Determination of likelihood of the development of pleural empyema in patients with cancer after pneumonectomy

Management of 150 patients with lung cancer after pneumonectomy has shown that the basic factors causing the onset of postoperative pleural empyema are chronic nonspecific pulmonary diseases, pronounced obstructive syndrome and right heart overload, tumor histology, local tumor size and cancer complications, duration and techniques of surgery, duration of controlled lung ventilation, as well as the onset of postoperative suppurative tracheobronchitis and surgical wound suppuration. The likelihood of empyema development may be assessed only upon analysis of the combination of risk factors with reference to their low informative value, preoperative patients' condition and intraoperative factors which have an equal impact on the onset of this complication. The efficacy of the algorithm elaborated is as follows: if the likelihood of empyema development exceeds 50%, it occurs in 96.3% of cases, if the likelihood of the complication is less than 10%, the postoperative period is uncomplicated in 87.8% of patients.     

Surgical treatment of lung abscesses

The authors analysed a group of patients with lung abscesses that received surgical treatment, as well as the characteristics of their evolution. Seventeen patients with lung abscesses which underwent surgical therapy from 1984 to 1995 were analysed. The group was composed of 12 male and 5 female. The age varied from 25 to 78 years (mean-50.1 years). The etiologies were: post-pneumonic, tuberculosis, foreign-body, empyema. Two types of surgical procedures were performed: pulmonary resection and transthoracic drainage. The indication of surgery was based on the failure of clinical treatment, massive hemoptysis, pleural empyema and residual cavity wider than 2 cm after 6 weeks of clinical treatment. The patients with poor clinical conditions were selected to transthoracic drainage, the less invasive procedure. Most patients had a satisfactory post-operative evolution (58.9%). Five patients had complications (29.4%) as empyema and air leak for more than three weeks and two patients died (11.9%). Regarding the surgical technics, the pulmonary resection (lobectomy and segmentectomy) showed no morbidity and mortality. The usage of external chest tube drainage of the abscess had a morbidity of 40% and mortality of 20%. In conclusion, the complicated lung abscess is still a surgical pathology and the best approach seems to be the resection of the pulmonary segment affected. The drainage has specific indication, mainly in patients with deteriorating condition, but this procedure has high mortality and morbidity rates.     

Exhaled nitric oxide is not elevated in the inflammatory airways diseases of cystic fibrosis and bronchiectasis

Airways inflammation has been associated with increased nitric oxide (NO) in the exhaled breath. It was, therefore, questioned whether exhaled NO could act as an indicator of the severity of airways inflammation in the chronic suppurative lung diseases cystic fibrosis (CF) and bronchiectasis. NO levels in a single exhalation were measured using a chemiluminescence analyser. Thirty-six patients with CF and 16 with bronchiectasis were studied and compared with 22 normal subjects and 35 asthmatic patients. All subjects were nonsmokers and all measurements were made when patients were clinically stable. In addition, exhaled NO was measured in 10 CF patients at the time of onset of an acute infective exacerbation and followed for 7 days during the treatment of the exacerbation in eight of the 10 patients. No significant differences were found in NO levels in patients with CF or bronchiectasis compared with normals (median 4.0, 5.5 and 4.4 parts per billion (ppb), respectively), but all were lower than in asthma patients (10.4 ppb). The NO levels in the CF patients at time of exacerbation were not increased and did not change during treatment. These data show that nitric oxide levels in the exhaled breath of patients with chronic suppurative lung diseases, in contrast to asthma, are not elevated, despite the presence of substantial airways inflammation. Possible explanations include poor diffusion of nitric oxide across increased and viscous airway secretions, removal of nitric oxide by reaction with reactive oxygen species in the inflamed environment and failure of upregulation of epithelial inducible nitric oxide synthase in chronic suppurative conditions.     

A surgical case of achalasia with empyema

A 57-year-old man who had been complicated with achalasia for thirty years was admitted because of back pain and low grade fever. Chest X-p and Chest CT showed consolidation in the left lower lung field. His respiratory condition was diagnosed as lung abscess preoperatively. After systemic chemotherapy, surgical management was done for both achalasia and this inflammatory respiratory disease. In the operation by left thoracotomy, it was revealed that this case had empyema, not lung abscess. Thus decortication of left lung and esophagomyotomy were performed simultaneously. In the treatment of achalasia, respiratory complications due to aspiration may appear. In addition, it is sometimes difficult to distinguish empyema from lung abscess preoperatively. Therefore much care should be taken during operation in order to treat these respiratory diseases.     

