Empyema thoracis: a role for open thoracotomy and decortication

Background-Thoracentesis and antibiotics remain the cornerstones of treatme nt in stage I empyema. The management of disease progression or late presen tation is controversial. Open thoracotomy and decortication is perceived to be synonymous with protracted recovery and prolonged hospitalisation. Advo cates of thoracoscopic adhesiolysis cite earlier chest drain removal and ho spital discharge. This paper challenges traditional prejudice towards open surgery. Methods-A five year audit of empyema cases referred to a regional cardiotho racic surgical unit analysing previous clinical course, surgical management , and outcome. Results-Between February 1992 and February 1997, the number of referrals to this centre increased dramatically. Twenty two children were referred for surgery (15 boys, seven girls; age range, 0.5-16 years). Before referral, p atients had been unwell for 6-50 days (median, 15), had been treated with s everal antibiotics, and had undergone chest ultrasound (15 patients), compu ted tomography (five patients), pleural aspiration attempts (13 patients), and intercostal drainage (seven patients). The organism responsible was ide ntified in only two cases (Streptococcus pneumoniae). Three patients had in traparenchymal abscess formation. Eighteen patients underwent open thoracot omy and decortication. Drain removal was performed on the first or second d ay. Fever resolved within 48 hours. Median hospital stay was four days. All patients had complete clinical and radiological resolution. Conclusions-Treatment must be tailored to the disease stage. In stage II an d III diseases, open decortication followed by early drain removal results in rapid symptomatic recovery, early hospital discharge, and complete resol ution. In the early fibrinopurulent phase, alternative strategies should be considered. However, even in ideal cases, neither fibrinolysis nor thoraco scopic adhesiolysis can achieve more rapid resolution at lower risk.