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Ann Thorac Surg 1990;49:940-947
© 1990 The Society of Thoracic Surgeons
Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia USA
* Address reprint requests to Dr Gustafson, Department of Surgery, Health Sciences Center North, West Virginia University, Morgantown, WV 26505.
Despite appropriate antibiotics and pleural drainage, the condition of some children with empyema fails to improve. In a 5-year period, 10 children ranging in age from 2 to 16 years underwent lung decortication for a refractory, symptomatic empyema, which had developed 3 to 5 weeks after an initial pneumonic infiltrate. Responsible organisms included β-hemolytic streptococci, Haemophilus influenzae, or Streptococcus pneumoniae in 6 children. Negative cultures were found in 4 children. The initial computed tomographic scan of the chest in 4 of 8 patients showed more than 75% limitation of lung expansion by the contents of the empyema cavity. In 4 other patients, an extensive pleural peel was seen on initial computed tomographic scan of the chest. Several studies also showed cystic lesions in the collapsed lung. Multiple computed tomographic scans in 3 patients confirmed the lack of clinical and chest roentgenographic improvement with conservative therapy. At decortication in each, the visceral and parietal pleural peel was completely removed, freeing the trapped lung. Two patients also had a concomitant lobectomy for a necrotic right upper lobe (1 patient) and left lower lobe (1). Clinical improvement was marked, with return of temperature, white blood cell count, and appetite to normal. Postoperative morbidity was minimal. Analysis of these patients in whom traditional conservative therapy failed suggested that the initial management during the early exudative phase was often delayed and was not aggressive enough from the standpoint of pleural drainage. Early decortication in these highly select patients with symptomatic, refractory empyemas shortened the hospital stay, minimized the risks of long-term use of antibiotics and prolonged chest tube drainage, completely reexpanded the trapped lung, and led to excellent long-term results.
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