Remote results of surgical treatment of chronic suppurative lung diseases

The work was undertaken to study late results of surgical treatment of suppurative lung diseases during 1950-1974. Questionaries were sent to 420 operated patients. Answers were received from 328 (78%) patients, 86% of them were examined clinically, 14%--were estimated according to questionaries and their physician findings. 50 per cent of patients were followed up for 10-24 years. A positive effect was gained in 94.8%. 82 per cent of the operated patients have practically recovered well. The causes of poor issues are described, and trends for their improvement are delineated.     

Early decortication for anaerobic empyema in children

Nine children underwent early decortication for empyema. Three had posttraumatic empyema and six had postpneumonic empyema. The decision for decortication was made 3-5 days after diagnosis of empyema, when it was judged that conventional treatment by antibiotics and intercostal catheter drainage was failing. Such failure was manifested by: loculated effusions (9), persistent fever (8), persistent respiratory distress (3), pulmonary air leak (3), and worsening parenchymal disease (1). The decortication procedure consisted of a standard posterolateral thoracotomy, removal of the fibrinous peel from the visceral and parietal pleurae, debridement or resection of necrotic lung tissue, irrigation of the pleural space, and drainage by intercostal catheters. In the 9 children who underwent this procedure, there were no deaths and a single complication, suppurative thrombophlebitis. Recovery was rapid in 6 out of 9 children, who were discharged within 10 days of operation. The remaining 3 out of 9 children had associated injuries or illnesses that necessitated a longer hospital stay. Bacteriologic studies confirmed anaerobic bacteria in the infected pleural contents of 5 out of 9 children. Bacteroides and anaerobic streptococci were the commonest isolates. Anaerobic infection of the pleural space cannot be cured without aggressive surgical drainage, in addition to antibiotics. Our experience suggests that early decortication is an efficacious procedure for selected children with empyema. The presence of anaerobic bacteria in the empyema may constitute an unequivocal indication for early decortication.     

Surgical aspects of mycobacterioses. Evolution during the last 20 years

INTRODUCTION: Tuberculosis remains one of the major infectious diseases. Its incidence has grown in immigrants and in immunosuppressed patients, and, moreover, cases of drug resistance are on the increase. The goal of this study was to analyze the implications of these new developments and surgical experience in our patients. METHODS: The cases of 104 patients with tuberculosis hospitalized between 1975 and 1995 were reviewed retrospectively. RESULTS: 22% of the patients (23/104) were immigrants. No HIV-positive patients were described but association with debilitating diseases was frequent. Diagnosis was chiefly by histology. The culture was positive in only 30/104 patients (29%). Drug resistance was seen in only one patient (1%). 72/104 patients (69.2%) presented with an infection of the pulmonary parenchyma, 21/104 (20.2%) with pleural tuberculosis including tuberculous empyema, 3/104 (2.9%) with tuberculosis of the chest wall and 8/104 (7.7%) with mediastinal tuberculosis. Surgery was performed in 84/104 patients (80.8%). The chief indications were suspected carcinoma in 39/84 cases (46.4%), destroyed lung in 11/84 (13.1%), empyema combined with bronchopleural fistula in 10/84 (11.9%), enlarged mediastinal lymph-nodes of unknown dignity in 7/84 (8.3%), recurrent pleural effusion in 5/84 (5.9%) and bronchial stenosis in 4/84 (4.8%). CONCLUSION: The number of surgical patients with tuberculosis has remained fairly stable over the last 20 years, but the proportion of immigrants has grown since 1990. Thoracoscopy is playing an increasingly important role in the diagnosis and surgical treatment of tuberculosis (recurrent pleural effusion, resection of peripheral pulmonary nodules turning out to be tuberculoma).     

Surgery for thoracic empyema concurrent with rupture of lung abscesses in a child

The authors report surgical treatment for thoracic empyema concurrent with rupture of lung abscesses and completely collapsed lung in a child. Right middle lobectomy for ruptured abscess, debridement and closure with interrupted sutures for another abscess in the lower lobe, and decortication were performed. Positive-pressure ventilation was needed to prevent reexpansion pulmonary edema because of long-term collapsed lobes. The patient is doing well with no recurrent empyema or thoracic deformity at 3 years postoperation.     

