|Year : 2013 | Volume
| Issue : 2 | Page : 161-165
Open drainage for chronic empyema thoracis; clarifying misconceptions by report of two cases and review of literature
Sunday A Edaigbini1, Ndubuisi Anumenechi1, Vincent I Odigie2, Lawal Khalid3, Aliyu D Ibrahim1
1 Department of Surgery, Division of Cardiothoracic Surgery, ABU Zaria, Nigeria
2 Division of Breast and Endocrine Surgery, ABU Zaria, Nigeria
3 Division of Hepartobiliary Surgery, ABU Zaria, Nigeria
|Date of Web Publication
Sunday A Edaigbini
Department of Surgery, Cardiothoracic Surgery Unit, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Empyema thoracis is quite appreciated as a purulent pleural effusion. The basis for open drainage as an option for the treatment of chronic empyema thoracis is that the lung is trapped beneath a thickened and fibrosed visceral peel, which stabilizes and shields the trapped lung from the possible effect of pneumothorax when such a lung is exposed to the atmosphere either deliberately or accidentally. This is often unappreciated by many clinicians especially those with limited experience. From first principles, pus anywhere requires drainage and this applies equally to pleural space pus. Since these patients are often unfit for stressful procedures like decortication or the underlying lung is often unhealthy and will fail to expand or would be seriously violated in an attempt to free it, open drainage provides a safe and suitable option for the treatment of this pathology. We present the successful management of two patients by this approach as well as the review of literature in this respect.
Keywords: Chronic empyema, open drainage, pneumothorax
|How to cite this article:
Edaigbini SA, Anumenechi N, Odigie VI, Khalid L, Ibrahim AD. Open drainage for chronic empyema thoracis; clarifying misconceptions by report of two cases and review of literature. Arch Int Surg 2013;3:161-5
|How to cite this URL:
Edaigbini SA, Anumenechi N, Odigie VI, Khalid L, Ibrahim AD. Open drainage for chronic empyema thoracis; clarifying misconceptions by report of two cases and review of literature. Arch Int Surg [serial online] 2013 [cited 2024 Mar 1];3:161-5. Available from: https://www.archintsurg.org/text.asp?2013/3/2/161/122972
Empyema thoracis is generally appreciated as the presence of pus in the pleural space or a purulent pleural effusion. ,,, It must be appreciated that once actively multiplying bacteria can be demonstrated by either microscopy or can be cultured in a pleural fluid, it qualifies as empyema no matter how clear it may appear as this would definitely become purulent in the course of time without intervention or antibiotic treatment. Open drainage for chronic empyema thoracis is often mentioned even by medical students but the practical application is often not appreciated by even surgical residents especially in institutions where the expertise of the thoracic surgeon is lacking. In these settings, patients with chronic empyema thoracis are subjected to the trauma of repeated tube thoracostomy for recurrence of their effusion. The outcome of this mismanagement includes depression, economic loss to the family and the nation and the cosmetic defect from the many scars of repeated tube insertion. The objective of this paper was to present the management of two patients with chronic empyema by open drainage as well as the review of literature in this respect.
| Case Reports
This was a 40-year-old woman, who presented with 2 years history of cough, low grade fever, weight loss and difficulty with breathing. The cough was productive of scanty white sputum with only two episodes of streaky blood stains. There was no history of contact with a patient with chronic cough or drenching night sweats. 6 months prior to presentation, she developed difficulty with breathing especially on exertion with left sided pleuritic chest pain. She was managed at a peripheral hospital as a sputum negative tuberculosis patient based on the history and chest X-ray finding of left pleural effusion. Before referral to the cardiothoracic unit, she had had six tube thoracostomies for recurrent left pleural effusion. When she presented to us she already was on antituberculosis chemotherapy for 9 months with some improvement in her clinical symptoms. Examination revealed a young woman chronically ill-looking afebrile, anicteric, acyanosed, with some multiple, but insignificant cervical and axillary lymphadenopathy. She was scoliosed to the left, with multiple scars of previous tube thoracostomies on the left lateral chest wall. There were two sinuses discharging pus from the chest close to the scars. The left anterior chest wall was depressed at the apex and there was significantly reduced excursion on the left chest. The percussion note was dull and the breath sound was absent. The right chest was essentially normal as well as other systemic examinations. A diagnosis of left chronic empyema thoracic with empyema necessitans secondary to pulmonary tuberculosis was made. She had a chest X-ray [Figure 1], which showed marked reduced left lung volume with trapped left lung, crowded ribs on the left side and an air-liquid level suggestive of chronic empyema thoracis. Her packed cell volume was 36%, the serum electrolyte and urea assay was normal and she was retroviral negative. The pus microscopy and culture was sterile. She could not afford a computed tomography (CT)-scan of her chest so she had rib resection and open drainage. The finding at surgery included a thickened parietal peel (outer empyema membrane) of 2 cm, 400 ml of offensive and very thick pus and a left lung trapped beneath a dense visceral peel (inner empyema membrane) with areas of calcification. Post-operatively she had daily irrigation of the cavity with normal saline. She was encouraged to lie on the left lateral decubitus position to facilitate drainage of the cavity. She improved significantly, was discharged 6 weeks after surgery while it took 6 months for complete healing of drainage site. She has being followed-up for 3 years with no more discharge from the drainage site [Figure 2] and no other complaint, except for the ugly scar of repeated intubation and the cosmetic defect resulting from the residual fistulous tract, which is now almost sealed and no longer discharging. The histology of the empyema membrane came out as nonspecific chronic inflammation.
