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The management of empyema after thoracic wounding
The management of empyema after thoracic wounding Observations on 25 Vietnam casualties Sidney Levitsky, M.D.* Charles A. Annable, Major, MC, USA, and Paul A. Thomas, Colonel, MC, USA, Phoenixville, Pa.
z v l t h o u g h there have been marked advances in the treatment of penetrating wounds of the chest since the early descriptions of John Hunter in 1761 and Baron Larrey during the Napoleonic Wars, posttraumatic empyema continues to plague the military surgeon. Throughout World War I, the early years of World War II, and the early months of the Korean War, the incidence of empyema following thoracic wounds ranged from 25 to 30 per cent. 1 ' 2 - 3 The management of post-traumatic empyema continues to remain controversial. Recurrent consideration has been given to the merits of closed versus open drainage and more recently to the applicability of early formal thoracotomy. A recent experience with 25 thoracic casualties with empyema who were wounded in Vietnam and admitted to the U.S. Army Valley Forge General Hospital between March, 1966, and May, 1968, illustrates the dimensions of this problem. Clinical material During this 26 month period, out of a total of 4,149 casualties admitted from VietFrom The Department of Surgery, Thoracic Surgery Service, U.S. Army Valley Forge General Hospital, Phoenixville, Pa., 19460. Received for publication July 11, 1969. ♦Present address: Clinic of Surgery, National Heart Institute, National Institutes of Health, Bethesda, Md. 20014.
630
nam, 68 were admitted to the Thoracic Surgical Service and 37 per cent (25) had empyema. Only patients with chest wounds requiring further surgical evaluation were admitted to the thoracic surgical wards. Thus, this series does not reflect the true incidence of empyema among thoracic casualties returning from Vietnam. All of the patients were males varying in age from 18 to 29 years, with an average age of 21.8 years. They were admitted to this hospital 12 to 97 days after being wounded, with an average of 43.9 days. The majority of these patients (20) were wounded with high velocity missiles. In 17 patients with additional extrathoracic injuries, the diaphragm was involved in 12 and the abdominal viscera in 14. Initial care. Half of the patients exhibited the manifestations of severe hypovolemic shock immediately after being wounded and required up to 22 units of blood to achieve a stabilized condition. Twenty-three patients were treated initially by tube thoracostomy for hemopneumothorax. Two other patients had upper abdominal wounds in which the thoracic component was not appreciated until exploratory laparotomy was performed. Local wound debridement and closed tube thoracostomy were judged sufficient for the initial definitive management in 17 patients. Formal open thoracotomy was necessary in
Volume 59
Number 5
Management of empyema after thoracic wounding
631
May, 1970
Fig. 1. A, Empyema noted 15 days after patient was wounded and which was treated initially with a closed tube thoracostomy. This tube was removed after 7 days before adequate pulmonary re-expansion had occurred. B, A fluid level indicating a recurrent empyema and the presence of a foreign body are noted in this film obtained 38 days after wounding. C, Sinogram obtained 4 weeks after open drainage of empyema cavity and removal of the foreign body (portion of armored vest and missile). D, Complete wound closure 8 weeks following open-drainage procedure.
8 patients to control exsanguinating intrathoracic hemorrhage or a major air leak. This is four times greater than the previously reported incidence of open thoracotomy in thoracic combat casualties and reflects the severity of the injury encountered in this group of patients. All of the patients received penicillin, streptomycin, and chloramphenicol preoperatively. Two patients required tracheostomy and ventilatory support during this initial treatment phase. Diagnosis. Complicating empyema was first recognized 4 to 49 days after the patient was wounded, with an average time of 16.7 days. The diagnosis was suspected by
changes in the chest roentgenogram, which usually included the presence of fluid levels (Fig. 1). It was confirmed by the culture of the aspirated pleural fluid. An associated bronchopleural fistula was present in 13 patients. Bacteriologic studies available in 18 patients revealed an equal incidence of infection with a single organism and with a mixed flora. Staphylococcal and Pseudomonas infections predominated (Table I). Treatment. Initial management of the empyema during evacuation of these patients was concerned either with provision for pleural space drainage or with obliteration by operative removal of the infected con-
632
The Journal of
Levitsky, Annable,
Thomas
Thoracic and Cardiovascular Surgery
Table I. Bacteriological studies Organism
Number of patients (18)
Staphylococcus aureus Pseudomonas aeruginosa Klebsiella-Aerobacter Escherichia coli Streptococcus faecalis Proteus species Paracolon species
9 7 5 4 4 4 1
Table II. Initial unsuccessful forms of treatment for empyema in 25 casualties Closed drainage Open drainage Decortication Decortication and resection Aspiration
5 3 3 6 "35
Table III. Final mode of treatment Tube thoracostomy Rib thoracostomy Pulmonary Resection Excision of bronchopleuralcutaneous fistula Decortication
9 10 1 2 3
tents (Table II). Aspiration was useful in establishing bacteriologic diagnosis but did not provide adequate pleural space drainage for patients treated solely by this technique. Failure of closed drainage to permanently relieve the patients treated in this manner was usually associated with premature tube removal. Two patients treated initially by open drainage subsequently required formal thoracotomy to control a persistent bronchopleural fistula. Three patients previously treated by open drainage required secondary surgical revision to provide more dependent drainage. Six patients with high velocity wounds had early thoracotomy and decortication as the initial treatment for empyema. All of
