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DECORTICATION IN THE MANAGEMENT OF THE COMPLICATIONS OF STAPHYLOCOCCAL PNEUMONIA IN INFANTS AND CHILDREN
DECORTICATION I N T H E M A N A G E M E N T OF T H E COMPLICATIONS OF STAPHYLOCOCCAL P N E U M O N I A I N I N F A N T S A N D CHILDREN Malcolm J. Thomas, M.D.*
Frederick H. Taylor,
M.D.,
Paul W. Sanger, M.D., and Francis Robicsek, M.D., Charlotte, N, C.
W
ITH the recent increase in incidence of staphylococcal pneumonia in infants and children, complications requiring surgical treatment have become a frequent and distressing problem. The management of such complications has been repeatedly discussed in the past, but with the increasing incidence of anti biotic-resistant staphylococcal infections, a re-emphasis of the surgical prin ciples seems advisable. The physician who first treats a patient with staphylo coccal pneumonia should understand thoroughly the complications of the dis ease and the frequent necessity for surgical intervention. Adequate antibiotic therapy following sensitivity studies of the organism may be life-saving, both in the acute phase, to prevent fulminating infection, and in the surgical con valescence phase, to prevent further complications. This report is a review of the histories of 16 infants and children who had decortications for problems presented by this disease. The patients varied in age from 3 months to 9 years, with an average age of 2 years. The Staphylococcus aureus was isolated from the pleural fluid of 8 patients and was the probable causative organism in the remaining cases. INTRATHORACIC SURGICAL COMPLICATIONS
Table I shows the surgical complications that we encountered in patients who developed staphylococcal pneumonia. Empyema was the most frequently encountered complication (Fig. 1) in these infants and children and was the most frequent reason for thoracic con sultation. For all patients, preliminary needle aspirations to obtain pleural exudate were done for localization of pleural accumulations, and for immediate Gram stain, culture, and sensitivity studies. In 11 of the 16 patients, one or From the Laboratory for Cardio-Pulmonary Research, Charlotte Memorial Hospital, Charlotte, N. C. This research was supported by grants by the John A. Hartford Foundation and the United Medical Research Foundation of North Carolina. Received for publication Sept. 3, 1964. 'Present address: Department of Surgery, The University of Texas M. D. Anderson Hos pital and Tumor Institute, Texas Medical Center, Houston, Texas. 708
Vol. 49, No. 4 April, 1965
STAPHYLOCOCCAL P N E U M O N I A I N CHILDREN
7f
TABLE I. SURGICAL COMPLICATIONS ENCOUNTERED I N 16 P A T I E N T S W I T H STAPHYLOCOCCAL PNEUMONIA
COMPLICATIONS Empyema Intrapulmonary abscess Pneumatocele Bronchopleural Tension pneumothorax
I
fistula
NUMBER 16 14 8 6 5
more chest tubes were inserted into the pleural space and connected to watersealed drainage to prevent the reaccumulation of fluid, tension pneumothorax, and absorption of toxic products (Fig. 2). The 5 children who did not have tube thoracostomies had been found by needle aspiration to have small amounts (2 to 8 c.c.) of purulent material; the pleural cavities in these children could not be adequately drained because of a diffuse, multiloculated form of empyema. The instillation of enzymes in an attempt to dissolve the loculations was not used since that technique has proved to be of doubtful value in the management of empyema and has been reported to occasionally open a bronchopleural fistula. Likewise, antibiotics were not used in the pleural space because they did not seem to offer more than effective drainage and would only have delayed the recovery of an infant in need of drainage. Intrapulmonary abscesses were found in 14 of the 16 patients. Interestingly, only 3 of the patients demonstrated true abscess formation on x-ray films. This finding may be explained by the characteristic pathologic pattern of the nee-
Fig. 1.—X-ray film of chest taken at admission to the hospital shows opaciflcation of entire left side of chest with shift of mediastinum to opposite side. Figr. 2.—After insertion of chest tube, there is considerable decrease in left pleural effusion.
