Thoracic infections – Thoracic Surgery

Treating Empyema: Changing the algorithm for better patient care

This fear of thoracotomies dwarfs the very real risks of prolonged illness and debility.

The story of empyema is as old as surgery itself. Hippocrates himself describes treating empyema with chest tube placement. However, over the years – the urge to treat this condition with the expediency and urgency it requires, has waned. With the advent of antibiotics came the idea of a “wait and see” philosophy. When the alternative was a thoracotomy, this could be forgiven. In the age of uniportal VATS, it is not.

Current treatment algorithm (with basic variations)

Patient w/ parapneumonic effusion/ empyema –> antibiotics –> still sick –> more antibiotics –> still sick –> chest tube (or pigtail placement) –> fibrinolytics then —-> If treatment fails, consult thoracic surgery

The current treatment algorithm, which often starts as several weeks of outpatient antibiotics, (usually initiated for treatment of community acquired pneumonia that develops into a parapneumonic effusion), that engenders an even longer period after subsequent follow up chest x-rays, then CT scan fail to show improvement.

A pneumonia in late September, becomes an effusion in October, then progresses to empyema as various strategies are attempted and fail. One antibiotic is switched to another, a pigtail is placed in radiology (with partial results), then perhaps, a larger tube, and fibrinolytics. Then, only then – is the thoracic surgery service consulted.

At this point, the patient has been sick for several days to weeks. As they remain sick, there is a decline in both nutritional and functional status. The “spry” and youthful 75-year-old becomes a mostly bedridden and frail elderly patient. This too, works against the patient and their recovery, as internal medicine physicians and pulmonologists are reluctant to refer this now frail patient due to the perceived rigors of surgery. This fear of thoracotomies dwarfs the very real risks of prolonged illness and debility.

For most modern-day practices, thoracotomies for decortication are a thing of the past. Minimally invasive surgeries such as VATS or uniportal VATS have replaced the large incisions of the 1980’s and reduced, if not eliminated, the incidence of morbidity and mortality related to this procedure. But our treatment algorithms haven’t kept up with surgical advances.

Proposed treatment algorithm:

Patient sick –> CT scan showing effusion –> thoracic surgery consultation with uniportal VATS for any effusion/empyema

Uniport VATS, (which is basically a glorified tube thoracostomy with anesthesia and a camera) allows for more than drainage of fluid from the pleural cavity. It also allows visualization, for better evacuation of infected material. Surgeons are able to target areas of loculation; and complete a full decortication, if necessary. While the use of anesthesia may add a degree of risk for the frailest of patients, it is the anesthetic/ and analgesic effects that allow for optimal patient positioning, and instrument manipulation, allowing for better results that bedside tube thoracostomy alone.

Why then, are we, the thoracic surgery service still only receiving consultations at the 23^rd hour? Why isn’t the literature pushing for a change in perspective, or a change in practice?

Current literature on empyema

Chin, Redden, Hsu and Driel (2017, 2013) published a Cochrane review of multiple randomized control trials comparing outcomes for tube thoracostomy versus VATS. However, this review, which found in favor of VATS, was primarily based on pediatric studies.

Notably, this Cochrane review (which did not include uniportal VATS), showed decreased mortality and length of stay in the thoracotomy and multi-port VATS groups compared with the tube thoracostomy group.

Another Cochrane study, Cootes et al. (2009), which also demonstrated a decreased length of stay, and decreased duration of chest tube placement with VATS) was withdrawn due to questions about inclusion criteria.

The remainder of the existing studies

The remainder of studies published since the Cochrane database review had similar limitations. A German study published in 2017 (Segerer et al.) that reviewed 645 children throughout the country that presented with empyema and showed no different in the length of stay. But only 7% of these children underwent surgical procedures compared to 46.9% that underwent lesser procedures (thoracentesis or chest tube placement).

