Presentation on theme: "PLEURAL EMPYEMA Department of Thoracic, General and Oncological Surgery Medical University of Lodz Head of the Department: Prof. Marian Brocki Szanowni."— Presentation transcript:
1PLEURAL EMPYEMADepartment of Thoracic, General and Oncological Surgery Medical University of LodzHead of the Department: Prof. Marian BrockiSzanowni PaństwoKorzystając z okazji spotkania na dzisiejszej konferencji pozwoliliśmy sobie poruszyć zagadnienia resekcji tchawicy w zwężeniach pointubacyjnych z dwóch powodów:po pierwsze w ostatnich latach ukazało się niewiele doniesień zarówno w krajowych piśmiennictwie jak również prezentacjach zjazdowych dotyczące tego zagadnieniapo drugie w naszej klinice wznowiono powtórnie wykonywanie tych zabiegów po przerwie trwającej ok. 8 lat wynikającej z różnych perturbacji. Zabiegi te wykonywano w naszej Klinice z powodzeniem wcześniej w latach tych pod kierunkiem prof. Stanisława Barcikowskiego.Nasz aktualny materiał jest bardzo skromny liczy bowiem 5 przypadków stąd też naszą intencją było w zasadzie przypomnienie wskazań i zasad wykonywanie resekcji tchawicy oparte na przeglądzie piśmiennictwa oraz omówienie na tym tle operowanych przez nas przypadków.Author of the lecture: Sławomir Jabłoński, MD
2or DEFINITION Pleural empyema thoracic empyema The inflamatory process in a preformedanatomical space defined by the visceraland parietal pleura
3Incidence & epidemiology Empyema is the presence of gross pus in the pleural cavity; it consists of an effusion containing polymorphonuclear leukocytes and fibrin.The Greek philosopher, Aristotle, recognized empyema and described the drainage of pus with incision and a metal tube as early as 300 BC.A parapneumonic process is defined as a pleural effusion associated with pneumonia, lung abscess or bronchiectasis.Not all parapneumonic processes are empyemas.
4PLEURAL EMPYEMA (empyema pleurae) Pleural empyema is a kind of exudative pleuritis causedby microorganisms (bacteria, fungi, some protozoa) that infectedthe pleural cavity.Inflammation of organs or anatomical structures localized withinthe chest and out its anatomical borders can caused a retentionof effusion in the pleural space (hydrothorax)A reason for pleural effusions are also systemic diseases.Initially sterile exudate can be resorbed by the pleura if a primarydisease is treated effectively.The infection of the exudate causes its transformation into purulentliquid that fills the pleural cavity and forms pleural empyema(empyema pleurae).
5PLEURAL EMPYEMA (empyema pleurae) The presence of purulent liquid within the pleural cavity for severalWeeks leads to the formation of fibrin deposits on both the visceraland parietal pleura and an imprisoning fibrothorax appears (fibrothorax).Progressing empyema organization causes lung compressionand atelectasis, decreases lung volume and leads to inflammatory changeswithin pulmonary parenchyma.As a result ventilation and gas exchange disturbances are observed.Within a fibrinopurulent capsule (membrana pyogenes) a collectionof pus is frequently present. However, septic liquid has no contactwith adjacent tissue well supplied with blood that’s why a clinicalpresentation of empyema may be uncharacteristic and poorly expressed.
7PLEURAL EMPYEMA (empyema pleurae) CLINICAL CONDITIONS CAUSING LIQUID RETENTION IN THE PLEURAL CAVITY :TRANSUDATE - circulatory insufficiency, hepatic cirrhosis, nephroticsyndrome, superior vena caval obstruction.EXUDATE – malignancy, infection, pulmonary embolism, esophagealperforation, pancreatitis, sarcoidosis, systemic diseases.LYMPH (chylothorax) – trauma, surgery, malignancy, subclavian veinthrombosis.BLOOD (haemothorax) - trauma, malignancyIn a case when a liquid collected in the pleural space becomes infectedby virulent microorganisms it transforms into pus.Pleural empyema can develop in any individual but it seems to be morefrequent in younger people in whom immune system is weakened.
9PLEURAL EMPYEMA (empyema pleurae) The most frequent reason for pleural empyema are complicationsof pneumonia (parapneumonic empyemas) and other diseases of tissuesadjacent to the pleural cavity.An important etiological group for pleural empyema are complications of surgical treatment of pulmonary, esophageal and mediastinal pathologiesand frequent, repeated thoracocentesis for pleural effusion.Lung resections with incomplete postoperative expansion of the lungpromote the formation of a cavity that creates good conditions for liquidretention and its infection with bacteria from the bronchial tree, infectedpostoperative wound or drains.Complications of thoracic injuries and among them the infection ofnon-evacuated posttraumatic hemothorax are significant etiologicalfactors of pleural empyema formation.