Fig. 3.—Posteroanterior x-ray films of chest made 5 days after admission shows pneumatoceles throughout left lung. Fig. 4.—Chest x-ray film taken after 13 days of hospitalization demonstrates a large pyopneumothorax on left side.
rotizing process, which extends to the periphery of the lungs via the smaller bronchi, and ruptures intrapleurally before an air-fluid level can be demon strated. Pneumatoceles were noted on chest x-ray examination (Fig. 3) in 8 pa tients and were believed to be responsible for tension pneumothoraxes in 3 patients who were treated immediately by underwater catheter drainage (Pig. 4). Two other patients had tension pneumothoraxes which had resulted from ruptured subpleural abscesses and the establishment of a bronchopleural fistula. INDICATIONS FOR THORACOTOMY
When the above-mentioned surgical procedures failed to clear the pleural cavity (Pig. 4), early thoracotomy with decortication and pleural resection, if necessary, was performed. When empyema becomes organized, the decortica tion procedure is associated with significant blood loss and increased air leak age from the lung surface which will add to the morbidity of the procedure. In this series, the average number of days in the hospital before thoracotomy was 13.3. Before admission to the hospital, each child had been sick for an average of 11.7 days. Nine of the children had been treated as outpatients with nonspecific antibiotics for an average of 18 days. DISCUSSION
Table I I shows the operative procedures performed on the 16 infants and children. There was no surgical mortality.
Vol. 49, No. 4 April, 1965
STAPHYLOCOCCAL
PNEUMONIA
IN
CHILDREN
TABLE II. OPERATIVE PROCEDURES PERFORMED ON 16 PATIENTS PROCEDURE Decortication Right upper lobectomy Right lower lobectomy Left lower lobectomy Segmental resection
:
j
NUMBER 16 3 4 4 2
Preoperative bronchoscopy was done in all patients to clear the tracheobronchial tree of thick tenacious mucus, to rule out stenosis or occlusion of the bronchial orifices, and to obtain material for further culture and sensitivity studies. When the pleural cavity was opened, the 16 patients demonstrated un resolved loculated empyema with partially expanded lungs surrounded by a thick pleural "peel." Excision of this infected membrane allowed the lungs at the completion of the procedure to expand adequately, to fill the chest cavity, and to return the patient to a less toxic state. Pulmonary resections were performed in 13 patients who were found at thoracotomy to have intrapulmonary abscesses. The involved lobes showed areas of intensive necrosis and suppuration that required resection to prevent further pulmonary complications, the possibility of hematogenic spread, and such later sequelae as chronic bronchitis and bronchiectasis (Figs. 5, 6). The average postoperative hospital stay for the 16 patients was 11.4 days.
Pig. 5.—Chest x-ray film taken 9 days after decortication and left lower lobectomy shows expansion of left upper lobe and pleural effusion. Fig. 6.—Chest x-ray film taken 1% years after decortication and left lower lobectomy shows good expansion of the left upper lobe.
J. Thoracic and Cardiovas. Surg.
THOMAS ET AL.