A more recently published study, Tanbrawarsin et al. (2018) showed a decreased incidence in recurrent bacterial empyema in patients who underwent surgery, but it is difficult to apply these findings to our algorithm, since it was based on just 34 patients, and was not randomized. Furthermore, all advanced empyema patients received open thoracotomies. Some patients also underwent thoracoplasties, which is a procedure not commonly used in many parts of the world, including the North America.

Patients deserve better

While the published data appears to remain undecided on the algorithm, it is clear, our patients deserve better. They deserve an approach that is timely, and effective. There is significant data that demonstrates that early surgical intervention improves outcomes. But unless thoracic surgeons present an overwhelming mountain of evidence [at pulmonary and internal medicine conferences] that uniportal VATS is superior to lesser therapies, patients with empyemas will continue to receive lesser therapies, first, before we receive the thoracic surgery consult.

They deserve the opportunity to rapidly return to health and full function. For that, we need to commit to performing and reporting more research aimed at looking at the most effective treatment for empyema. We, in thoracic surgery, know that that the answer is not more of the same; increasingly ineffective antibiotic regimens and a long convalesce. Now, we have to prove it, and publish it, over and over, to get past the persistent belief that risk of surgery outweighs the risk of continued illness.

Now, we need to conduct and publish studies, and reviews that compare nonsurgical treatment with uniportal VATS (excluding the dread thoracotomy) and looking for meaningful end points beyond mortality. Studies need to look at the length of stay, chest tube duration, morbidities related to either treatment (deconditioning, blood transfusions, DVT, malnutrition, etc. ) as well as both the 30-day recurrence and re-admission rate.

Surgeons, this is your call to action.

References (with links to full text articles when possible)

Cootes et. al. (2009) Surgical versus nonsurgical management of empyema. Cochrane database. Paper withdrawn.

Redden, Chin, & Van Driel (2013, 2017). Surgical versus nonsurgical management of empyema. Cochrane database.

Segerer, et al. (2017). Therapy of 645 children with parapneumonic effusion and empyema – a German nationwide surveillance study. Pediatric Pulmonol 2017 Apr, 52 (4): 540-547.

Shresthra et. al. (2011). Evolving experience in the management of empyema thoracis. KUMJ 2011 Jan-Mar 9 (33) 5-7. In this study, 82% of patients treated with tube thoracostomy eventually needed thoracotomy. Full text link not available.

Tanbrawasin, A. et al. (2018). Factors associated with recurrent bacterial empyema thoracis. Asian J. Surg 2018 Jul, 41(4) 313-320.

There are multiple studies showing early surgical intervention improves outcomes in empyema, but only a single selection was placed within the editorial above.

Chung et. al. Optimal timing of thoracoscopic drainage and decortication for empyema

A new Korean study looks at the best time to perform surgical interventions on patients with empyema thoracis.

In a recent issue of the Annals of Thoracic Surgery, Chung et al. attempt to answer the long-standing question over the optimal timing of surgical intervention for empyema. This has been a long-standing debate among surgeons and other medical specialists. Despite advances in thoracic surgery (such as video-assisted thoracoscopy) as well as wealth of surgical commentary suggesting earlier intervention, surgery is usually considered a last resort; often after weeks or months of antibiotics, tube thoracoscopy or fibrinolytic therapy.

Chung et. al raise the stakes for this discussion with their research into this issue. In “Optimal timing of thoracoscopic drainage and decortication for empyema,” over the course of 8 years, the authors compared outcomes such as chest tube duration, number of persistent air leaks and overall length of stay by the time interval of symptomology and surgical treatment.

Why this is important

As discussed in previous posts, empyema is a serious infection with a mortality rate of approximately 1 in 5 patients. Empyema is frequently found in the chronically ill, debilitated or malnourished. Delays in definitive treatment (surgical decortication) plays a role in the high rate of mortality with this condition; with increased hospital stays, and increased patient debility as the patient continues to sicken, and consume their health reserves while less effective treatments are initiated.

What is early? What is optimal?