these patients failed to achieve postoperative obliteration of the pleural space and went on to develop recurrent empyema. Five of these patients subsequently responded to open drainage and one required a pneumonectomy for eventual cure. A total of fifty-four operative procedures were required in the entire group of 25 patients to accomplish complete closure of the empyema cavity. Seventeen patients required two or more procedures. Open drainage, either by tube or rib thoracostomy, was the final mode of treatment in 19 (76 per cent) patients (Table III). All of the patients were eventually rehabilitated and discharged with completely closed wounds. In no case was thoracoplasty necessary. Discussion During the Civil War a 62.6 per cent mortality rate was noted in 8,715 cases of penetrating chest wounds in Union soldiers and Confederate prisoners.4 Although the specific incidence of post-traumatic empyema was not recorded, individual case reports suggest thoracentesis and open drainage as acceptable methods of treatment. During World War I and early World War II, empyema occurred in 25 to 30 per cent of the thoracic casualties. With the establishment of specific thoracic surgery centers and Burford's suggestion of early evacuation of the organized residual hemothorax, the empyema rate was reduced to 10 per cent by the end of World War II. 2 However, in the early months of the Korean War, the incidence of empyema again rose to 26 per cent.3 Patterson and co-authors,5 in a report from an intermediate care center, cite an empyema incidence of 6.1 per cent in Vietnam thoracic casualties. However, this estimate may require re-interpretation as 2 cases in our series were originally unrecognized by that group during the patients' sojourn in that center. During the Korean conflict, there was disagreement over whether intercostal tube drainage alone or multiple thoracentesis was more effective in reducing the incidence of an infected hemothorax. Valle3 observed that
Volume 59
Number 5
Management of empyema after thoracic wounding
633
May, 1970
92 per cent of the patients requiring decortication in Korea were among those who had closed intercostal tube drainage of the pleural space as opposed to thoracentesis. It is presently common practice in Vietnam for penetrating chest wounds to be treated by tube thoracostomy.0 All of the patients in this series were initially treated in this manner. However, in many of the cases in which empyema developed, there was evidence of premature tube removal before the hemothorax was fully evacuated and full pulmonary re-expansion had occurred. Over the past decade there has been some disagreement over the management of acute empyema. There have been advocates for open- or closed-drainage procedures7- s while others have favored early thoractomy. 910 In a recent editorial on this problem, Langston11 focused on two major errors of management: (1) overly long persistence in closed drainage, and (2) overenthusiasm for early decortication at formal thoracotomy. Six patients in this series underwent early thoracotomy for mechanical cleansing of the pleural cavity, and empyema recurred in all cases. Although no compliance studies have been performed, personal observation in Vietnam at open thoracotomy indicates an increased stiffness in the contused lung immediately after a high velocity wound. Radiologic evidence of this pulmonary contusion usually persists 3 to 6 weeks after wounding. It seems probable that the major reason for failure of early decortication in these cases of a high-velocity injury to the lung is the inability to obtain complete pulmonary re-expansion in the early postoperative period. Adequate open drainage continues to remain the most successful therapeutic procedure in the treatment of post-traumatic empyema. In 76 per cent of the patients treated in this manner, no further operative intervention was necessary. In addition, five out of the six treatment failures of early thoracotomy for empyema responded to open drainage. As soon as the diagnosis of post-traumatic empyema is suspected, pleural aspiration fol-
lowed by bacterial evaluation and the administration of appropriate antibiotics constitute the initial steps in treatment. If this therapy proves to be inadequate, as judged by the reaccumulation of fluid in the pleural space, closed drainage by tube thoracostomy is instituted. The frequently associated bronchopleural fistula may be evident at this juncture and should be evaluated by bronchography in individuals in whom a formal thoracotomy is anticipated. When the need for prolonged drainage of the pleural space becomes evident, conversion to an open system is effected by using the same tube site or by rib resection to ensure adequate dependent egress of pleural accumulations. Formal thoracotomy with decortication is indicated when there is lack of progressive cavity closure or the persistence of a bronchopleural fistula. Summary A series of 25 patients with pleural empyema complicating treatment for chest wounds sustained in Vietnam is reported. The following observations have been made. 1. Early thoracotomy directed toward elimination of the infected pleural space did not appear to reduce morbidity; continued pleural drainage was necessary in each of 6 patients so treated. 2. Ultimate establishment of open pleural space drainage was sufficient to relieve 76 per cent of these patients of their empyema. REFERENCES 1 The Medical Department of The United States Army in the World War, Washington, D. C , 1925, U. S. Government Printing Office, Vol. 15, p. 2. 2 Burford, T. H., Parker, E. P., and Samson, P. C : Early Pulmonary Decortication in the Treatment of Post-traumatic Empyema, Ann. Surg. 122: 163, 1945. 3 Valle, A. R.: Management of War Wounds of the Chest, J. THORACIC SURG. 24: 457,
1952.