712
Postoperative complications occurred in only 3 patients. The first complication was atelectasis of the right lower lobe following decortication and right upper lobectomy. The patient responded to bronchoscopy and frequent endotraeheal suction. The second complication, a pneumothorax, occurred 8 days after dis charge from the hospital; the patient responded to tube thoracostomy with closed drainage. Residual empyema that drained spontaneously through the thoracotomy incision was the third complication, and necessitated further de cortication and thoracoplasty (ribs 2-4) to obliterate the dead space. SUMMARY
This report concerns 16 infants and children with staphylocoecal empyema that necessitated decortication. Indications for surgical management and post operative complications are discussed. No surgical deaths occurred in this series. REFERENCES 1. Bie, K., and Steen, J . : Staphylocoecal Empyema in Children, Acta paediat. (Upps) 49: 605, 1960. 2. Bloomer, W. E., Giammona, S., Lindskog, G. E., and Cooke, E. E . : Staphylocoecal Pneu monia and Empyema in Infancy, J. THORACIC SURG. 30: 265, 1955. 3. Campbell, T. M., Jr., Jenkins, M. C , and Scott, R. B . : Empyema in Infants and Chil dren as a Clinical Problem, J . Nat. M. A. 5 1 : 344, 1959. 4. DeNiord, E. N., J r . : Decortication for Empyema and Hemothorax, Virginia M. Monthly 87: 627, 1960. 5. Fobes, G. B . : Diagnosis and Management of Severe Infections in Infants and Children, J . Pediat. 29: 45, 1946. 6. Gourlay, E. H . : Staphylocoecal Pneumonia and Empyema in Infants and Children, Canad. M. A. J . 87: 1101, 1962. 7. Hendren, W. H., and Haggerty, E. J . : Staphylocoecal Pneumonia in Infancy and Chil dren, J . A. M. A. 168: 6, 1958. 8. Hertzler, J . H., Miller, A. E., and Tuttle, W.: Present Concepts in the Treatment of Empyema in Children, Arch. Surg. 68: 38, 1954. 9. Jewett, T. C , Jr., Carberry, O. M., and Neter, E . : Staphylocoecal Empyema in Children, Ann. Surg. 153: 447, 1961. 10. Kiesewetter, W. B., Eusnock, J . R., and Girdany, B. R.: Pediatric Empyema: A Second Look at I t s Incidence and Importance, J . Pediat. 54: 81, 1959. 11. Koch, R., Carson, M. J., and Donnell, G.: Staphylocoecal Pneumonia in Children. A Re view of 83 Cases, J . Pediat. 55: 473, 1959. 12. Lionakis, B., Gray, S. W., Skandalakis, J., and Hopkins, W. A.: Empyema in Children, J . Pediat. 53: 719, 1958. 13. Magovern, G. J., and Blades, B . : Staphylocoecal Empyema, J . A. M. A. 168: 365, 1958. 14. Minor, C. L., and Moschakis, E. A.: Staphylocoecal Pneumonia and I t s Complications. A Surgical Emergency in Infants and Children, Clin. Pediat. 1: 111, 1962. 15. Moore, T. C , and Battersby, J . S.: Pulmonary Abscess in Infancy and Childhood: Report of 18 Cases, Ann. Surg. 151: 496, 1960. 16. Netterville, R. E . : Staphylocoecal Empyema in Infants and Children, J . Mississippi M. A. 1: 363, 1960. 17. Pont, M. E., and Rountree, W. C.: The Medical and Surgical Treatment of Staphylocoecal Pneumonia, Dis. Chest 4 3 : 176, 1963. 18. Ravitch, M. M., and Fein, R.: The Changing Picture of Pneumonia and Empyema in Infants and Children, J . A. M. A. 175: 1039, 1961. 19. Rebhan, A. W., and Edwards, H. E . : Staphylocoecal Pneumonia: A Review of 329 Cases, Canad. M. A. J . 82: 513, 1960. 20. Richardson, W. R.: Surgical Complications of Staphylococcus Pneumonia in Infants and Children, Am. Surgeon 27: 354, 1961. 21. Sabiston, D. C , Jr., Hopkins, E. H., Cooke, R. E., and Bennett, I. L., J r . : The Surgical Management of Complications of Staphylocoecal Pneumonia in Infancy and Child hood, J .
THORACIC & CARDIOVAS. SURG. 38:
421,
1959.
22. Seley, G. P . : Staphylocoecal Pneumonia and Pvopneumothorax, S. Clin. North America 40: 1029, 1960.
Vol.49, No. 4 April, 1965
STAPHYLOCOCCAL P N E U M O N I A I N CHILDREN
713 '
23. Taylor, E. R.: Staphylococcal Pneumonia and Empyema in Infants and Children, Tr. South. S. A. 72: 379, 1960. 24. Watkins, E., Jr., and Hering, A. C.: Surgical Considerations in the Treatment of Staphylo coccal Pneumonia, S. Clin. North America 4 1 : 695, 1961. 25. Watkins, E., Jr., and Fielder, C. R.: Management of Nontubereulous Empyema, S. Clin. North America 4 1 : 681, 1961. 26. Wheeler, W. E . : Certain Aspects of the Treatment of Staphylococcal Infections, Pediat. Clin. North America 7: 825, 1960. 27. Willman, V. L., Lewis, J . J., and Hanlon, C. R.: Staphylococcal Pneumonia, Arch. Surg. 83: 93, 1961.