The interpretation of the data from the ultrasonic examination of patients with acute and chronic suppurative lung and pleural diseases

Observations were made in 104 patients with acute and chronic lung abscesses and pleural empyema. The endoscopic, bacteriological and ultrasonic methods were used to make full diagnosis and to begin treatment. This article describes the part of the work devoted to the ultrasonic diagnostics. Different forms of lung abscesses were revealed and explained. The method was used to differentiate the collection of pus in the lung and pleural cavity, to reveal the structure of pathologic processes and its development, to learn the character of changes in the lungs and pleural space. The method is rather simple and gives the doctor much information about the condition of the pathologic tissue.     

Surgical management of pulmonary aspergilloma

Between 1983 and 1996., 79 patients'--operated on for pulmonary aspergilloma--clinical data has been analysed. The patients were comprised of 67 males and 12 females, with a mean age of 49 years (range, 24 to 69). Previous lung disorders were observed in about half of the cases (most frequently tuberculosis), while in the other half aspergilloma was developed on the basis of (sub)-acute infections. The most common symptom was haemoptysis (in 45% of cases). Aspergilloma was diagnosed preoperatively (especially by typical chest x-ray) in 62 patients. In the other cases tb, lung cancer, pyosclerosis were suspected. 67 patients underwent pulmonary resection (50 lobectomies, 12 wedge resections, 5 pneumonectomies), 12 cavities were opened by cavernostomy. The postoperative mortality rate was 10.1%. The most frequent complications were bleeding, prolonged air leak, pleural rest space, empyema, bronchial fistula and wound infection, which were occurred in cases with bigger cavities near chest wall. In most cases with pulmonary aspergilloma surgery remains the only effective treatment. Operation has a lower risk in asymptomatic patients, without chest wall involvement. In several cases cavernostomy might be applied successfully.     

Thoracic surgery and liver dysfunction

Lung resection results in loss of lung parenchyma including residual healthy lung tissue and in reduction in pulmonary vascular bed. A decrease in residual pulmonary vascular bed after lung resection causes an increase in right heart afterload, and in some patients, it would be associated with an increase in right heart preload and consequent the changes in hepatic circulation which would lead to liver damage. Preceding thoracotomy, unilateral pulmonary arterial occlusion test (UPAO) was performed to simulate the hemodynamic changes after lung resection to evaluate the increase in right heart preload after surgery. Patients with the decreases in cardiac index or PaO2 during UPAO showed a higher levels of GPT during postoperative period when compared with those with the increase in either parameters. In a surgical treatment for empyema, bronchiectasis, or other infectious lung diseases, bronchial angiography (BAG) and also bronchial arterial embolization (BAE) were useful methods to prevent from exceeding bleeding during thoracotomy, which is one of the risk factors to cause liver damage after surgery. These results suggest that, in the field of thoracic surgery, the preoperative assessment of the hemodynamic changes caused by lung resection and the preoperative attempt to prevent from bleeding during thoracotomy are both important to protect from liver damage caused by surgical stress.     

Use of the omentum in the treatment of chronic thoracic empyema

Thoracic empyema (development of suppuration in the thoracic cavity, usually after pneumonectomy) remains a serious complication which is difficult to treat. Failure of classical procedures (lavage-drainage) in the treatment of certain forms of pleural empyema (post-pulmonary resections), with or without associated fistula, led the authors to use the pedicled omental flaps filling material for the chronic empyema cavity. They report their experience (6 cases over a period of 4 years) and define the indications. Omentoplasty has a real place, next to myoplasty, in the therapeutic arsenal for chronic empyema due to its detersion capacity, particularly useful in a "septic" context and because of its volume which is usually sufficient in retracted cavities. The existence of an associated bronchial fistula, history of radiotherapy, posterolateral thoracostomy (sectioned latissimus dorsi) are additional reasons to prefer omentoplasty over myoplasty.     