4 The Medical and Surgical History of the War of the Rebellion (1861-1865), edited by Barnes, J. K., Washington, D. C , 1870, U. S. Government Printing Office, Part I, pp. 526-606. 5 Patterson, L. T., Schmitt, H. J., and Armstrong, R. G.: Intermediate Care of War
6 34
The Journal of
Levitsky, Annable,
Thomas
Thoracic and Cardiovascular Surgery
Wounds of the Chest, J. THORAC. CARDIOV. SURG. 55: 16,
1968.
6 Military Surgical Practices of the United States Army in Vietnam in Current Problems in Surgery, November, 1966, p. 34. 7 Bryant, L. R., Chicklo, J. M., Crutcher, R., Danielson, G. K., Malette, W. G., and Trinkle, J. K.: Management of Thoracic Empyema, J. THORAC. CARDIOV. SURG. 55: 850,
1968.
8 Humphrey, E. W.: Therapy of Acute Empyema, Surgery 59: 661, 1966.
9 Mayo, P., and Mc Elvain, R. B.: Early Thoracotomy for Pyogenic Empyema, Ann. Thorac. Surg. 2: 649, 1966. 10 Yeh, T. J., Hall, D., and Ellison, R. G.: Empyema Thoracis: A Review of 110 Cases, Am. Rev. Resp. Dis. 88: 785, 1963. 11 Langston, H. T.: Empyema Thoracis, Ann. Thorac. Surg. 2: 766, 1966.
z v l t h o u g h there have been marked advances in the treatment of penetrating wounds of the chest since the early descriptions of John Hunter in 1761 and Baron Larrey during the Napoleonic Wars, posttraumatic empyema continues to plague the military surgeon. Throughout World War I, the early years of World War II, and the early months of the Korean War, the incidence of empyema following thoracic wounds ranged from 25 to 30 per cent. 1 ' 2 - 3 The management of post-traumatic empyema continues to remain controversial. Recurrent consideration has been given to the merits of closed versus open drainage and more recently to the applicability of early formal thoracotomy. A recent experience with 25 thoracic casualties with empyema who were wounded in Vietnam and admitted to the U.S. Army Valley Forge General Hospital between March, 1966, and May, 1968, illustrates the dimensions of this problem. Clinical material During this 26 month period, out of a total of 4,149 casualties admitted from VietFrom The Department of Surgery, Thoracic Surgery Service, U.S. Army Valley Forge General Hospital, Phoenixville, Pa., 19460. Received for publication July 11, 1969. ♦Present address: Clinic of Surgery, National Heart Institute, National Institutes of Health, Bethesda, Md. 20014.
630
nam, 68 were admitted to the Thoracic Surgical Service and 37 per cent (25) had empyema. Only patients with chest wounds requiring further surgical evaluation were admitted to the thoracic surgical wards. Thus, this series does not reflect the true incidence of empyema among thoracic casualties returning from Vietnam. All of the patients were males varying in age from 18 to 29 years, with an average age of 21.8 years. They were admitted to this hospital 12 to 97 days after being wounded, with an average of 43.9 days. The majority of these patients (20) were wounded with high velocity missiles. In 17 patients with additional extrathoracic injuries, the diaphragm was involved in 12 and the abdominal viscera in 14. Initial care. Half of the patients exhibited the manifestations of severe hypovolemic shock immediately after being wounded and required up to 22 units of blood to achieve a stabilized condition. Twenty-three patients were treated initially by tube thoracostomy for hemopneumothorax. Two other patients had upper abdominal wounds in which the thoracic component was not appreciated until exploratory laparotomy was performed. Local wound debridement and closed tube thoracostomy were judged sufficient for the initial definitive management in 17 patients. Formal open thoracotomy was necessary in
Volume 59
Number 5
Management of empyema after thoracic wounding
631
May, 1970
Fig. 1. A, Empyema noted 15 days after patient was wounded and which was treated initially with a closed tube thoracostomy. This tube was removed after 7 days before adequate pulmonary re-expansion had occurred. B, A fluid level indicating a recurrent empyema and the presence of a foreign body are noted in this film obtained 38 days after wounding. C, Sinogram obtained 4 weeks after open drainage of empyema cavity and removal of the foreign body (portion of armored vest and missile). D, Complete wound closure 8 weeks following open-drainage procedure.