Frederick H. Taylor,
M.D.,
Paul W. Sanger, M.D., and Francis Robicsek, M.D., Charlotte, N, C.
W
ITH the recent increase in incidence of staphylococcal pneumonia in infants and children, complications requiring surgical treatment have become a frequent and distressing problem. The management of such complications has been repeatedly discussed in the past, but with the increasing incidence of anti biotic-resistant staphylococcal infections, a re-emphasis of the surgical prin ciples seems advisable. The physician who first treats a patient with staphylo coccal pneumonia should understand thoroughly the complications of the dis ease and the frequent necessity for surgical intervention. Adequate antibiotic therapy following sensitivity studies of the organism may be life-saving, both in the acute phase, to prevent fulminating infection, and in the surgical con valescence phase, to prevent further complications. This report is a review of the histories of 16 infants and children who had decortications for problems presented by this disease. The patients varied in age from 3 months to 9 years, with an average age of 2 years. The Staphylococcus aureus was isolated from the pleural fluid of 8 patients and was the probable causative organism in the remaining cases. INTRATHORACIC SURGICAL COMPLICATIONS
Table I shows the surgical complications that we encountered in patients who developed staphylococcal pneumonia. Empyema was the most frequently encountered complication (Fig. 1) in these infants and children and was the most frequent reason for thoracic con sultation. For all patients, preliminary needle aspirations to obtain pleural exudate were done for localization of pleural accumulations, and for immediate Gram stain, culture, and sensitivity studies. In 11 of the 16 patients, one or From the Laboratory for Cardio-Pulmonary Research, Charlotte Memorial Hospital, Charlotte, N. C. This research was supported by grants by the John A. Hartford Foundation and the United Medical Research Foundation of North Carolina. Received for publication Sept. 3, 1964. 'Present address: Department of Surgery, The University of Texas M. D. Anderson Hos pital and Tumor Institute, Texas Medical Center, Houston, Texas. 708
Vol. 49, No. 4 April, 1965
STAPHYLOCOCCAL P N E U M O N I A I N CHILDREN
7f
TABLE I. SURGICAL COMPLICATIONS ENCOUNTERED I N 16 P A T I E N T S W I T H STAPHYLOCOCCAL PNEUMONIA
COMPLICATIONS Empyema Intrapulmonary abscess Pneumatocele Bronchopleural Tension pneumothorax
I
fistula
NUMBER 16 14 8 6 5
more chest tubes were inserted into the pleural space and connected to watersealed drainage to prevent the reaccumulation of fluid, tension pneumothorax, and absorption of toxic products (Fig. 2). The 5 children who did not have tube thoracostomies had been found by needle aspiration to have small amounts (2 to 8 c.c.) of purulent material; the pleural cavities in these children could not be adequately drained because of a diffuse, multiloculated form of empyema. The instillation of enzymes in an attempt to dissolve the loculations was not used since that technique has proved to be of doubtful value in the management of empyema and has been reported to occasionally open a bronchopleural fistula. Likewise, antibiotics were not used in the pleural space because they did not seem to offer more than effective drainage and would only have delayed the recovery of an infant in need of drainage. Intrapulmonary abscesses were found in 14 of the 16 patients. Interestingly, only 3 of the patients demonstrated true abscess formation on x-ray films. This finding may be explained by the characteristic pathologic pattern of the nee-
Fig. 1.—X-ray film of chest taken at admission to the hospital shows opaciflcation of entire left side of chest with shift of mediastinum to opposite side. Figr. 2.—After insertion of chest tube, there is considerable decrease in left pleural effusion.
