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Ann Thorac Surg 1999;67:1829
© 1999 The Society of Thoracic Surgeons
a Service de Chirurgie Thoracique, Hôpital Laennec, 42 rue de Sèvres, 75007 Paris, France
Letter to the Editor
In one of the recent issues of The Annals of Thoracic Surgery [1], Thourani and coauthors evaluated the treatment modalities for thoracic empyema (TE) and advocated the use of early surgical intervention as the most optimal and cost effective initial modality. The study was based on 77 patients suffering TE of different etiologies: 50 parapneumonic, 12 post thoracotomy, 4 post traumatic, 3 tuberculosis related, 3 malignant pleural effusions, 3 intrabadominal sepsis and 2 esophageal-related. If the 6 last etiologies may occasionally require invasive surgery, we would like to discuss the treatment of parapneumonic TE (PTE) and advocate the absolute need to separate them from the others when debating on their treatment. In 1983 we [2] reported 113 cases of PTE treated by chest tube drainage and fibrinolytics (Trypsine at that time) 3 times daily with good results in 93.8% of cases (n = 103) and no need for surgery. Since that time and until 1997 we managed 203 new cases of PTE (men 159, women 44) aged 18 and 94 years (mean 55 years). Pleural liquid was purulent in all cases. Antibiotherapy had been already given to 90% of patients but germs were isolated in 79% of cases despite this antimicrobial therapy. PTE history before admission in our department ranged from 3 to 111 days (mean 23, median 18) and 62% of empyemas were multilocated. All patients were drained using intermediate caliber tubes 16F or 18F (Monaldi tube, Porges). Tubes were positioned using bony landmarks visualized on chest x-rays or, when needed, by help of image guidance in 9% of cases (ultrasound n = 6, CT scan n = 13). On the second day instillation of fibrinolytic agents (Streptokinase 250,000 UI/day) was started. Small volumes were instillated (15 to 20 mLs) 3 times daily, the tube clamped 2 to 3 hours and then set to suction. Simultaneously parenteral antibiotics were administered and the patients had physical respiratory exercises. One tube was sufficient in 74.5% (n = 151) but 2 were necessary in 23.6% (n = 48) and 3 in 1.9% (n = 4). Average hospital stay was 21 days (med 19, range 2 to 72d). This was correlated with the duration of the PTE prior admission to operation: when mean duration of PTE prior admission had been 37 days, operation stay was more than 19 days and when mean duration of PTE had been 18 days, operation stay was less than 19 days. We did not observe any complication directly related to the treatment or the fibrinolytics used. We observed successful outcome in 187 cases (92%). Fifteen patients died (8%) during the course of treatment or during hospital stay: death being unrelated to empyema or sepsis but to debilitating severe neurologic disease in elderly patients. No patient needed surgical intervention in that group of PTE. Furthermore this technique, if instituted early in the course of PTE, allowed recovery after a short hospitalization. We think then that the message that should be clear for the physicians is: PTE must be distinguished from other empyemas and may be managed in most cases without surgery. Fibrinolytics and chest tube drainage permit deloculation: the sooner the drainage the quicker the recovery.
References
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