansion defect persisted for more than 7 days, since the patients were young and had no parenchymal pathology or sign of chronic disease like dense calcific plaques, decrease in thoracic volume, or destroyed lung. Two elderly patients were treated with open drainage since they had parenchymal diseases and a long clinical history. One patient died because of his existing multiorgan failure during observation with a chest tube, and the last patient who was treated with open drainage had a final diagnosis of carcinoma and died from respiratory failure. We applied open drainage by inserting a soft, large chest tube following partial resection of one or two ribs. Pleural irrigation with 500 cc of saline solution was applied to all patients via the chest tube twice a day, with the aim of mechanical debridement and facilitating the drainage of the dense empyema fluid. Final diagnoses were tuberculous empyema with cultures positive for Mycobacterium tuberculosis in two patients, tuberculous pleuritis in three patients, chronic fibrinous pleuritis in three patients, and squamous cell carcinoma in one patient. In two patients with chronic pleuritis, Pseudomonas aeroginosa was detected in cultures of surgically resected pleural specimen. Antituberculosis drugs were added to surgery in patients with the diagnosis of tuberculous empyema.
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All but two patients were discharged from our clinic with no complications. One of the patients treated with chest tube drainage died because of serious multiorgan failure, and another patient with carcinoma died from respiratory failure. Tube thoracostomy was the initial procedure used for treatment, especially in young patients who had minimally thickened pleura with no parenchymal damage, no specific medical history, and short duration of disease (\12 months), and in elderly patients in poor physical condition. In young patients with chronic disease who had pleural thickness, tube drainage was not enough, so decortication was applied to obliterate the space. For elderly patients with a serious chronic pathology and parenchymal calcific lesions, tube thoracostomy followed by open drainage was the preferred treatment modality. A rigid respiratory exercise program for all patients and antituberculosis medications for patients with the diagnosis of tuberculosis were prescribed in addition to the invasive procedures. Median follow-up period was 52 months (range = 1–76). In this follow-up period we examined the patients twice a month for the first 3 months, then once a month up to a year, then twice a year. In their follow-up controls, chest X-rays and sputum tests were applied. Antituberculosis therapy with clinical investigation of related patients was observed by pneumologists. Six patients were alive at the end of follow-up and there was no recurrence. The elderly patient treated with open drainage died from cardiac disorder during his follow-up period.
Discussion The earliest description of the diagnosis and treatment of empyema is attributed to Hippocrates who, approximately 2400 years ago, first noted that one could distinguish between empyema and hydrothorax by auscultation of the chest, and that proper treatment of empyema required adequate drainage by means of either an intercostal incision or rib resection [5, 6]. Infections, both thoracic and extrathoracic, can invade the normally sterile pleural space and lead to the development of an uncomplicated parapneumonic effusion, a complicated parapneumonic effusion requiring tube thoracostomy for its resolution, or a pyogenic collection referred to as an empyema. Although empyema affects patients of all ages and social classes, they appear to occur more frequently and with more devastating consequences among the elderly and debilitated. Commonly associated illnesses include neoplasms, pulmonary diseases, cardiac disorders, diabetes mellitus, alcoholism, drug abuse, and immunosuppression [7].
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Since the advent of antituberculous chemotherapy and preventive medicine, tuberculous empyema has become an uncommon disease, and thus empyema necessitatis has become extremely rare. Empyema necessitatis occurs when an encapsulated empyema erodes through the parietal pleura and discharges its contents outside the pleural cavity [1, 8]. Tuberculosis is more likely to give rise to empyema necessitatis than abscesses produced by other pyogenic organisms because of the chronicity of tuberculous empyema. The most common site of empyema necessitatis is the subcutaneous tissue of the chest wall. Other sites that are sometimes involved include the esophagus, vertebral column, retroperitoneum, pericardium, flank, and groin [2]. A careful clinical examination with radiologic techniques, especially CT images, can be very useful in diagnosis. Surgery plays a critical role in the treatment of empyema in selected patients. In the management of empyema necessitatis, physical condition, age, duration of symptoms, etiology, and existing parenchymal pathology play important roles in deciding what type of surgery to use. Careful physical and radiological examinations with a detailed clinical history and laboratory tests are important. Cytological and microbiological examinations of the material aspirated from the cavitary subcutaneous lesion relating with thorax is the important part of etiological diagnosis. Use of a chest tube must be the first approach for treatment. If the expansion failure persists after at least
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7 days after simple drainage, we believe that decortication is necessary to obliterate the cavity and regenerate pulmonary function in young patients with no parenchymal disease, dense calcifications, progressive reduction in volume, and no comorbidities. We also think that open drainage in older patients with destroyed parenchyma and a history of chronic disease is the best surgical procedure.
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