Fig. 3.—Posteroanterior x-ray films of chest made 5 days after admission shows pneumatoceles throughout left lung. Fig. 4.—Chest x-ray film taken after 13 days of hospitalization demonstrates a large pyopneumothorax on left side.
rotizing process, which extends to the periphery of the lungs via the smaller bronchi, and ruptures intrapleurally before an air-fluid level can be demon strated. Pneumatoceles were noted on chest x-ray examination (Fig. 3) in 8 pa tients and were believed to be responsible for tension pneumothoraxes in 3 patients who were treated immediately by underwater catheter drainage (Pig. 4). Two other patients had tension pneumothoraxes which had resulted from ruptured subpleural abscesses and the establishment of a bronchopleural fistula. INDICATIONS FOR THORACOTOMY
When the above-mentioned surgical procedures failed to clear the pleural cavity (Pig. 4), early thoracotomy with decortication and pleural resection, if necessary, was performed. When empyema becomes organized, the decortica tion procedure is associated with significant blood loss and increased air leak age from the lung surface which will add to the morbidity of the procedure. In this series, the average number of days in the hospital before thoracotomy was 13.3. Before admission to the hospital, each child had been sick for an average of 11.7 days. Nine of the children had been treated as outpatients with nonspecific antibiotics for an average of 18 days. DISCUSSION
Table I I shows the operative procedures performed on the 16 infants and children. There was no surgical mortality.
Vol. 49, No. 4 April, 1965
STAPHYLOCOCCAL
PNEUMONIA
IN
CHILDREN
TABLE II. OPERATIVE PROCEDURES PERFORMED ON 16 PATIENTS PROCEDURE Decortication Right upper lobectomy Right lower lobectomy Left lower lobectomy Segmental resection
:
j
NUMBER 16 3 4 4 2
Preoperative bronchoscopy was done in all patients to clear the tracheobronchial tree of thick tenacious mucus, to rule out stenosis or occlusion of the bronchial orifices, and to obtain material for further culture and sensitivity studies. When the pleural cavity was opened, the 16 patients demonstrated un resolved loculated empyema with partially expanded lungs surrounded by a thick pleural "peel." Excision of this infected membrane allowed the lungs at the completion of the procedure to expand adequately, to fill the chest cavity, and to return the patient to a less toxic state. Pulmonary resections were performed in 13 patients who were found at thoracotomy to have intrapulmonary abscesses. The involved lobes showed areas of intensive necrosis and suppuration that required resection to prevent further pulmonary complications, the possibility of hematogenic spread, and such later sequelae as chronic bronchitis and bronchiectasis (Figs. 5, 6). The average postoperative hospital stay for the 16 patients was 11.4 days.
Pig. 5.—Chest x-ray film taken 9 days after decortication and left lower lobectomy shows expansion of left upper lobe and pleural effusion. Fig. 6.—Chest x-ray film taken 1% years after decortication and left lower lobectomy shows good expansion of the left upper lobe.
J. Thoracic and Cardiovas. Surg.
THOMAS ET AL.
712
Postoperative complications occurred in only 3 patients. The first complication was atelectasis of the right lower lobe following decortication and right upper lobectomy. The patient responded to bronchoscopy and frequent endotraeheal suction. The second complication, a pneumothorax, occurred 8 days after dis charge from the hospital; the patient responded to tube thoracostomy with closed drainage. Residual empyema that drained spontaneously through the thoracotomy incision was the third complication, and necessitated further de cortication and thoracoplasty (ribs 2-4) to obliterate the dead space. SUMMARY