|Figure 1: Chest X-ray of patient 1, showing crowded and collapsed ribs on the left, signifi cantly reduced viable lung volume at medial left apex with rest of the radiolucent zone been the empyema cavity
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|Figure 2: Patient 1: Two years after surgery; fi gure showing the residual cosmetic defect after rib resection surrounded by multiple scars from previous tube thoracostomy
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This was an 18-year-old boy who presented with 1 year history of recurrent right pleural effusion and 4 months history of purulent discharge from the right chest wall. He was referred as a confirmed tuberculosis patient who had anti-tuberculosis drugs for a year. Prior to presentation, he had three different tube thoracostomies for recurrent right pleural effusion. A month after removal of the last chest tube, he noticed spontaneous purulent discharge from the site of last tube drainage. There was history of difficulty with breathing especially on exertion and extreme tiredness. He had lost weight significantly, but there was no history of cough, fever, orthopnea, body swellings or bone pains. On examination, he was found to be cachetic, afebrile, anicteric, not pale, no significant peripheral lymphadenopathy and no pedal oedema. He weighed 44 kg, but could not walk without support. Chest examination revealed kyphosis and scoliosis to the right. The right apical chest region was depressed with the scars of two previous tube thoracostomy and a fistula discharging pus in the mid right lateral chest wall. His respiratory rate was 39/min and his trachea deviated to the right. The intensity of breath sound was markedly diminished on the right side. The left chest was normal. The cardiovascular and abdominal findings were normal. A diagnosis of chronic right empyema thoracis with pleurocutaneous fistula was made. He had a chest X-ray [Figure 3], which revealed right pyopneumothorax, trapped right lung with thickened parietal and visceral pleurae and tracheal deviation to the right with hyperinflated left lung. His packed cell volume was 34%, electrolyte and urea and random blood sugar was normal and retroviral screen was negative. The pus microscopy and culture yielded a mixed growth of Candida albicans and Staphylococcus aureus sensitive to clindamycin and oxacillin while his erythrocyte sedimentation rate was 82 mm/h. He could not afford a chest CT-scan. He was placed on the high protein diet, multivitamins oral clindamycin and ketoconazole. He was counselled, for surgery and had rib resection and open drainage [Figure 4]. He was continued on his pre-operative drugs post-operatively for 2 weeks and daily irrigation and drainage of the empyema. He was discharged on the 25 th post-operative day with a weight of 47 kg (2 kg above the pre-operative weight). By the 4 th month the drainage site was completely healed and much reduced in size. He was followed-up for 9 months after discharge after which he was lost to follow-up.
