THORACIC EMPYEMA
Category: Pediatric Surgery
Abstract : Thoracic Empyema (TE) is an infection (pus) of the pleural cavity. TE develops after complications of bacterial pneumonia (most commonly), thoracic trauma or surgery. Three distinct phases of TE developments are recognized: exudative, fibrinopurulent and organizing. In the early exudative phase the fluid is thin with a low viscosity and cellular content. Intravenous antibiotics, aspiration or ches
Thoracic Empyema (TE) is an infection (pus) of the pleural cavity. TE develops after complications of bacterial pneumonia (most commonly), thoracic trauma or surgery. Three distinct phases of TE developments are recognized: exudative, fibrinopurulent and organizing. In the early exudative phase the fluid is thin with a low viscosity and cellular content.
Intravenous antibiotics, aspiration or chest tube drainage accomplishes successful management as the lung expands rapidly. This phase can be followed by bacterial invasion, deposition of fibrin, increase turbidity and cellular content with fixed, less expandable, lung tissue known as fibrinopurulent stage. Loculations form, effective closed pleural drains become impossible and antibiotics are less effective in this phase. If left untreated (two to four weeks after primary infection) the TE goes through a final organizing stage with thickening of the fibrinous peel and complete lung entrapment. In this final stage open decortication may be required. Success in management of TE consists in identifying its early phases followed by thorough debridement and lysing of the pleural space of all fibrinous material, adhesions and loculations during the fibrinopurulent phase before fibrosis begins. Indication for video-assisted thoracoscopic debridement includes lack of medical response, pulmonary air leakage, localized effusion, persistent respiratory distress and pleural thickening without resolution on imaging (US or CT Scan). Thoracoscopic debridement and irrigation have accomplished this goal in several series of children reducing complications from open thoracotomy and hospital stay. Early thoracoscopy facilitates removal of restrictive purulent debris, decreases parenchymal injury, promotes rapid recovery and has a high rate of success. Benefits include good visualization of the entire thoracic cavity for more effective debridement and efficient drainage, and subjectively diminished postoperative pain and associated morbidity.
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