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PubMed2004

Intrapleural streptokinase for empyema and complicated parapneumonic effusions.

We conducted a single-center, randomized, placebo-controlled trial to determine whether streptokinase instillations adjunctive to chest tube drainage reduce the need for surgery and improve outcome in patients with pleural empyema. Fifty-three patients (frank pus aspirated, 81%; microbiological agent cultured, 62%; mean effusion pH, 6.6 +/- 0.4) received antibiotic treatment, chest tube drainage, and once-daily pleural rinses with either normal saline or normal saline with streptokinase (250,000 IU). Nine patients were excluded for various reasons before pleural rinses were started. Streptokinase (n = 22) was instilled over 4.5 +/- 2 days and saline (n = 22) was instilled over 3 +/- 1.3 days. One patient in each group died during treatment. Clinical treatment success and need for referral to surgery were the main outcome measures. No difference was observed after 3 days. After 7 days, streptokinase-treated patients had a higher clinical success rate (82 vs. 48%, p = 0.01) and fewer referrals for surgery (45 vs. 9%, p = 0.02). No significant radiologic or functional differences were observed between groups during follow-up over 6 months. We conclude that intrapleural streptokinase adjunctive to chest tube drainage reduces the need for surgery and improves the clinical treatment success in patients with pleural empyema.

Adult↗
PubMed1993

Tangential fluoroscopic guidance of the anesthetizing needle during transthoracic needle lung biopsy: a randomized controlled clinical trial.

The effectiveness of tangential fluoroscopic guidance of the anesthetizing needle to avoid transgression of the pleura and therefore lower pneumothorax and chest tube insertion rates after transthoracic needle lung biopsy (TNB) was investigated. Tangential guidance was used in 41 patients (group A) and was not used in 51 (group B). The pneumothorax rate was 39% (16 of 41) for group A and 31% (16 of 51) for group B. The chest tube insertion rate was 12% (five of 41) for group A and 4% (two of 51) for group B. None of the differences in rates were significant. Use of this technique does not lower pneumothorax or chest tube insertion rates in patients undergoing TNB.

Adult↗
PubMed1992

Exigent postinjury thoracotomy analysis of blunt versus penetrating trauma.

We reviewed the recent experience with urgent thoracotomy performed in the operating room (OR) to compare the relative indications and injury pattern after blunt versus penetrating trauma. Among 2,316 patients admitted with acute trauma of the chest, excluding 319 undergoing thoracotomy at the emergency department, 83 required urgent OR thoracotomy; 27 patients (3 percent) sustained blunt trauma, 32 (4 percent) had stab wounds (SW) and 24 (7 percent) had gunshot wounds (GSW). The indications for operation after blunt trauma were shock (48 percent) and angiographically defined great vessel injuries (48 percent). For SW, thoracotomy was done for tamponade (50 percent), excessive chest tube output (28 percent) or shock (15 percent), and for GSW, thoracostomy output (50 percent), shock (25 percent) or tamponade (12.5 percent). Descending thoracic aorta (DTA) or other arch vessel tears were confirmed in 48 percent of patients with blunt trauma requiring thoracotomy; the remaining had pulmonary (31 percent) or cardiac wounds (7 percent). The most frequently encountered injuries in patients with SW were cardiac (46 percent) and pulmonary (37 percent), while the patients with GSW had predominantly pulmonary (72 percent) and cardiac (14 percent) injuries. The surgical management of blunt versus penetrating chest trauma differs with respect to the indications for urgent thoracotomy as well as the underlying injury pattern. The most common indication for urgent thoracotomy after penetrating injuries was excessive chest tube output (37.5 percent). Excluding torn DTA, only 14 of 822 patients (1.7 percent) admitted with blunt chest trauma required urgent thoracotomy and 13 of these patients (93 percent) presented in a state of refractory shock because of active thoracic hemorrhage. Thus, in contrast with penetrating wounds, urgent thoracotomy for blunt trauma is rarely justified on the basis of chest tube output alone.

Adult↗
PubMed2003

A comparison between the prone and lateral position for performing a thoracoscopic anterior release and fusion for pediatric spinal deformity.