Early surgical intervention has been theorized since the turn of the 20^th century to lessen morbidity and mortality, however there have been very few actual studies to address the question of timing. This study, while small, directly compares outcomes in patients receiving VATS at different points in the infectious process/ illness spectrum.

Using a retrospective study design, patients from April 2004 to March 2012 were subdivided into three different time intervals; symptoms for less than 2 weeks, 2 to 4 weeks and patients with symptoms persisting longer than 4 weeks prior to surgery. Of the 128 empyema patients, the vast majority (93.7%) were treated with VATS, with only 8 patients undergoing open procedures like thoracotomy.

Who:

Patients included in the study met criteria set forth in 2000 by the American College of Chest Physicians for diagnoses of Empyema and Loculated pleural effusions with thickened parietal pleura. Patient symptomology including symptoms such as dyspnea, persistent fever and sepsis were also taken into account when determining eligibility for surgical management.

Patients by intervals:

Less than 2 weeks (group 1) : 73 patients

2 to 4 weeks (group 2) : 43 patients

More than 4 weeks (group 3) : 14 patients

The vast majority of patients were male, with only 14 female patients in this study – spread throughout the groups. Additional variables such as age and pre-existing and co-morbid conditions (diabetes, liver disease, TB or other lung disease, etc.) were also collected*. The percentage of patients in each group who had undergone additional treatments for empyema pre-operatively (thoracentesis, antibiotics, etc.) was similar in all groups for antibiotics (ranging from 93% in group 1 to 100% of group 3) with around a quarter of both group 1 (24.6%) and group 3 (28.6%) requiring immediate surgery due to deteriorating status.

The 8 thoracotomy patients were used as a comparison group to evaluate the effectiveness of VATS for chronic empyema. All eight open surgical had pre-operative empyemas of 4 weeks duration or more.

What was compared/ measured?

While patient pre-operative characteristics were collected and analyzed as part of the evaluation of the empyema groups, the main surgical outcome measures were:

– Duration of procedure: Shorter in group 1 (average 100 minutes) versus group 2 (125 minutes) and group 3 (138 minutes).

– Chest tube duration – shorter in groups 1 (6.92 days) and 2 (7.45 days) than group 3 (10 days).

– Length of overall post-operative hospitalization: shorter in group 1 (9.49 days) and 2 (9.73 days) compared to group 3 (13.5 days).

– Length of post-operative ICU stay: no significant difference

Other surgical outcomes

Overall post-operative mortality was zero. There was no incidence of post-operative respiratory failure.

Re-operations/ Additional procedures:

Group 1 (73 patients) 2 patients with treatment failure/ empyema reoccurrence requiring re-operation with VATS (2.7%).

1 patient without complete resolution with VATS, required conversion to open decortication.

1 patient that developed a contralateral pleural effusion that required chest tube placement.

Total re-operations: 3 (4.0%)

Group 2: No re-operations.

Group 3 (14 patients)

1 patient required re-operation with VATS for treatment failure.

Prolonged air leak

Group 1: 2 patients (2.7%)

Group 2: 1 patient (3%)

Group 3: 4 patients (28.6%)

Study Weaknesses

The biggest weaknesses in this study are the small number of participants in group 3, and the lack of a control group.

Small numbers = reduced strength of findings

How much more powerful would similar results be, had the numbers of participants in all the groups been equivalent? For example, if Chung et al. presented data showing that air leaks occurred in over 28% of patients with older empyemas (group 3) in comparison with groups 1 (2.7% and group 2: (3%) if these groups had been equally populated, would be a much stronger argument for earlier intervention.

As it is, with just 14 participants in group 3, 28.6% is less of a dramatic finding than false precision from small numbers. However, it serves as a credit to Dr. Chung and his medicine colleagues, as clinicians, that the majority of these patients received definitive treatment at earlier stages.

