Original article
General thoracic
Choice of First Intervention is Related to Outcomes in the Management of Empyema

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.
https://doi.org/10.1016/j.athoracsur.2009.01.028Get rights and content

Background

The study determined whether the first procedure; simple drainage (tube thoracostomy, pigtail catheter) or operation (video-assisted thoracic surgery [VATS], thoracotomy) was related to outcomes in the management of empyema.

Methods

Data were collected from 104 consecutive patients with empyema. Primary outcomes were additional procedures and death. Predictor variables included age, delay, Karnofsky performance status (KPS), Charlson comorbidity index (CCI), serum albumin, malignancy, Acute Physiology and Chronic Health Evaluation II score, loculations on computed tomography scan, empyema stage, and first procedure choice.

Results

Advanced empyema (≥ stage IIA) was present in 84% of patients. Overall treatment success rates (no death, no additional drainage procedures) among evaluable patients for pigtail drainage, tube thoracostomy, VATS, and thoracotomy were 40% (4 of 10), 38% (14 of 37), 81% (13 of 16), and 89% (32 of 36), respectively. Five patients underwent miscellaneous procedures. Univariate variables associated with hospital death included KPS, CCI, and drainage as the first procedure. In multivariate analyses, KPS (coefficient, –0.06, p = 0.002) and failure of the first procedure (odds ratio [OR], 6.76; 95% confidence interval [CI], 1.45 to 31.4, p = .01) were independent predictors of death. Simple drainage as the first procedure was a strong, independent predictor of failure of the first procedure (OR, 11.1; 95% CI, 3.51 to 34.9; p = .00004).

Conclusions

The choice of the first procedure is critical in the outcome for treatment of empyema, even with adjustment for confounding variables. VATS or thoracotomy as initial therapy for advanced empyema is associated with better outcomes.

Section snippets

Patients and Methods

The study (552-06-021, SC #3278) was approved without reservations by the Wright State University Institutional Review Board on March 22, 2007. Individual consent was waived for this retrospective record review. We examined hospital records from the VA Medical Center and Miami Valley Hospital between the years 2000 and 2006. Patients with empyema were identified by searching operating room databases, microbiology laboratory records, and discharge diagnoses.

To form a truly consecutive,

Results

We identified 106 consecutive patients with empyema. Two patients with ATS stage III empyema and fibrothorax were excluded from further analysis. The remaining 104 patients (85 men, 19 women) were aged 17 to 89 years. Smoking, alcohol abuse, multiple medical problems, poor performance status, and impaired nutrition characterized many of the patients. Most patients had clinically advanced empyema (Table 1).Table 2 provides the pleural culture results. Multiple organisms were identified, the

Comment

Although we recognize the limitations of a retrospective study, the results appear helpful in determining the best initial therapy for empyema. Our experience suggests strongly that early and aggressive management is best for most patients, especially those with empyema that is at a clinically advanced stage. These results are consistent with findings of numerous other studies suggesting the superiority of VATS or thoracotomy over simple drainage techniques [8, 9, 10, 11, 12].

Some have

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