STUDY DESIGN: Retrospective review of all patients who had a single stage thoracoscopic anterior release and spine fusion followed by a posterior spinal fusion with posterior instrumentation. OBJECTIVE: To analyze the results and complications of patients undergoing a thoracoscopic anterior release and fusion comparing those performed prone with those in the lateral position. SUMMARY OF BACKGROUND DATA: The lateral position has traditionally been used when performing a thoracoscopic anterior spinal release and fusion during a single-stage anterior spinal release and fusion/posterior spinal fusion with instrumentation. Although some have reported the thoracoscopic technique in the prone position, there are no direct comparison studies between the prone and lateral position. METHODS: A retrospective review was performed of all patients who had a single stage thoracoscopic anterior spinal release and fusion and posterior spinal fusion with instrumentation from a single institution. The medical record was reviewed to determine demographic data, positioning of the patient, levels fused, anesthesia time, operative time, chest tube drainage, and complications. Radiographs were reviewed to determine preoperative curve magnitude and postoperative curve correction. The Student t test was used to compare groups and statistical significance was defined as P < 0.05. RESULTS: There were 16 patients in the prone group and 27 in the lateral group. Adolescent idiopathic scoliosis was the most common diagnosis in both groups. All patients had a single-stage thoracoscopic anterior spinal release and fusion/posterior spinal fusion with instrumentation. In the prone group, the patient was positioned prone on a Hall-Relton frame or roll (small patients) for both the anterior spinal release and fusion and posterior spinal fusion with instrumentation. There were no significant differences between the prone and lateral groups with respect to age, gender, height, weight, and curve magnitude (73.8 degrees vs. 71.5 degrees ). There were fewer fused anterior levels in the prone group (5.3 vs. 6.2) (P = 0.05). When analyzing parameters that reflect potential difficulties imposed by the prone position, there were no statistically significant differences noted between groups, although there was a trend toward less anterior operative time per disc (24.3 vs. 25.9 minutes/disc), greater blood loss/anterior disc level (33.5 vs. 26.8 cc/disc), greater total chest tube drainage (445 vs. 419 cc), and less days with the chest tube in place (2.2 vs. 2.3 days) for the prone group when compared to the lateral group. There were statistically significant differences between the prone and lateral groups with respect to anesthesia preparation time (42.8 vs. 64.8 minutes), delay between the completion of the anterior procedure and the start of the posterior procedure (11.8 vs. 69.5 minutes), and the incidence of complications related to the use of single-lung ventilation (0 vs. 14.8%)(P < 0.05). Patients in the prone group required less time on oxygen after surgery (34.8 vs. 51.6 hours) and were discharged home earlier (4.6 vs. 5.5 days) (P < 0.05). CONCLUSIONS: A thoracoscopic anterior spinal release and fusion in the prone position appears to achieve the same results as when performed in the lateral position for pediatric spinal deformity. The prone position saves time in the operating room due to decreasing the time needed by the anesthesiologists and the transition time between the anterior and posterior procedures. Potentially serious complications related to single-lung ventilation are avoided with bilateral-lung ventilation in the prone position.

Adolescent↗
PubMed2004

Pain levels experienced with activities after cardiac surgery.

BACKGROUND: Acute pain is common after cardiac surgery and can keep patients from participating in activities that prevent postoperative complications. Accurate assessment and understanding of pain are vital for providing satisfactory pain control and optimizing recovery. OBJECTIVES: To describe pain levels for 5 activities expected of patients after cardiac surgery on postoperative days 1 to 6 and changes in pain levels after chest tube removal and extubation. METHODS: Adults who underwent cardiac surgery were asked to rate the pain associated with various types of activities on postoperative days 1 to 6. Pain levels were compared by postoperative day, activity, and type of cardiac surgery. Pain scores before and after chest tube removal and extubation also were analyzed. RESULTS: Pain scores were higher on earlier postoperative days. The order of overall pain scores among activities (P < .01) from highest to lowest was coughing, moving or turning in bed, getting up, deep breathing or using the incentive spirometer, and resting. Changes in pain reported with coughing (P = .03) and deep breathing or using the incentive spirometer (P = .005) differed significantly over time between surgery groups. After chest tubes were discontinued, patients had lower pain levels at rest (P = .01), with coughing (P = .05), and when getting up (P = .03). CONCLUSIONS: Pain relief is an important outcome of care. A comprehensive, individualized assessment of pain that incorporates activity levels is necessary to promote satisfactory management of pain.