|Figure 3: Chest X-ray of patient 2, showing the pyopneumothorax and crowded ribs on the right. The thick visceral peel can be appreciated as the dense white opacity at the medial end of the triangle with viable
lung reduced to a fraction at the apex of the lung
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|Figure 4: Open drainage for patient 2, showing an 8 cm × 4 cm wide defect in the lateral right chest wall
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The optimal treatment for chronic empyema thoracis is controversial. , This is because the management of the chronic empyema thoracis depends upon the degree of chronicity. The treatment option depends on the surgeon's judgement, of patient's fitness and the quality of the underlying lung.  The American Thoracic Society defines any empyema lasting 4 weeks and beyond as chronic. , The options in the surgical management of chronic empyema thoracis include decortication, rib resection and tube drainage or rib resection and open drainage and thoracoplasty (collapse therapy). ,, Thoracoplasty considered to be a mutilating procedure and poorly tolerated by patients is rarely practiced today. It requires the segmental resection of variable number of ribs posteriorly (sparing the first) considered as sufficient to obliterate the empyema cavity by collapsing the chest wall.  Decortication is done through a posterolateral thoracotomy for chronic empyema in a fit patient with the healthy ipsilateral lungs confirmed by CT scan. It requires the excision of the thickened visceral peel (which trapped the lung and the) parietal peel. Expansion of the freed lung allows apposition with the chest wall allowing for obliteration of the space(similar to pleurodesis). , It is important to note that many patients with chronic empyema thoracis can be managed successfully with tube thoracostomy particularly in children. This is often the approach to management in resource poor environment.  This however, would often require a prolonged hospital stay and its attendant cost implication. Patient may however be discharged on tube drainage connected to a drainage bag until chest X-ray confirms space obliteration.  In chronic cases where the parietal peel is very thick, sometimes up to 3 cm and even calcified (as in our first patient), the intercostal spaces are so reduced that one or two rib segments (5 cm long) have to be resected to allow for passage of the chest tube.  In some instances, the tube could be cut flush with the skin as a modification of an open drainage. Open drainage of empyema thoracis is advocated in chronic cases often with deformed chest wall and patients who are unfit for thoracotomy or whose underlying lung is so diseased that re-expansion can neither be achieved by tube drainage nor decortication.  This was the scenario in both our patients. The principle is based on the fact that the residual lung is already trapped by the thick empyema membrane, which equally stabilizes the mediastinum such that the flutter effect that results from exposure of the pleural space to atmospheric pressure is prevented.  The procedure requires resection of 7-8 cm segment of two consecutive ribs in the lateral chest wall through a H-shaped incision. The limbs of the H should overlap two ribs while the bridge should be at least 7.5 cm long. The redundant flaps between the limbs of the H-incision are now sutured (marsupialisation) to the underlying parietal empyema membrane to allow for a fistulous connection (eloesser window). ,, The cavity is daily irrigated with antiseptic solution and can be packed with gauze. Over time, there is granulation and the cavity reduces by a combination of diaphragmatic elevation and gradual chest wall collapse. The size of the window also reduces with time allowing for only a small cosmetic defect so also is the purulent discharge, which ceases after some months. It is however necessary not to place the window too low in the lateral chest wall as the rising diaphragm could occlude the window and prevent drainage. For this reason, the region of the 5 th to 6 th rib is suggested from experience, but some surgeons advocate positioning the window in the most dependent part of the cavity. , For our patients; however, the 5 th and 6 th region was chosen. When the trauma of surgery has reduced and pain is no longer severe patient is encouraged to lie on the side of the window to facilitate drainage. By the 3 rd post-operative week most patients should be fit for discharge and capable of managing the drainage at home with few instructions, most importantly change of dressing when soaked. It is important to state that the pus would always re-accumulate unless the space is obliterated by one of the several options earlier mentioned. Prior to the establishment of the cardiothoracic unit in our institution most cases of empyema where drained by tube thoracostomy repeated as many times as the patient presented (as in Patient 1). This was as a result of lack of expertise and the erroneous opinion that pneumothorax would complicate the procedure. This impression has been eroded following a better appreciation of the pathology of empyema and the management options as a result of the series of patients managed in the institution.  Other advantage of this open-flap is that it creates a skin-lined fistula that provides drainage without tubes. It can therefore be more easily managed by the patient at home and permits gradual obliteration of the empyema space.  It is important not to perform an open drainage procedure too early in the course of a complicated parapneumonic effusion. If the visceral and parietal pleura adjacent to the empyema cavity have not been fused by the inflammatory process, exposure of the pleural space to atmospheric pressure will result in a pneumothorax. Before open-drainage procedures, this possibility can be evaluated by leaving the chest tube exposed to atmospheric pressure for a short period and determining radiologically whether the lung has collapsed. The high mortality with parapneumonic effusions during World War I has been attributed to performing open drainage procedures too early.  Patients treated with open-drainage procedures can expect to have an open chest wound for a prolonged period. In one older series of 33 patients treated by open drainage procedures, the median time for healing the drainage site was 142 days.  It took 6 months and 4 months to achieve same in our first and second patients respectively. The longer duration in the former may be due to the degree of chronicity as evidenced by calcification of the visceral peel and the fibrosis in the vicinity due to the trauma from multiple tube thoracostomies at the site. With decortication, the period of convalescence is much shorter, but decortication is a major surgical procedure that cannot be tolerated by debilitated patients. In some rare instances, some patients who have had open drainage may eventually be fit to undergo decortication or the residual opening is closed after several months when there is no longer drainage and there is radiological evidence that the empyema cavity is obliterated.
In conclusion, open drainage for empyema is an option for the management of chronic empyema patients who are too sick to withstand decortication and whose residual lung is so diseased that it is not expected to re-expand by whatever means. This is particularly true in our environment where patients present late either due to poverty and ignorance or are poorly managed by inexperienced physicians. Pneumothorax is not a complication following this procedure because the chest wall and the mediastinum have been stabilized against atmospheric pressure by the thick empyema membrane.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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