Surgical Management of Empyema. Mr Nadeem Haider Paediatric Surgeon Christchurch Hospital

Transcription

1 Surgical Management of Empyema Mr Nadeem Haider Paediatric Surgeon Christchurch Hospital

2 History A person with empyemata shall die on 14 th day unless something favourable supervene" would rather die at the hand of God than surgeons

3 Stages of Development Exudative (PPE) Fibrinopurulent Organised

4 Aims of Treatment To restore normal lung function by 1) Eradicating infection 2) Draining pleural fluid, if necessary 3) Re-expansion of lung

5 When to Refer? Disease progression despite intensive/appropriate medical management

6 Guidelines for Treatment Summary of position statement from Thoracic society of Australia and New Zealand Admit CXR U/S (Main initial investigation) Moderate to large effusions to be drained Fluid

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9 Treatment Options Antibiotics only (No pleural intervention) When should pleural fluid be managed?(critical clinical decision) Paed retrospective study 2010 Size Symptoms Loculations

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13 Optimal Timing for Surgical Intervention Padman R et al;parapneumoniceffusion and empyema in children: Retrospective review of the dupont experience; Clin Paediatr;2007; VATS performed within 48 hours of diagnosis LOS Kalfa et al; Thoracoscopy in paediatric pleural empyema: A prospective study of prognostic factors; JPS; 2006;41; Delay in diagnosis of > 4 days = longer operative time, post op fever,drainage, hospitalization, and more post operative complications

14 Single Multiple Thoracocentesis Not tolerated well by younger children LOS longer Prospective nonrandomized trial (Shoseyov et al; Short term course and outcome of treatments of pleural empyema in paediatric patients: repeated ultrasound guided needle thoracocentesis vs chest tube drainage. Chest;2002;121: )

15 Tube Thoracostomy BTS guidelines Small calibre drains Multiple studies confirm that size of drain does not matter

16 Real Debate Tube thoracostomy with intrapleural fibrinolysis v/s VATS Traditionally, surgery has been mainstay of empyema treatment With increasing acceptance of MIS, VATS has gained popularity

17 Two Prospective Controlled Trials UK and USA 3 doses of fibrinolytics used Primary outcome (LOS post treatment) Failure rate was 16.6% in both studies Significantly higher cost in VATS group

18 Fibrinolysis or VATS Pro Fibrinolysis Non operative No GA Less resource mobilization Outcome similar Physiologic upset can result in clinical deterioration VATS more expensive Pro VATS Fibrinolysis makes VATS difficult One curative procedure, mostly Comparison between VATS and thoracotomy

19 Results Sonnapa 2006 N = 60 St. Peter 2009 N = 36 Arm Urokinase VATS tpa VATS Length of stay (days) 6 (4-25) 6 (3-16) Charges Failure rate 16.6% 16.6%

20 Which Fibrinolytic Agents? Streptokinase Urokinase tpa

21 Deoxyribonuclease Mucolytic Independently, inferior In combination with fibrinolytics, it decreases viscosity of fluid Rabbit model: superior results No data on children Prospective trial in adults

22 VATS after Fibrinolytic Therapy When? Persistently ill (T>38 degree C)after completion of fibrinolysis and despite decrease in drain output Imaging: substantial pleural disease

23 Christchurch Experience 21 VATS further interventions (2 repeat VATS, 1 thoracotomy, I chest drain)

24 Hamilton Experience 23 Empyema 11 (Medical management or ICD without fibrinolysis) 12 Fibrinolysis None required VATS.

25 Cost Implications of Fibrinolysis Urokinase $160 ($960) Streptokinase $129 ($774) tpa $1018 ($3054) 1 day on paediatric ward ($900) 1 hour operation under GA ($5500)

26 Cost Comparison of Treatment Options in NZ Urokinase tpa VATS $ 12,000 $ 14,000 $13,600

27 Management of Empyema with Abscess CT: peripheral and not communicating with airway (antibiotics and drainage) If communicates: AB s and resection if does not resolve

28 Management of Empyema with Necrosis Continue intravenous antibiotics If child becomes toxic, thoracotomy and resection

29 Duration of antibiotics Standard 2-6 weeks

30 Conclusion Management of large complex pleural effusion remains controversial Thoracostomy drain with fibrinolysis and VATS are both accepted forms of treatment Local facilities and technical expertise may influence the treatment option

31 Thank You