Adult↗
PubMed1989

Intrapleural streptokinase in management of parapneumonic effusions. Report of series and review of literature.

Noncommunicating locules of fluid may develop in the setting of a thoracic empyema or a complicated parapneumonic effusion. When this occurs a single chest tube may not provide adequate drainage. In an effort to promote drainage and thereby obviate the need for further procedures, instillation of streptokinase into the involved pleural space has been advocated. This communication reviews the literature and reports our experience with intrapleural streptokinase. In our retrospective review of nine patients, instillation of streptokinase resulted in an obvious increase in chest tube drainage in six. Of the nine patients, four with improved drainage required no further procedures. Two patients with improved drainage and the three with no change in drainage required an additional chest tube, a decortication procedure, or were lost to follow-up. None of the four patients with an empyema were benefitted. Intrapleural instillation of streptokinase may be a useful adjunct in the treatment of a complicated parapneumonic effusion but appears less likely to be of benefit in the management of an empyema.

Adult↗
PubMed2006

Management of spontaneous pneumothorax: state of the art.

Spontaneous pneumothorax remains a significant health problem. However, with time, there have been improvements in pathogenesis, diagnostic procedures and both medical and surgical approaches to treatment. Owing to better imaging techniques, it is now clear that there is almost no normal visceral pleura in the case of spontaneous pneumothorax, and that blebs and bullae are not always the cause of pneumothorax. In first episodes of primary spontaneous pneumothorax, observation and simple aspiration are established first-line therapies, as proven by randomised controlled trials. Aspiration should be better promoted in daily medical practice. In the case of recurrent or persistent pneumothorax, simple talc poudrage under thoracoscopy has been shown to be safe, cost-effective and no more painful than a conservative treatment using a chest tube. There are also new experimental data showing that talc poudrage, as used in Europe, does not lead to serious side-effects and is currently the best available pleural sclerosing agent. Alternatively, surgical techniques have considerably improved, and are now less invasive, especially due to the development of video-assisted thoracoscopic surgery. Studies suggest that video-assisted thoracoscopic surgery may be more cost-effective than chest tube drainage in spontaneous pneumothorax requiring chest tube drainage, although it is more expensive than simple thoracoscopy and requires general anaesthesia, double-lumen tube intubation and ventilation. Recommendations are made regarding the treatment of pneumothorax. In secondary or complicated primary pneumothorax, i.e. recurrent or persistent pneumothorax, some diffuse treatment of the visceral pleura should be offered, either by talc poudrage under thoracoscopy or by video-assisted thoracoscopic surgery. Moreover, all of these new techniques should be better standardised to permit comparison in randomised controlled studies.

Cost-Benefit Analysis↗
PubMed2002

Intentional resection of the diaphragm during cytoreductive laparoscopic radical nephrectomy.

PURPOSE: Laparoscopic radical nephrectomy is being performed more commonly. To our knowledge intentional resection of the diaphragm during laparoscopic radical nephrectomy for large renal tumors has not yet been described. We detail the laparoscopic management of diaphragmatic resection. MATERIALS AND METHODS: From March 1996 to February 2001, 36 patients underwent cytoreductive laparoscopic radical nephrectomy at our institution in preparation for systemic immunotherapy. Charts and operative tapes were reviewed and cases were identified in which diaphragmatic resection was performed for locally invasive tumors. RESULTS: In 3 patients a portion of the diaphragm was dissected via laparoscopy during debulking nephrectomy. All patients had renal cell carcinoma with documented metastatic disease. The diaphragm was repaired laparoscopically using intracorporeal suturing techniques in 2 of the 3 patients and a chest tube was placed in all 3. Transient systolic hypotension and hypercarbia in 1 case resolved with manual ventilation. The chest tube was removed on postoperative days 2 to 4. There were no complications and no ipsilateral pleural metastasis was identified at an average of 6 weeks (range 2 to 23) of followup. CONCLUSIONS: A portion of the diaphragm may be intentionally resected during laparoscopic radical nephrectomy. This maneuver may be successfully managed without conversion to an open procedure. In cases of a large diaphragmatic defect or the potential for coagulopathy postoperatively a chest tube should be inserted. Potential invasion of the diaphragm by large tumors should not be considered a contraindication to cytoreductive laparoscopic radical nephrectomy.

