in thoracic surgery empyema main disease which need to handle through decortication either open or vats. there is number of modalities which favor its treatment

2. Empyema thoraces
Dr Ibrahim Baloch
Resident, Thoracic surgery department
Combined Military Hospital
Rawalpindi, Pakistan

3. • Patient Name XYZ
• Gender Male
• Age 43
• Profession worker

4. • Referred from pulmonary ward
• CO
• Fever 1month
• chest pain 15days
• Cough with sputum 15days
OE
Right sided crept and reduced air entry

6. • Diagnosed
• Empyema thoraces
• Operated
• open decortication

7. Empyema Thoracis
• Defined as “pus in the
chest”
• Ancient disease
• Hippocrates credited
with first description of
natural history and
treatment
• Most common precursor is
bacterial pneumonia and
subsequent
parapneumonic effusion
Hippocrates of Kos 460-370 B.C.

8. When empyemata are opened by cautry or by knife;
and the pus flows out pure and white, the patient
survives, but if it is mixed with blood; muddy and
foul smelling, he will die

9. EMPYEMA THORACIS
STATISTICS
• 32,000 patients treated for empyema per year
• 30% require surgical drainage of the pleural space
• PARA PNEUMONIC EFFUSIONS 20-60%
• PROGRESSION TO EMPYEMA 5-10%
• ELDERLY/DEBILITATED mortality 25-75%

10. TEST ABNORMAL
VALUE
FREQUENTLY
ASSOCIATED
CONDITION
WBCs >10000 PYOGENIC INFECTION
MESOTHELIAL CELLS ABSENT TB
PROTEIN PF/S >0.5 EXUDATE
LDH PF/S >0.6 EXUDATE
LDH I/U >200 EXUDATE
GLUCOSE mg/dl <60 EMPYEMA,TB
MALIGNANCY,RA
pH <7.21-7.29 EMPYEMA,TB
MALIGNANCY,RA,ESOPHAG
EAL RUPTURE

11. ETIOLOGY OF EMPYEMA
• Infective 40-60%
• Post thoracotomy 20%
• Post traumatic 4-10%

12. STAGES OF EMPYEMA THORACIS
• Exudative stage
• Fibrinopurulent stage
• Organization stage
ACUTE
CHRONIC

13. COMPLICATIONS OF UNTREATED EMPYEMA
• Sepsis and its complications
• MODS
• Pulmonary fibrosis and contraction of pleural cavity
• Empyema necessitatum-drainage through the chest wall
• Bronchopleural fistula
• Local spread
• Mediastinum
• Pericardium
• Distant infections
• Osteomyelitis
• Brain abcesses

14. INVESTIGATIONS
• Thoracentesis
• Physical exam
• Microbiology
• Biochemistry
• Protiens
• pH
• LDH
• Glucose
• Chest X ray
• US Chest
• CT scan
• Ventilation perfusion scan (selected cases)

15. RADIOLOGICAL SIGNS

17. SPLIT PLEURAL SIGN

19. FACTORS AFFECTING TREATMENT OPTIONS
• ETIOLOGY OF EMPYEMA
• TIME OF PRESENTATION TO THORACIC SURGEON
• ADEQUACY OF INITIAL MANAGEMENT
• GENERAL CONDITION
• CONDITION OF UNDERLYING LUNG
• CO-MORBIDS
• PREVIOUS OPERATIONS

20. TREATMENT MODALITIES
• INERCOSTAL TUBE DRAINAGE
• SIMPLE INTUBATION
• WITH FIBRINOLYTIC AGENTS
• WITH IRRIGATION
• VATS EMPYEMALYSIS
• DECORTICATION
• VATS DECORTICATION
• OPEN DECORTICATION
• LUNG RESECTION +
• SPACE FILLING THERAPY
• SPACE COLLAPSE THERAPY
• OPEN DRAINAGE
• TUBE DRAINAGE
• PLEUROCUTANEOUS WINDOW
STAGE I & II
STAGE III

21. Surgical management of empyema

22. STAGE I EMPYEMA THORACIS
BEFORE CHEST DRAINAGE AFTER CHEST DRAINAGE
CHEST TUBE

23. STAGE II EMPYEMA THORACIS
(FIBRINOPURULENT STAGE)
VATS EMPYEMALYSIS

24. VATS PRE-OPERATIVE
POSTOPERATIVE

27. STAGE III EMPYEMA THORACIS
OPEN DECORTICATION

31. CALCIFIED
PEEL

32. EMPYEMA
NECESSITATUS

33. OPEN DRAINAGE
• CLAGGET
,
S WINDOW
(PLEURO CUTANEOUS WINDOW)

34. PLEUROCUTANEOUS WINDOW

35. PLEUROCUTANEOUS WINDOW

36. COMPLICATED EMPYEMAS
• POLYMICROBIAL INFECTIONS
• UNDERLYING LUNG DISEASE
• MDR TUBERCULOSIS
• RECURRENT EMPYEMAS
• POST RESECTIONAL EMPYEMA
• BRONCHOPLEURAL FISTULA

37. EMPYEMA WITH BRONCHOPLEURAL
FISTULA

38. EMPYEMA WITH BRONCHOPLEURAL
FISTULA

40. BRONCHIAL
COMMUNICATION

41. CLOSURE OF
FISTULA WITH
INTERCOSTAL FLAP

42. THORACOPLASTY

43. THORACOPLASTY

44. TYPICAL X RAYS POST
THORACOPLASTY

45. SPACE OBLITERATION PROCEDURES
• SPACE FILLING PROCEDURES
• POST DECORTICATION LUNG REEXPANSION
• MUSCLE FLAP TRANSPOSITION
• APICAL SPACE
• PECTORALIS MAJOR
• SERRATUS ANTERIOR
• BASAL & POSTEROLATERAL SPACE
• LATTISSIMUS DORSI
• GREATER OMENTUM

46. THANK YOU