Chest
Volume 128, Issue 5, November 2005, Pages 3303-3309
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Clinical Investigations: PLEURAL DISEASE
Treatment of Sonographically Stratified Multiloculated Thoracic Empyema by Medical Thoracoscopy

https://doi.org/10.1378/chest.128.5.3303Get rights and content

Introduction: In cases of empyema, some form of intervention, either chest tube drainage, thoracoscopy, video-assisted thoracic surgery (VATS), or thoracotomy, with or without pleural fibrinolysis, is required. What the best approach is and when and how to intervene is a matter of debate.

Study objective: To analyze the safety and outcome of medical thoracoscopy in the treatment of multiloculated empyema.

Methods: We report a retrospective series of 127 patients with thoracic empyema treated with medical thoracoscopy from 1989 to 2003 in three hospitals in Switzerland and Italy. All patients had multiloculated empyema as identified by chest ultrasonography. In the absence of multiloculation, or in case of fibrothorax, simple chest tube drainage or surgical VATS/thoracotomy were performed, respectively.

Results: Mean age ± SD was 58 ± 18 years (range, 9 to 93 years). In 47%, a microbiological diagnosis was made. Complications occurred in 9% of patients (subcutaneous emphysema, n = 3; air leak of 3 to 7 days, n = 9). No mortality was observed. Forty-nine percent of patients received postinterventional intrapleural fibrinolysis. Medical thoracoscopy was primarily successful in 91% of cases. In four patients, the insertion of an additional chest tube or a second medical thoracoscopy was required. Finally, 94% of patients were cured by nonsurgical means. Six percent of patients required surgical pleurectomy, mostly through thoracotomy.

Conclusion: Multiloculated empyema as stratified by ultrasonography can safely and successfully be treated by medical thoracoscopy.

Section snippets

Study Design and Patients

We performed a retrospective case chart review in three departments of pulmonology (Basel, Switzerland; Brescia, Italy; and Montana, Switzerland). From 1989 to 2003, all files of patient referred for multiloculated pleural empyema and treated by medical thoracoscopy were reviewed. Empyema was defined as frank pus on thoracocentesis with or without positive smear and bacteriologic culture findings, or pH < 7.2 with signs of infection. The diagnosis had to be confirmed by chest radiography, and

RESULTS

A total of 127 patients with multiloculated pleural empyema were included in the study, of whom 73% (93 of 127 patients) were male. Mean age was 58 ± 18 years (range 9 to 93 years). The etiology of multiloculated pleural empyema is given inTable 1. In 60 of 127 patients (47%), a microbiological diagnosis could be made (Table 2). The patients received antibiotic treatment prior to medical thoracoscopy for a median of 8 days (range, 0 to 73 days; n = 42). In 91% of cases, the duration of

DISCUSSION

Our study shows that multiloculated pleural empyema stratified by chest ultrasonography can safely and successfully be treated with medical thoracoscopy. In our 127 patients, no deaths and no chronic morbidity related to empyema were observed.

Like most of the published studies on pleural empyema derived from a case series,3 patient selection and treatment biases cannot be excluded in this retrospective study. Over the study period, advances in the medical treatment of empyema were made

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