Adult↗
PubMed1979

[Therapeutic recommendations in idiopathic spontaneous pneumothorax].

The treatment of spontaneous pneumothorax is still controversial. To evaluate pleural drainage with a chest tube the therapeutic results in 73 patients with benign pneumothorax were reviewed. Benign spontaneous pneumothorax treated with a thick chest tube size Charrière 18-22 disappeared within an average of only 6.6 days. On the other hand, the high recurrence rate of 24% after the initial pneumothorax and 37% after the first recurrence is comparable with the results of conservative management in other pneumothorax series in the literature. Small pneumothorax without severe symptoms should therefore be supervised conservatively on an outpatient basis. The more extended forms of pneumothorax should be treated with thick chest tubes. Failure of therapeutic effect, second ipsilateral relapse or the first contralateral pneumothorax are indications for parietal pleurectomy.

Adult↗
PubMed2001

Tension pneumocephalus resulting from iatrogenic subarachnoid-pleural fistulae: report of three cases.

BACKGROUND: Symptomatic pneumocephalus may result from a cerebrospinal fluid leak communicating with extradural air. However, it is a rare event after thoracic surgical procedures, and its management and physiology are not widely recognized. METHODS: During the past 2 years, we have identified 3 patients who developed pneumocephalus after thoracotomy for tumor resection. Only 1 patient had a discernible spinal fluid leak identified intraoperatively. Two patients experienced delayed spinal fluid drainage from their chest tubes and subsequently developed profound lethargy, confusion, and focal neurologic signs. The third patient was readmitted to the hospital with a delayed pneumothorax and altered mental status. Radiographic imaging in all patients showed significant pneumocephalus of the basilar cisterns and ventricles. RESULTS: The first 2 patients were managed by discontinuation of the chest tube suction and bedrest. The third patient underwent surgical reexploration and nerve root ligation. All 3 patients had resolution of their symptoms within 72 hours. CONCLUSIONS: Pneumocephalus is a rare, but serious, complication of thoracotomy. Previous patients reported in the literature have been managed with reoperation to ligate the nerve roots. However, the condition resolved nonoperatively in 2 of our patients. Discontinuation of chest tube suction may be definitive treatment and is always the important initial management to decrease cerebrospinal fluid extravasation into the pleural space and allow normalization of neurologic symptoms.

Adenocarcinoma↗
PubMed1998

Serial observations after high dose talc slurry in the rabbit model for pleurodesis.

The mechanisms leading to a pleurodesis after the intrapleural injection of a sclerosing agent are not completely understood. The purpose of the present study was to make serial observations over 28 days on the pleural fluid findings and the gross and microscopic changes in the pleura after talc slurry administered intrapleurally at a high dose. Sixty-six rabbits received 400 mg/kg talc slurry. Ten to 12 rabbits were sacrificed 1, 2, 4, 7, 14, and 28 days after the intrapleural injection. At sacrifice the pleural fluid was measured and analyzed, and the pleural surfaces were studied grossly and microscopically. The intrapleural injection of 400 mg/kg talc slurry resulted in an acute exudative pleural effusion that persisted for 4 days. There was a progressive increase in the gross and microscopic fibrosis over the 28 days. Talc was present at the time of sacrifice in all animals. At 28 days there was a clinically significant pleurodesis in all rabbits; pleurodesis was not observed before this time. From this study we conclude that the intrapleural injection of 400 mg/kg talc slurry leads to an acute exudative pleural effusion and clinically significant pleurodesis that is present on day 28 but not day 14. It appears that the production of a pleurodesis requires higher doses of talc in rabbits without a chest tube than in humans with a chest tube.

