Empyema after image-guided percutaneous intercostal drainage of subdiaphragmatic collection: a case series

Abstract

Background: Treatment of subdiaphragmatic collection by intercostal image-guided drain placement is associated with a risk of pleural complications including potentially life-threatening pleural empyema. Descriptions of patient characteristics and clinical course of postinterventional pleural empyema are lacking. We aim to present characteristics, clinical course and outcomes of patients with empyema after intercostal approach of drain placement.

Methods: Data was collected as a retrospective single center case series and included adult patients with decortication for treatment of pleural empyema after image-guided percutaneous intercostal drainage of a subdiaphragmatic collection between 01.01.2009 and 31.01.2021.

Results: We identified ten patients, nine male and one female, all suffering from subdiaphragmatic collection treated with intercostal drain. All patients developed pleural empyema after drain placement and received surgical decortication. Similarities between patients were drain placement under computed tomography (CT)-guidance (eight of ten patients), lateral position of the drain (seven of ten patients), drain insertion in the eighth intercostal space (ICS) (six of ten patients) and existing comorbidities as malnutrition (six of ten patients), diabetes (four of ten patients) and cancer (three of ten patients). The majority of patients had a prolonged length of hospital stay (LOS) with an average duration of 40 days. Nearly half of the patients needed intensive care unit (ICU) treatment and one patient died postoperatively from respiratory exhaustion.

Conclusions: In this series, empyema after intercostal drainage was associated with prolonged LOS and was potentially life-threatening. The most commonly shared features in our cohort were the high prevalence of comorbidities, drain insertion above ninth ICS as well as lateral position of the drain. These factors should be addressed in prospective studies to evaluate potential correlation with postinterventional empyema. For optimal management of patients with subdiaphragmatic collection treated by intercostal drainage, awareness of potential associated complications is crucial.

Keywords: Intercostal drainage; case series; decortication; empyema; subdiaphragmatic collection.

Figure 1

CT-scan of case 1 demonstrating (A) pleural empyema with air entrapments; (B) splenic abscess; (C) drain through the ninth ICS via the diaphragm (dashed line). CT, computed tomography; ICS, intercostal space.

Figure 2

Fluoroscopy image of case 4 during reposition of pleural drain eight days after intercostal drain placement into abdominal collection: (A) pleural drain; (B) drain through the eighth ICS traversing the diaphragm (dashed line); (C) supradiaphragmatic contrast medium after administration via the intercostal drain. ICS, intercostal space.

Figure 3

Images show CT-guided drain placement of case 6: (A) intercostal drain inserted through the eighth ICS; (B) collection in splenic bed; (C) anterior pneumothorax indicating pleural lesion during drain placement. CT, computed tomography; ICS, intercostal space.

Figure 4

Images of CT-guided drainage insertion of case 7: (A) abscess in liver; (B) intercostal drain via eighth lateral ICS; (C) intercostal drain through the ventral seventh ICS; (D) extensive pleural effusion five days after drain placement; (E) persisting air entrapment after iatrogenic pneumothorax during pleural punction. CT, computed tomography; ICS, intercostal space.

Figure 5

Image of case 9 during drain placement under CT-guidance: (A) drain through sixth ICS in a subdiaphragmatic abscess; (B) normal lung expansion without effusion. CT, computed tomography; ICS, intercostal space.