This report concerns 16 infants and children with staphylocoecal empyema that necessitated decortication. Indications for surgical management and post operative complications are discussed. No surgical deaths occurred in this series. REFERENCES 1. Bie, K., and Steen, J . : Staphylocoecal Empyema in Children, Acta paediat. (Upps) 49: 605, 1960. 2. Bloomer, W. E., Giammona, S., Lindskog, G. E., and Cooke, E. E . : Staphylocoecal Pneu monia and Empyema in Infancy, J. THORACIC SURG. 30: 265, 1955. 3. Campbell, T. M., Jr., Jenkins, M. C , and Scott, R. B . : Empyema in Infants and Chil dren as a Clinical Problem, J . Nat. M. A. 5 1 : 344, 1959. 4. DeNiord, E. N., J r . : Decortication for Empyema and Hemothorax, Virginia M. Monthly 87: 627, 1960. 5. Fobes, G. B . : Diagnosis and Management of Severe Infections in Infants and Children, J . Pediat. 29: 45, 1946. 6. Gourlay, E. H . : Staphylocoecal Pneumonia and Empyema in Infants and Children, Canad. M. A. J . 87: 1101, 1962. 7. Hendren, W. H., and Haggerty, E. J . : Staphylocoecal Pneumonia in Infancy and Chil dren, J . A. M. A. 168: 6, 1958. 8. Hertzler, J . H., Miller, A. E., and Tuttle, W.: Present Concepts in the Treatment of Empyema in Children, Arch. Surg. 68: 38, 1954. 9. Jewett, T. C , Jr., Carberry, O. M., and Neter, E . : Staphylocoecal Empyema in Children, Ann. Surg. 153: 447, 1961. 10. Kiesewetter, W. B., Eusnock, J . R., and Girdany, B. R.: Pediatric Empyema: A Second Look at I t s Incidence and Importance, J . Pediat. 54: 81, 1959. 11. Koch, R., Carson, M. J., and Donnell, G.: Staphylocoecal Pneumonia in Children. A Re view of 83 Cases, J . Pediat. 55: 473, 1959. 12. Lionakis, B., Gray, S. W., Skandalakis, J., and Hopkins, W. A.: Empyema in Children, J . Pediat. 53: 719, 1958. 13. Magovern, G. J., and Blades, B . : Staphylocoecal Empyema, J . A. M. A. 168: 365, 1958. 14. Minor, C. L., and Moschakis, E. A.: Staphylocoecal Pneumonia and I t s Complications. A Surgical Emergency in Infants and Children, Clin. Pediat. 1: 111, 1962. 15. Moore, T. C , and Battersby, J . S.: Pulmonary Abscess in Infancy and Childhood: Report of 18 Cases, Ann. Surg. 151: 496, 1960. 16. Netterville, R. E . : Staphylocoecal Empyema in Infants and Children, J . Mississippi M. A. 1: 363, 1960. 17. Pont, M. E., and Rountree, W. C.: The Medical and Surgical Treatment of Staphylocoecal Pneumonia, Dis. Chest 4 3 : 176, 1963. 18. Ravitch, M. M., and Fein, R.: The Changing Picture of Pneumonia and Empyema in Infants and Children, J . A. M. A. 175: 1039, 1961. 19. Rebhan, A. W., and Edwards, H. E . : Staphylocoecal Pneumonia: A Review of 329 Cases, Canad. M. A. J . 82: 513, 1960. 20. Richardson, W. R.: Surgical Complications of Staphylococcus Pneumonia in Infants and Children, Am. Surgeon 27: 354, 1961. 21. Sabiston, D. C , Jr., Hopkins, E. H., Cooke, R. E., and Bennett, I. L., J r . : The Surgical Management of Complications of Staphylocoecal Pneumonia in Infancy and Child hood, J .
THORACIC & CARDIOVAS. SURG. 38:
421,
1959.
22. Seley, G. P . : Staphylocoecal Pneumonia and Pvopneumothorax, S. Clin. North America 40: 1029, 1960.
Vol.49, No. 4 April, 1965
STAPHYLOCOCCAL P N E U M O N I A I N CHILDREN
713 '
23. Taylor, E. R.: Staphylococcal Pneumonia and Empyema in Infants and Children, Tr. South. S. A. 72: 379, 1960. 24. Watkins, E., Jr., and Hering, A. C.: Surgical Considerations in the Treatment of Staphylo coccal Pneumonia, S. Clin. North America 4 1 : 695, 1961. 25. Watkins, E., Jr., and Fielder, C. R.: Management of Nontubereulous Empyema, S. Clin. North America 4 1 : 681, 1961. 26. Wheeler, W. E . : Certain Aspects of the Treatment of Staphylococcal Infections, Pediat. Clin. North America 7: 825, 1960. 27. Willman, V. L., Lewis, J . J., and Hanlon, C. R.: Staphylococcal Pneumonia, Arch. Surg. 83: 93, 1961.