Acute Disease↗
PubMed1992

Communication between the two pleural cavities after major cardiothoracic surgery: relevance to percutaneous intervention.

The authors describe evidence of communication between the two pleural cavities after major cardiothoracic surgery (combined heart and lung transplantation, heart transplantation, and correction of complex congenital heart disease) performed in three patients. In two patients, unilateral lung biopsy caused a symptomatic bilateral pneumothorax. This was successfully treated with insertion of a single chest tube in one patient and two chest tubes in the other patient. In the third patient, simultaneous evacuation of large bilateral pleural effusions was performed by means of unilateral thoracentesis because of the presence of a common pleural cavity.

Biopsy, Needle↗
PubMed1997

A randomized trial of empyema therapy.

STUDY OBJECTIVES: To determine the optimal treatment of empyema thoracis (within the fibrinopurulent phase of illness) comparing pleural drainage and fibrinolytic therapy vs video-assisted thoracoscopic surgery (VATS), with regard to efficacy and duration of hospitalization. DESIGN: Twenty patients with confirmed parapneumonic empyema thoracis were randomized to chest tube pleural drainage plus streptokinase (CT-SK) vs VATS. SETTING: University-based teaching hospital providing for Dallas County. PATIENTS AND METHODS: Equivalent groups of patients with parapneumonic empyema thoracis were randomized to receive either of two therapies: CT-SK (n=9) or VATS (n=11). Outcomes analysis with respect to treatment efficacy, hospital duration, chest tube duration, hospital costs, and need for subsequent procedures was performed. RESULTS: Each group suffered one mortality (p=not significant). When compared with the CT-SK group, the VATS group had a significantly higher primary treatment success [10/11, 91% vs 4/9, 44%; p<0.05 Fisher's Exact Test], lower chest tube duration (5.8+/-1.1 vs 9.8+/-1.3 days; p=0.03), and lower number of total hospital days (8.7+/-0.9 vs 12.8+/-1.1 days; p=0.009). Clinically relevant but not statistically significant differences in hospital costs ($16,642+/-2,841 vs $24,052+/-3,466, p=0.11) also favored the VATS group. Of note, all the CT-SK treatment failures could be salvaged with VATS, and none required thoracotomy. CONCLUSIONS: In patients with loculated, complex fibrinopurulent parapneumonic empyema thoracis, a primary treatment strategy of VATS is associated with a higher efficacy, shorter hospital duration, and less cost than a treatment strategy that utilizes catheter-directed fibrinolytic therapy.

Adult↗
PubMed1994

Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas.

Acute multiloculated thoracic empyemas incompletely drained by tube thoracostomy alone usually require operation. To avoid a thoracotomy yet treat this difficult problem, intrapleural fibrinolytic agents were employed. Between April 1, 1990, and April 1, 1993, 13 consecutive patients presenting with a fibrinopurulent empyema were demonstrated to have incomplete drainage. To facilitate drainage, streptokinase, 250,000 units in 100 mL 0.9% saline solution (3 patients), or urokinase, 100,000 units in 100 mL 0.9% saline solution (10 patients), was instilled daily into the chest tube, and the tube was clamped for 6 to 12 hours followed by suction. This routine was continued daily for a mean of 6.8 +/- 3.7 days (range, 1 to 14 days) until resolution of the pleural fluid collection was demonstrated by computed chest tomography and clinical indications. This regimen was completely successful in 10 of 13 patients (77%), who had resolution of the empyema, eventual withdrawal of chest tubes, and no recurrence. Two patients, both pediatric liver transplant patients, had an initial good response but eventually required decortication. One patient with a good radiographic response became increasingly febrile during streptokinase therapy and underwent a thoracotomy, but no significant undrained fluid was found. This patient's continued fever was believed to be a streptokinase reaction. Urokinase was used subsequently. No treatment-related mortalities or complications occurred. Intrapleural fibrinolytic agents, especially urokinase, are safe, cost-effective means of facilitating complete chest tube drainage, thereby avoiding the morbidity of a major thoracotomy for 77% of a group of multiloculated empyema patients who traditionally would have required open surgical therapy.