Lack of control group

Had researchers included patients who were treated only by non-surgical methods (up to 2 weeks duration) and compared the overall length of stay, incidence of respiratory failure, ICU days and mortality in these patients, the data would have had an increased impact. However, questions remain regarding the use of VATS versus the current standards of treatment in this ‘early’ group. While we can partially speculate that treatment failures of patients in this group represent later patients (i.e. Patient fails treatment and is referred for surgery and becomes part of group 1, 2 or 3), the missing information may have represented a crucial factor to drive the decision-making process.

For example, how many patients in that same time period, presented with early empyemas and:

– Received antibiotics and recovered?

– Were admitted to the hospital and died of respiratory failure/ sepsis etc. without ever making it to surgery?

But, presumably, the difficulties of collecting this data retrospectively were prohibitive. However, does the high rate of immediate surgery in group 1 due to patient deterioration serve as a partial stand-in for this data?

Conclusions

While further study is warranted to determine the optimal time for surgical intervention in empyema thoracis, this study does an adequate job at demonstrating the benefits of earlier surgical intervention. While there was no mortality in any of the groups, patients who were operated on 4 weeks or more after being diagnosed/ demonstrating symptoms of empyema, required longer operations, developed more persistent air leaks post-operatively, with longer chest tube duration and longer overall hospital stays.

Further research in this area could include the use of experimental algorithms and protocols to ‘fast-track’ patients with loculated effusions/ empyemas to surgical decortication in an attempt to replicate or further demonstrate improved patient outcomes with earlier surgical intervention. These algorithms would explore the use of surgery as a first-line treatment with adjuvant antibiotics independent of thoracentesis, tube thoracostomy.

*Full information is provided within several tables in the original article.

Chung, Jae Ho et al. (2013). Optimal timing of thoracoscopic drainage and decortication for empyema. Annals of Thoracic Surgery, 2013.

mystery diagnosis: pleural plaques

Discovery of extensive pleural plaques during VATS

Usually with pleural plaques, you think of two possible diagnoses: metastatic cancer and tuberculosis.

But which is the more likely culprit?* That kind of depends on both your patient and your geographic location.

If this had been in my native Virginia – I’d “assume/ guess” metastatic cancer (since my patient population is usually older, high rate of smoking, other risk factors for cancer).

But luckily (who ever thought I’d be saying luckily) in my current location (Northern Mexico) in this patient (with multiple risk factors for infectious disease but no asbestos exposure) – tuberculosis is the more likely diagnosis.

* Prior to formal tissue pathology results, which confirmed tuberculosis in this patient.

** I apologize for the lack of formal references, but I was unable to find any comprehensive literature (available as free articles).

Radiology Reference on-line article

Mediastinitis: a potentially lethal infection

Exploring the causes of mediastinitis in non-cardiac surgery patients with review of recent cases in the literature.

Mediastinitis is a serious, and potentially life-threatening infection of the mid-chest area (or mediastinum.) While it most commonly occurs after cardiac surgery* (and is a dreaded complication of), it can also occur after large thoracic procedures or blunt trauma.

Sternotomy incisions, along with clamshell/ hemi-clamshell incisions may be utilized for large anterior mediastinal tumor resections, which places patients at the same risk of mediastinitis as traditional cardiac surgery procedures.

Blunt trauma can include injuries such as an esophageal tear that allows bacterial/ food/ fluids to seep from the torn esophagus into the chest. In rare cases, it can occur due to the spread of an infection affecting the head /neck. Recently, there have been several case reports of mediastinitis resulting from necrotizing fascitis which is particularly devastating, with cases originating as dental infections.

If untreated, mediastinitis can rapidly progress to sepsis (a systemic bloodstream infection causing numerous serious sequelae) and death. Mortality related to the development of mediastinitis ranges from 21 – 60% (depending on sources).