Psychiatric manifestations of systemic lupus erythematosus

Low-intensive laser radiation used by topical, intravenous, and transendoscopic routes was employed in the complex antituberculosis therapy of 120 patients with pulmonary tuberculosis concurrent with chronic nonspecific respiratory diseases (n = 48), diabetes mellitus (n = 20 patients), gastrointestinal diseases (n = 45). The results of treatment were compared with the parameters of 62 patients with the similar clinical and X-ray characteristics of a tuberculosis process and concomitant diseases. It was ascertained that laser therapy might enhance the efficiency of treatment of patients with concurrent abnormality statistically significantly, by reducing the time of bacterial isolation, closure of decay cavities in the lung tissue, hospital treatment and by accelerating the onset of stable remission of concomitant diseases.     

Relationship between cardioventilatory coupling and respiratory sinus arrhythmia

The clinical data, microbiological results and antibiotic treatment of 65 children who have required incision and drainage of suppurative head and neck abscesses was retrospectively investigated with the aim of developing a more effective clinical protocol of treatment, improving speed of resolution and rationalizing the need for surgical intervention. A positive culture grew in 78% of children and of these 45% were Staphylococcus aureus, 9% Streptococcus pyogenes, and 8% atypical mycobacteria. Only 3% of the samples grew anaerobes. All isolates of S. aureus were sensitive to Flucloxacillin and all isolates of S. pyogenes were sensitive to penicillin. All anaerobes were Metronidazole sensitive. In 40% of the children there were no localizing symptoms which could guide the treatment, therefore we recommend Flucloxacillin and Metronidazole as the antibiotic regimen of choice in acute suppurative lymphadenitis. The increasing incidence of atypical mycobacterial lymphadenitis is noteworthy.     

Infratentorial empyema: analysis of 22 cases

OBJECTIVE: Infratentorial empyema is an uncommon form of intracranial suppuration that is usually secondary to neglected otogenic infection. The diagnosis is frequently delayed and often confused with that of meningitis. The associated mortality is distressingly high, yet it has, as a clinical entity, received scant attention in the literature. We present a 13-year experience of this condition. PATIENTS AND METHODS: From a retrospective analysis of 3865 patients with intracranial suppuration during a 13-year period, 22 patients with infratentorial empyema were identified. The inpatient notes for these patients were analyzed with reference to clinical, radiological, bacteriological, operative, and outcome data. RESULTS: Twenty-two patients with infratentorial empyema accounted for 0.6% of admissions caused by intracranial suppuration during the study period. Of these 22 empyemas, 13 were subdural and 9 epidural. Hydrocephalus was present in 17 (77.3%). Except for two epidural empyemas that did not warrant neurosurgical intervention, all patients underwent standard surgical management (wide posterior fossa craniectomy). Nineteen underwent mastoidectomy because the source of infection was otogenic. Concomitant and persistent hydrocephalus was treated aggressively. Five patients died (mortality rate of 22.7%). All fatalities had subdural empyemas, and all three patients with cerebellopontine angle extension of subdural purulent collections died. CONCLUSION: Although rare, infratentorial empyema, especially when subdural, is a lethal disease. Cerebellopontine angle extension of pus was a particularly ominous sign in our experience. Early surgical drainage via wide posterior fossa craniectomy, aggressive treatment of associated hydrocephalus, eradication of the primary source of sepsis, and, finally, intravenous high dosage of appropriate antibiotics form the mainstay of treatment.     

Identification of cardiovascular abnormalities in children with empyema thoracis by two-dimensional and Doppler echocardiography

To our knowledge, echocardiographic assessment of children with empyema has not been reported previously in the literature. Two-dimensional and Doppler echocardiography were performed in 47 children with acute (n = 23) and chronic (n = 24) empyema and 34 control subjects. Echocardiography demonstrated pericardial effusion in 11 of 47 patients (23 percent). Those with acute empyema had significantly thicker pericardium (p < 0.009) than control subjects. Tricuspid regurgitation was present in 21 of 47 patients (45 percent). The mean right ventricular internal dimension in diastole was significantly larger in patients with acute (p < 0.00002) and chronic (p < 0.006) empyema than that of control subjects. The mean tricuspid pressure gradients indicated an elevated mean right ventricular systolic pressure with increased calculated mean pulmonary arterial systolic pressures of children with acute empyema (38.5 +/- 6.4 mm Hg) and chronic (39.8 +/- 5.6 mm Hg) empyema than the normal mean (20 +/- 4 mm Hg). Children with chronic empyema had significantly less mean left ventricular internal dimension in diastole (p < 0.005) and left ventricular internal dimension in systole (p < 0.02) than control subjects. Strikingly, their mean left ventricular mass was also significantly less (p < 0.05) than that of subjects with either acute empyema or control subjects. These results provide baseline data for follow-up of children with acute and chronic empyema.     

