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Ann Thorac Surg 1997;63:943
© 1997 The Society of Thoracic Surgeons
DR WADE L. KNIGHT (Temple, TX): I am curious as to whether you are using streptokinase. Intrapleural infusion of streptokinase has been very helpful for us in avoiding having to operate on so many of these empyema and hemothorax patients, but we really have not experienced bleeding problems. I apologize for not having data to present, but we really have not experienced bleeding problems. By using streptokinase you will reduce your number of cases requiring thoracoscopy; the patients certainly appreciate it, and you get them out of the hospital quickly. With intrapleural streptokinase, usually you have remarkable clearing of the chest roentgenogram, similar to what you have shown with your 24-hour postoperative drainage film. I am just curious as to whether your plan might not include streptokinase.
DR CARRILLO: In 2 patients with a retained hemothorax we have used streptokinase; however, our results were not very satisfactory. I am aware that there are several reports saying that streptokinase plays a significant role in trying to lyse these collections and make them more amenable to chest tube drainage. Unfortunately, in the only 2 patients in whom we have used it, it did not work. I am not sure if it was because of technique or something else, but we elected not to use it again.
DR RICHARD W. ZOLLINGER II (Charlotte, NC): We are not dealing with a high-quality Rhodes scholar population in our area. And it sounds like you want to do this early. We are not seeing these patients early. When would you clinically recommend that this procedure be performed: is it 7 days? Four days? Ten days? It sounds like once you pass a week it is not really that useful. And we are not seeing these patients in less than a week; a lot of them are referred from outside. So when do you use the computed tomographic scan, and when are you clinically more aggressive with thoracoscopy?
DR CARRILLO: I think that the computed tomographic scan has a role after 7 days. Before 7 days usually you can proceed with thoracoscopy, which is based on the roentgenographic findings as well as the clinical correlation. We have moved, since July of this year, toward more early drainage of these collections. Actually we have had patients who have gone to the operating room, for example, for abdominal exploration, with a retained collection in the plain films, in whom we have proceeded with thoracoscopy at the same time. And we have been surprised to see the size of these collections. They usually do not correlate well with what you see in the plain films.
So my recommendation is that the computed tomographic scan is useful after 7 days; before 7 days probably you can proceed without it. As I mentioned before, probably 2 days should be the cutoff mark to wait for any resolution of this with conventional management.
DR JOSEPH B. ZWISCHENBERGER (Galveston, TX): Can you give us a feel for the natural history of this disease? Your whole premise assumes that draining these collections is advantageous; and there is little question, in patients with an empyema, that is the case. But regarding a hemothorax, many of these patients may actually do quite well with follow-up and presumptive management. I was wondering if you would comment on that.
DR CARRILLO: Our experience, as well as that of others, suggests that three things happen with a retained hemothorax: (1) it goes away with time; (2) it can become infected after multiple attempts to try to drain it; and (3) the patient remains in the hospital usually for extended periods of time. And that is where I emphasize in our presentation that some of our patients stay in the hospital somewhere between 3 to 12 days longer than needed because they were kept to watch or to observe these retained collections.
On the other hand, you can make a case and say, well, we can discharge this patient home and watch him or her as an outpatient and follow up him or her with serial roentgenograms. That is controversial. But we believe that if the patients are in-house, adding a procedure that usually does not add more than placing a chest tube in our own experience can shorten significantly the length of hospital stay. The emphasis is more toward decreasing length of hospital stay and eventually decreasing some of the complications due to multiple attempts at drainage.
Related Article
Ann. Thorac. Surg. 1997 63: 940-943.
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