Additional Risk Factors for the development of mediastinitis

Any condition that delays or impedes healing can promote the development of mediastinitis – particularly in post-surgical patients. This includes diabetes, patients taking immunosuppressive therapies (such as Rheumatoid arthritis treatments, COPD and other patients on prednisone (and other steroids), transplant recipients and cancer patients receiving chemotherapy.) This is why care of sternotomy or large chest incisions should be taken very seriously.

Prevention of mediastinitis in patients with sternotomy incisions: (s/p thymectomies, mediastinal mass resections etc.)

Patients should be sure to follow all lifting or movement restrictions (sternotomy precautions) and report any drainage from their incisions. Patients should also contact their surgeons if they develop any wound dehiscence (wound edges come apart) or development fluctuance or swelling around the surgical site. Fever following discharge from the hospital should be reported to the surgical service, particularly if it accompanies any signs of wound breakdown.

Patients with diabetes or elevated serum blood glucose need to be aggressive in the treatment of hyperglycemia. Even patients who were previously well controlled on oral agents may require basal or correction insulins post-operatively to prevent elevated glucose, and increased risk of infection.

Large breasted female patients, or obese males should wear a support bra to keep gravity from pulling breast tissue apart, and placing stress on the healing incision. This is one of the most common reasons for poor wound healing of sternotomies. (This will also significantly reduce post-operative pain.)

Post-thoracic surgery patients receiving radiation early in the course of their surgical recovery are also at risk, even from smaller procedures such as mediastinoscopies and Chamberlain procedures. Aggressive surveillence and regular inspection of all wounds may help detect early signs of superficial infection/ wound breakdown to prevent the development of more serious complications.

Do not apply creams, lotions or ointments to incisions without speaking to your surgeon. Avoid overly harsh anti-bacterial soaps and scrubs. These products may actually damage the delicate tissues and promote infection.

Diagnosis may require CT scans of the chest to detect the development of a fluid collection within the chest.

Treatment of Acute Mediastinitis

Early treatment and surgical debridement of infected material (dead tissue, pus, etc) are essential for optimal results. Intravenous antibiotics are a crucial part of this treatment to help prevent / and treat possible sepsis. In patients presenting with more advanced infection – fluid resuscitation and treatment of underlying sepsis and sepsis related complications (organ failure) may be required along with other supportive measures. Urgent evacuation of mediastinal space should remain a priority, even in the critically ill and unstable patient to prevent further spread of infection, particularly if necrotizing organisms are suspected.

* Sternotomy or the surgical division of the sternum was actually first adopted by a thoracic surgeon to access the anterior chest and mediastinum almost fifty years prior to its use in cardiac surgery. Sternotomy remains one the primary ways (along with clamshell and hemi-clamshell incisions) that surgeons can access the anterior mediastinum for large tumor resections.

Additional References and Information about Mediastinitis

New York Times article on mediastinitis

Banazadeh M. (2011). Successful management of acute necrotizing mediastinitis with trans-cervical drainage. Ann Thorac Cardiovasc Surg. 2011 Oct 25;17(5):498-500. Epub 2011 Jul 13.

Dajer-Fadel, et al (2012). Thoracic necrotizing fasciitis due to snake ointment that progressed to a mediastinitis. Interact Cardiovasc Thorac Surg. 2012 Jan;14(1):94-5. Epub 2011 Nov 18. Story of fatal case of mediastinitis in Mexico City, Mexico. Please note: photos are fairly graphic.

Kim, et. al. (2011). Application of radiographic images in diagnosis and treatment of deep neck infections with necrotizing fasciitis: a case report. Imaging Sci Dent. 2011 Dec;41(4):189-93. Epub 2011 Dec 19. Discussion of case of serious, necrotizing infection originating from a dental infection- with CT images showing close proximity of infection to thoracic cavity. [Patient in case report did not develop mediastinitis.]

Mahmodlou (2011). Aggressive surgical treatment in late-diagnosed esophageal perforation: a report of 11 cases. ISRN Surg. 2011;2011:868356. Epub 2011 Jun 22. Iran case reports of mediastinitis after esophageal injury.