Adult↗
PubMed1999

Early definitive intervention by thoracoscopy in pediatric empyema.

PURPOSE: Nineteen children had early thoracoscopic intervention for empyema between 1992 and 1997 at the LeBonheur Children's Medical Center. The authors have evaluated the results of this treatment. METHODS: Thoracoscopic intervention was performed at the fibrinopurulent state of empyema. An irrigating laparoendoscope was inserted, loculi were disrupted, debris was evacuated, and a chest tube was passed through the port site. RESULTS: The patients were aged between 11 months and 16 years (mean, 6.5 years). The etiology of the empyema was parapneumonic in 17, and there was one case each of perforated appendicitis and mediastinal histoplasmosis. They underwent thoracoscopy at a mean of 4.6 days after hospital admission (range, 1 to 12 days). Chest tubes were removed at 1 to 5 days (mean, 2.9 days) after operation, and resolution of fever occurred at 1 to 9 days (mean, 3.8 days) postoperatively. Patients were discharged home between 4 and 10 days (mean, 6.1 days) postoperatively, and the mean hospital stay was 10.3 days (range, 5 to 21). There were no complications. The surgical technique was simple and well tolerated, requiring few disposable items, and the mean operating time was 77 minutes. CONCLUSIONS: Thoracoscopy eliminated the morbidity of thoracotomy and the discomfort and expense of prolonged chest tube drainage. Thoracoscopy may be used as early first-line therapy in a majority of pediatric patients with fibrinopurulent empyema.

Adolescent↗
PubMed1999

Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. A randomized, double-blind study.

Intrapleural administration of fibrinolytic agents has been shown to be effective and safe in the treatment of loculated parapneumonic pleural effusions. However, controlled studies of the possible role of the activity of urokinase (UK) through the volume effect are lacking. We therefore investigated the hypothesis that UK is effective through the lysis of pleural adhesions and not through the volume effect. Thirty-one consecutive patients with multiloculated pleural effusions were randomly assigned to receive either intrapleural UK (15 patients) or normal saline (NS) (16 patients) for 3 d, in a double-blind manner. All patients had inadequate drainage through a chest tube (< 70 ml/24 h). UK was given daily through the chest tube in a dose of 100.000 IU diluted in 100 ml of NS. Controls were given the same volume of NS intrapleurally. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasonography (US) and/or computed tomography (CT). Clinical and radiographic improvement was noted in all but two patients in the UK group but in only four in the control group. The net mean volume drained during the 3-d treatment period was significantly greater in the UK group (970 +/- 75 ml versus 280 +/- 55 ml, p < 0.001). Pleural fluid drainage was complete in 13 (86.5%) patients in the UK group (two patients were treated through video-assisted thoracoscopy) but in only four (25%) in the control group. Twelve patients in the control group were subsequently treated with UK and six of them had complete drainage; the remaining six patients had complete drainage after video-assisted thoracoscopy. Our results suggest that UK is effective in the treatment of loculated pleural effusions through the lysis of pleural adhesions and not through the volume effect.

Adult↗
PubMed1990

Usefulness of the blood patch technique after transthoracic needle aspiration biopsy.

The authors investigated the effectiveness of the blood patch technique in reducing the pneumothorax and chest tube insertion rates after transthoracic needle lung biopsy. Biopsy of 100 pulmonary nodules was performed with a coaxial system. In this prospective, randomized study, patients either received a blood patch (group A, n = 46) or did not (group B, n = 47). Seven procedures were excluded: five for technical reasons and two because of lack of follow-up information. Comparison of the two groups by means of X2 analysis and the Student t test revealed no difference in the mean age, gender, smoking history, proportion of heavy smokers, nodule size, presence of cavitation, or number of needle passes. The pneumothorax rate was 24% (11 of 46 patients) in group A and 30% (14 of 47 patients) in group B. The chest tube insertion rate was 2.2% (one patient) in group A and 2.1% (one patient) in group B. The difference between the groups in either rate was not significant (P greater than .5). The blood patch technique did not lower the rate of pneumothorax or chest tube insertion.

Biopsy, Needle↗