Surgical management of empyema thoracis - experience of a decade in a tertiary care centre in India

Abstract

Introduction and purpose: Empyema thoracis (ET) is defined as the accumulation of pus in the pleural cavity. Early stages of ET are treated medically and the late stages surgically. Decortication, thoracoplasty, window procedure (Eloesser flap procedure) and rib resections are the open surgical procedures executed. There are no strict guidelines available in developing nations to guide surgical decision-making, as to which procedure is to be followed.

Methods: Details of all adult patients treated surgically for ET, between the years 2009 and 2019, and maintained in a live database in our institute, were retrieved and analysed. Medically managed patients were excluded.

Results: There were 437 patients in the study. The average age was 38 years. There was right side preponderance with a male:female ratio of 5:1. Tuberculosis was the commonest aetiology identified in 248 (57%) patients and diabetes was the commonest co-morbidity present in 97 (22%) patients. There was a higher incidence of a window procedure (WP) in tubercular patients 145 (59%). Only 26 (14%) of the non-tubercular patients underwent a WP. Post-operative complications were persistent air leak in 12 (6%) patients and premature closure of a window in 7 (4%) patients. There were 4 (0.9%) post-operative mortalities.

Conclusion: Surgical management of late stages of ET provides good results with minimal morbidity and mortality. In developing nations like India, the high incidence of tuberculosis and late presentations make the surgical management difficult and the strategies different from those in developed nations. No clear guidelines exist for the surgical management of ET in developing nations. There is a need for a consensus on the surgical management of empyema in such countries.

Keywords: Decortication; Empyema; Rib resection; Thoracoplasty; Tuberculosis; Window procedure.

Fig. 1

a Late presentation of an empyema with a Malecot catheter in situ. b Sequelae of chronic empyema showing rib crowding, and thickened calcified pleura. c Right empyema extending across the mediastinum into the left side. d Empyema necessitans. e Ruptured hydatid cyst presenting as empyema. f Ruptured anterior mediastinal cyst presenting as empyema

Fig. 2

a Chest x-ray after a thoracoplasty for a left-sided post-pneumonectomy empyema with BPF. b CT scan of the same patient showing a completely collapsed left chest wall. c Clinical photograph post thoracoplasty, showing the collapse of the chest wall along with the scapula. d Clinical photograph demonstrating the limited mobility of the shoulder

Fig. 3

Stages in treatment by a WP. a X-ray at presentation. b X-ray in the immediate post-operative period. c Clinical photograph of window at creation. d X-ray 3 months after surgery. e X-ray 6 months after surgery. f Clinical photograph of the healed window at 6 months

Fig. 4

Peri-operative microbiological analysis

Fig. 5

Patient 1. a Healthy 5-year old window showing patent BPF. b Pedicled omentum being harvested by an upper midline laparotomy. c Healed window of the patient with primary closure of skin over transposed omentum. Patient 2. d TB right pyo-pneumothorax. e Healed window with an unsightly scar. f Elective repair of the scar after 5 years by a latissimus dorsi flap