Saha et. al (2011). Perils of prolonged impaction of oesophageal foreign bodies. ISRN Surg. 2011;2011:621682. Epub 2011 Jun 13. 2 Cases (with color photos and CT scans) of mediastinitis after foreign body ingestion.

VATS decortication: Empyema

an in-depth look at video-assisted thoracoscopy for decortication of advanced empyema.

In a previous series of posts discussing a recent paper presented by a group of Australian pulmonologists, we debated the use of VATS for decortication of advanced empyemas versus medical treatments. Today, I would like to talk more about the VATS decortication procedure itself. This procedure is performed to remove infected material (pus) from the thoracic cavity so the lung can re-expand.

In advanced empyema, a tough, fibrous layer (or peel) forms around the lung and prevents full re-expansion. (This peel has the appearance and texture of rubbery chicken skin.)

pleural peel — thick pleural removed during decortication

In these cases, decortication (or peel removal) is necessary for full recovery.

renteria 007 — VATS decortication of a loculated empyema

If the peel isn’t removed, the lung will remain compressed and infection can easily recur. In VATS surgery, several ports are used (small 2cm incisions) versus a larger thoracotomy incision. This isn’t always possible; if the infection is severe, or surgeons are unable to free the lung through the smaller incisions. Sometimes surgeons have to convert to open surgery intra-operatively. However, VATS is preferable for patients, (if possible). Smaller incisions mean less injury, less pain leading to fasting healing, and a shorter hospital stay.

empyema, advanced with extensive purulence — advanced empyema requiring open thoracotomy for decortication

Click here to see a video showing a standard thoracotomy incision (with retractors holding it open).

As we mentioned in a previous post – empyema is a serious, potentially fatal infection* – in fact – one out of three patients with this condition will die from it.

What’s the difference between empyema and a parapneumonic effusion? Answer: Pus.

*while this case report features a patient from Uganda, similar cases have been encountered in my practice here in the USA.

References:

Prilozi. 2010 Dec;31(2):61-70. Indications for VATS or open decortication in the surgical treatment of fibrino-purulent stage of parapneumonic pleural empyema. Colanceski R, Spirovski Z, Kondov G, Jovev S, Antevski B, Cvetanovski M V. Article linked in text above, recommending early surgical treatment for better patient outcomes. However, this study did not compare surgical treatments to medical therapies.

Asian Cardiovasc Thorac Ann 2010;18:337–43. Thoracic empyema in high-risk patients: conservative management or surgery? Bar I, Stav D, Fink G, Peer A, Lazarovitch T, Papiashvilli M. Limited study of 119 patients showing benefit in both groups of patients with surgery used as primary management strategy in clinically unstable patients. (Increased mortality in this limited study of surgical interventions versus medical management can be attributed to the fact that surgery was used as a last resort in the sicker, more debilitated patients by the authors descriptions).

Metin M, Yeginsu A, Sayar A, Alzafer S, Solak O, Ozgul A, Erkorkmaz U, Gürses A. Treatment of multiloculated empyema thoracis. Singapore Med J. 2010, Mar 51(3): 242-6. Comparison of VATS, open surgery and conventional treatment for empyema. Authors recommend VATS for first line treatment.

older references on VATS decortication:

J Thorac Cardiovasc Surg 1999;117:234-8. Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome. Cassina PC et al. Authors discuss the results of VATS decortication in 45 patients after failed medical treatment and attempted thoracostomy drainage. Several patients required open thoracotomy due to late organized infectious process.

Ann Thorac Surg 2006;81:309-313. Video-Assisted Thoracic Surgery for Pleural Empyema. Wurnig, S. S.,Wittmer, V., Pridun, N., & Hollaus, P. H. (2006). Linked in text above. Austrian study of 130 patients

Ann Thorac Surg 2003;76:225-30. Minimally invasive surgery in the treatment of empyema: intraoperative decision-making. Roberts, J. R