10ETIOLOGY OF PLEURAL EMPYEMA Etiology % Purulent pneumonia50Lung abscess rupture1-3SepsisPulmonary tuberculosis1Mycotic lung infectionTrauma3-5Pulmonary, esophageal and mediastinal surgery25Subphrenic abscess8-11Bronchial fistula causing spontaneous pneumothorax< 1Complications of parasitic invasionOthers
12PLEURAL EMPYEMA (empyema pleurae) PATHOPHYSIOLOGY – ways of infection :DIRECT INFECTION through the chest wall as a result ofinjury, thoracocentesis or surgical management (postoperativepleural empyemas constitute approximately 25% of pleuralempyema cases)CONTACT INFECTION – infection spreads from underlyinginfected pulmonary parenchyma, lung abscess, bronchiectases,subphrenic or perinephric abscess.HEMATOGENOUS SPREADLYMPHOGENOUS SPREAD
13PLEURAL EMPYEMA (empyema pleurae) PATHOPHYSIOLOGYPHASES OF PLEURAL EMPYEMA FORMATION :Serous phase (exudative empyema): clear, straw-colored effusion(pH>7.3, glucose concentration [GLU]>60 mg%, lactatedehydrogenase activity [LDH] < 500 U/L )Fibrinopurulent phase (fibrinopurulent empyema): effusion containslarge numbers of bacteria and polymorphonuclear granulocytes,intensification of clinical signs and symptoms of inflammation,deposition of fibrin on both the visceral and parietal pleura ( pH < 7,1, GLU < 40mg%, LDH > 1000 U/L)Organizing empyema phase (organizing empyema) (fibrothorax) –nonelastic, fibrinopurulent coat that imprisons the lung appears.An empyema capsule contains pus.
17PLEURAL EMPYEMA (empyema pleurae) CLASSIFICATION OF PLEURAL EMPYEMAS :Etiological classification:specific (tuberculosis)non-specific – non-specific bacterial infectionmixedmycoticPathogenetic classification:synpneumonic – empyema coexists with another lunginflammationmetapneumonic – it develops when a primary inflammation hasalready regressed
18PLEURAL EMPYEMA (empyema pleurae) CLASSIFICATION OF PLEURAL EMPYEMAS :Size criterion:non-localized empyemas – the whole pleural cavity is involvedlocalized (encapsulated) empyemas - ( unilocular or multilocular)Duration and pathologic criterion :acute empyemachronic empyemaJatrogenic empyemas:empyemas with preservedpulmonary parenchymaempyemas after lung resection(pneumonectomy)with bronchial fistulawithout bronchial fistula
19PLEURAL EMPYEMA (empyema pleurae) CLINICAL PRESENTATION:ACUTE PHASE:hectic fevershiveringdyspneatoxemiachest paintachypnoëasthenialack of appetiteweight losschest wall inflammation(sometimes)leucocytosisanemiaexpectoration ofpurulent sputum ( if bronchial fistulacoexists)CHRONIC PHASE:subfebrile bodytemperaturecachexialow body massparoxysmal coughdyspneacontraction ofintercostal spacesscoliosischest painattenuation ofrespiratory murmurdullness of sound
20PLURAL EMPYEMA (empyema pleurae) DIAGNOSIS :characteristic clinical presentationfeatures of hydrothoraxin physical examinationchest X-raypleural ultrasonographycomputed tomographydiagnostic thoracocentesis ( macroscopic features of liquid, positive bacterial cultures, glucoseconcentration< 40 mg/dl, pH<7,0, LDH > 1000 U/L)flexible bronchoscopy (useful in a case of bronchial fistula)needle pleural biopsydiagnostic videothoracoscopydiagnostic thoracotomy
21PLEURAL EMPYEMA (empyema pleurae) ROENTGENOGRAPHIC APPEARANCE OF PLEURAL EMPYEMA :opacification of the costophrenic angle compatible with pleural effusion(the beginning of the disease)roentgenographic features of lung compression caused by effusion(Ellis-Damoiseau line)the presence of an empyema capsule, on a lateral projection empyemahas a D-like shape.the mediastinum is shifted to the contralateral side of the chestpneumothorax with airfluid level (if bronchial fistula is present)roentgenographic features of empyema and spherical opacification withinpulmonary parenchyma (empyema accompanied by lung abscess)
24LUNG EMPYEMA (empyema pleurae) TREATMENT :The treatment of pleural empyema depends on its etiology, duration,patient’s general state and concomitant diseases.The general rules of empyema management are as follows: evacuation ofpurulent liquid out of the pleural space, obliteration of the empyema sac andaugmentation of patient’s immune system.Ubi pus evacua - ,,if you find pus remove it”The goals of treatment in pateints with pleural empyema are :to save lifeto elimintae the empyemato reexpand the trapped lungto restore the mobility of the chest wall and diaphragmto return respiratory functionto normalto eliminate complications and chronicityto reduce the duration of hospital stay(Mayo P, Saha SP, McElvein RB. Acute empyema in children treatedby open thoracotomy and decortication. Ann Thorac Surg. 1982;34: )
