Ann Thorac Surg 2003;76:1853
© 2003 The Society of Thoracic Surgeons
Invited commentary
Lary A. Robinson, MD
Division of Cardiovascular and Thoracic Surgery, Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL 33612-9497, USA
e-mail: robinson{at}moffitt.usf.edu
Over two millennia have passed since the first clinical description of pleural empyema by Hippocrates who recommended open incision and drainage. It was not until 1918 that Evarts Graham and the World War I Empyema Commission changed routine therapy to closed intercostal drainage resulting in a dramatic fall in mortality from 75% to 15% in streptococcal empyemas. But despite prompt intercostal tube insertion, some empyemas have already progressed to the multiloculated fibrinopurulent stage that precludes adequate treatment by simple drainage alone. For these patients, open surgical or thoracoscopic decortication, with its attendant mortality and morbidity, has been traditionally advocated. However, it was in 1949 that Sol Sherry described the first clinical use of intrapleural streptokinase to facilitate drainage of infected hemothoraces without surgery. Initially, this approach was successful but it soon lost favor because of the toxic side effects of this crude preparation of streptokinase. In subsequent years, a variety of successful clinical series have been published using this conservative, nonsurgical approach using more purified intrapleural fibrinolytic agents to treat multiloculated pleural empyemas (MPE) in patients that traditionally would have been treated with aggressive thoracotomy and decortication.
Almost all published clinical reports of intrapleural fibrinolysis for MPE involved a predominate adult population with a complete nonsurgical success rate averaging 80% in most series, and with a considerably lower actual hospital cost compared to the surgical approach. The authors of the current report address this problem in the pediatric population in a large single institution, well-documented series of 72 children who were treated for post-pneumonic MPE with the intrapleural fibrinolytic agents streptokinase or urokinase. Their results are remarkably similar to the prior adult series with an overall 81% complete recovery rate with minimal morbidity using the nonsurgical intrapleural fibrinolysis approach. These excellent results now extend the potential indications for this conservative approach to all patient age groups.
The key factor in predicting a successful outcome with any intervention, including intrapleural fibrinolyis for MPE, is appropriate patient selection, as advocated by the authors. In 1962, the American Thoracic Society described the current staging of empyemas into three phases: stage I Exudative stage with thin, free fluid which is readily drained by chest tube alone; stage II Fibrinopulent stage where there is early organization with thicker pus, fibrin and multiloculation, usually requiring more aggressive intervention; and stage III Organizing stage with fibroblast ingrowth and a thick inelastic pleural peel preventing lung expansion. Fortunately most empyemas are either stage I or II and are amenable to conservative chest tube drainage alone (stage I), with the needed addition of intrapleural fibrinolysis in stage II. Proper staging of the empyema, as described by the authors, generally predicts who will benefit from the nonsurgical approach with fibrinolytic therapy, and which of the much smaller patient population likely has a stage III empyema requiring open surgical decortication.
The authors, as well as most prior series, recommend an initial trial of drainage and possible intrapleural fibrinolysis in almost all patients with MPE, since computed tomography was not uniformly accurate in predicting which patients would fail fibrinolyic therapy and require surgery. Since urokinase is no longer available, streptokinase is once again the only practical agent for intrapleural fibrinolysis, although it has some possible febrile and allergic reactions. As an aside, in my own thoracic surgical practice I continue to successfully treat MPE nonsurgically as described herein, currently using intrapleural streptokinase, but have effectively prevented toxic side effects of this agent by administering a small intravenous dose of methylprednisolone 30 minutes prior to each daily instillation. Doctor Ozcelik and associates are to be commended not only for their excellent results in this difficult patient population, but also for sending the thoracic surgical community a clear message reiterating the effectiveness of this conservative, low morbidity, and low-cost approach to an old but controversial pleural problem.