A progressive postoperative increase in the serum level of soluble receptors for interleukin-2 is an indicator of a poor prognosis in patients with gastric cancer

Empyemas develop following bacterial pneumonias, thoracic trauma and surgery which are still among the common diseases, causing illness and death throughout the developing world. With the advent of potent antibiotics the mortality of empyema has been drastically reduced. In this study 52 patients (29 boys and 23 girls) with thoracic empyema were evaluated retrospectively. In this series the causes of empyema were postpneumonic in 50 patients, esophageal anastomotic leak in one patient, and thoracic trauma in one patient. The diagnosis was suspected clinically and by the finding of a pleural effusion on chest roentgenogram. Definitive diagnosis was confirmed by pleural aspiration which pus was obtained. Responsible organisms included; Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenza, pseudomonas, and Klebsiella. The most common is Staphylococcus aureus. The patients were treated in various ways; 14 patients were treated with antibiotics and thoracentesis, 38 patients were treated with a closed tube thoracostomy. Eight of 38 patients had the chest tube converted to an open empyema tubes for long term management. Fourteen of 38 patients developed abcess formation. Nine of 14 patients were treated with computed tomography guided catheter placement, five patients encountered thoracotomy and decortication. In this article, appropriate treatment and result of long-term follow-up of empyema were evaluated.     

Pleural empyema

Thoracic empyema may be based on four different etiologic mechanisms of infection: (1) parapneumonic, (2) posttraumatic, (3) postspecific, (4) postsurgical. According to morphologic processes, three different time-dependent stages may be present: (1) exudative phase, (2) fibrino-purulent phase, (3) organization and pleural peel formation. Diagnosis and pleural puncture are based on the findings of thoracic CT and transthoracic ultrasonography. Thoracocentesis, however--even if performed repeatedly--is not an appropriate treatment of empyema. Chest tube drainage and irrigation of the pleural cavity is appropriate only in stage I and early stage II disease to re-establish total lung inflation and healing without pleural peel formation. Selected stage II cases may benefit from video-assisted debridement, but a 30% conversion rate to open thoracotomy has to be assumed. Residual organized cavities, loculated peels etc. require open thoracotomy and empyemectomy, decortication or combined maneuvers. For treatment quality and outcome it is not only decisive to remove the source of infection but also to reexpand the entire lung without remaining restrictive peels and without relevant leaks.     

Natural history of diverticular disease: when to operate?

PURPOSE: The natural history of patients admitted because of acute diverticulitis is largely unknown, and the selection of patients for surgical treatment varies notably. This study presents our experience concerning the outcome for 366 patients admitted during a 10-year period. METHODS: Three hundred sixty-six patients admitted to our hospital with acute diverticulitis from 1981 to 1990 were identified from a computer database, and their clinical data up to the end of 1996 were reviewed from the database and patient records. RESULTS: There were significantly more males than females in the age group less than 50 years old, and young males underwent surgical treatment during the first treatment period more frequently than the others. Young patients were operated on without mortality, and all their temporary colostomies were closed. Older patients died more often of diseases unrelated to the diverticular disease during the years after the first episode of acute diverticulitis. Recurrences of diverticular disease developed in 22 percent of patients, and they were significantly more common in patients less than 50 years old than in the older age groups. Males less than 50 years old more often developed complications of diverticular disease after two hospital admissions. CONCLUSIONS: Males first admitted when less than 50 years of age undergo more primary operations and develop more recurrences of diverticular disease than do older people. Based on our data, however, we recommend surgery for all patients after two episodes of acute diverticulitis that resolves after conservative treatment with antibiotics.     

Surgical treatment of lung abscesses in children

The authors report their clinical observations of 44 patients, aged from 2 months to 14 years, with acute pulmonary abscesses. As evidenced by the authors a roentgenological examination in dynamics is of great value in establishing the diagnosis of pulmonary abscess, since it makes possible to follow the destruction of lung tissues and the formation of cavities. For treatment of lung abscesses different methods were employed: toilet bronchoscopy with antibiotics perfusion, puncture and drainage of the abscess, in case of pulmonary hemorrhage a resection of the lung portion involved, the complex conservative therapy.