25TREATMENT :ACUTE EXUDATIVE EMPYEMA :exudative empyema can be treated by aimed antibiotic therapyand repeated needle aspirations of pleural effusion.simultaneously coexistent pathologies are treated and nutritional therapy is carried out.intercostal tube drainage is usually a primary treatment for both acute and chronic pleural empyema.intrapleural antibiotic administration
26PLEURAL EMPYEMA (empyema pleurae) TREATMENT :CHRONIC EMPYEMA :suction intercostal tube drainage with interpleural antibiotic administrationirrigating pleural drainageafter 14 days a suction drainage can changed into an open drainage anda patient can continue his or her therapy in an outpatient clinic.interpleural administration of fibrinolytic agents in a case of encapsulatedempyema (Streptokinase or Streptodornase for 3-5 days)videothoracoscopy with mechanical debridement of the pleural space , ablation of dividing walls within the empyema, partial decortication and pleural drainage.
27PLEURAL EMPYEMA (empyema pleurae) SURGICAL MANAGEMENT :thoracotomy and decortication- if by intercostal tube drainage lungre-expansion isn’t achieved (decortication- a nonelastic fibrinopurulent coat is removed from the underlying lung and the chest wall to make re-expansion of the lung possible)decortication and lung resection ( empyema is accompanied by lung abscesses, lung mycosis or malignancy)chest wall fenestration- a technique used in debilitated patients. An upside downU-shaped skin incision is made to form a musculocutaneous flap. Shortfragments of 2 or 3 ribs are resected over the most dependent part of theempyema sac. Then the flap (Eloesser flap) is introduced into the pleural spaceand sutured together with the parietal pleura. A kind of a channel is formedthat enables effective pus drainage and repeated introduction of gauze saturatedwith antiseptic agents. Such a management leads to gradual sterilization of thepleural space and its healing by granulation.
28SURGICAL MANAGEMENT:in patients with pleural empyema after lung resection the ablation of theempyema sac by a surgical reduction of its size is the main goal(thoracoplasty, myoplasty, omentoplasty).in patients with pleural empyema with bronchial fistula afterpneumonectomy - removal of the empyema sac (membrana pyogenes) and theclosure of the fistula (myoplastic procedures- bronchial fistula is covered witha pedunculated muscle bundle) plus thoracoplasty.Clagett procedure - chest wall is fenestrated. When the healing of the parietalpleura by granulation appears the fenestration is closed and the pleural space issterilized by its filling throughout a drain with a solution of antibiotics selected onthe basis of bacterial culturesWeder procedure- three successive thoracotomies are performed every 2-3 days.During the first and the second thoracotomy fibrinopurulent empyema sac isremoved and gauze saturated with antibiotic solution is placed within the pleuralspace. During the third thoracotomy gauze is removed.
39Post lung resection empyema Post lobctomy(0,01%-2,0%), post pneumonectomy (2%-16%), residual space and air leakMethods of tretment: - Muscle flap clousure- Limited thoracoplasty- Open window thoracostomy
40The Clagett procedure -open-window thoracostomy in patient with pleural empyema and bronchialpostpneumonectomy fistula (own meterial)
43PLEURAL EMPYEMA (empyema pleurae) EMPYEMA COMPLICATIONS :atelectasis and respiratory insufficiencybronchopleural fistulapleurocutaneous fistulapleuroesophageal fistulasepsisperitonitismetastatic abscessespurulent inflammation of the chest wallprogressive respiratory insufficiency
44PLEURAL EMPYEMA (empyema pleurae) PROGNOSIS :Mortality in patients with pleural empyema ranges from 1% to 19%.A reason for death in an acute phase of empyema is sepsis or othercomplications of generalized infection.Late deaths are caused by toxemia, respiratory insufficiency ormultiorgan failure.In patients with concomitant diseases such as diabetes mellitus,malnutrition, systemic diseases, malignancy and alcoholism mortalityreaches 40%.