8 patients to control exsanguinating intrathoracic hemorrhage or a major air leak. This is four times greater than the previously reported incidence of open thoracotomy in thoracic combat casualties and reflects the severity of the injury encountered in this group of patients. All of the patients received penicillin, streptomycin, and chloramphenicol preoperatively. Two patients required tracheostomy and ventilatory support during this initial treatment phase. Diagnosis. Complicating empyema was first recognized 4 to 49 days after the patient was wounded, with an average time of 16.7 days. The diagnosis was suspected by
changes in the chest roentgenogram, which usually included the presence of fluid levels (Fig. 1). It was confirmed by the culture of the aspirated pleural fluid. An associated bronchopleural fistula was present in 13 patients. Bacteriologic studies available in 18 patients revealed an equal incidence of infection with a single organism and with a mixed flora. Staphylococcal and Pseudomonas infections predominated (Table I). Treatment. Initial management of the empyema during evacuation of these patients was concerned either with provision for pleural space drainage or with obliteration by operative removal of the infected con-
632
The Journal of
Levitsky, Annable,
Thomas
Thoracic and Cardiovascular Surgery
Table I. Bacteriological studies Organism
Number of patients (18)
Staphylococcus aureus Pseudomonas aeruginosa Klebsiella-Aerobacter Escherichia coli Streptococcus faecalis Proteus species Paracolon species
9 7 5 4 4 4 1
Table II. Initial unsuccessful forms of treatment for empyema in 25 casualties Closed drainage Open drainage Decortication Decortication and resection Aspiration
5 3 3 6 "35
Table III. Final mode of treatment Tube thoracostomy Rib thoracostomy Pulmonary Resection Excision of bronchopleuralcutaneous fistula Decortication
9 10 1 2 3
tents (Table II). Aspiration was useful in establishing bacteriologic diagnosis but did not provide adequate pleural space drainage for patients treated solely by this technique. Failure of closed drainage to permanently relieve the patients treated in this manner was usually associated with premature tube removal. Two patients treated initially by open drainage subsequently required formal thoracotomy to control a persistent bronchopleural fistula. Three patients previously treated by open drainage required secondary surgical revision to provide more dependent drainage. Six patients with high velocity wounds had early thoracotomy and decortication as the initial treatment for empyema. All of
these patients failed to achieve postoperative obliteration of the pleural space and went on to develop recurrent empyema. Five of these patients subsequently responded to open drainage and one required a pneumonectomy for eventual cure. A total of fifty-four operative procedures were required in the entire group of 25 patients to accomplish complete closure of the empyema cavity. Seventeen patients required two or more procedures. Open drainage, either by tube or rib thoracostomy, was the final mode of treatment in 19 (76 per cent) patients (Table III). All of the patients were eventually rehabilitated and discharged with completely closed wounds. In no case was thoracoplasty necessary. Discussion During the Civil War a 62.6 per cent mortality rate was noted in 8,715 cases of penetrating chest wounds in Union soldiers and Confederate prisoners.4 Although the specific incidence of post-traumatic empyema was not recorded, individual case reports suggest thoracentesis and open drainage as acceptable methods of treatment. During World War I and early World War II, empyema occurred in 25 to 30 per cent of the thoracic casualties. With the establishment of specific thoracic surgery centers and Burford's suggestion of early evacuation of the organized residual hemothorax, the empyema rate was reduced to 10 per cent by the end of World War II. 2 However, in the early months of the Korean War, the incidence of empyema again rose to 26 per cent.3 Patterson and co-authors,5 in a report from an intermediate care center, cite an empyema incidence of 6.1 per cent in Vietnam thoracic casualties. However, this estimate may require re-interpretation as 2 cases in our series were originally unrecognized by that group during the patients' sojourn in that center. During the Korean conflict, there was disagreement over whether intercostal tube drainage alone or multiple thoracentesis was more effective in reducing the incidence of an infected hemothorax. Valle3 observed that
Volume 59
Number 5
Management of empyema after thoracic wounding
633
May, 1970
92 per cent of the patients requiring decortication in Korea were among those who had closed intercostal tube drainage of the pleural space as opposed to thoracentesis. It is presently common practice in Vietnam for penetrating chest wounds to be treated by tube thoracostomy.0 All of the patients in this series were initially treated in this manner. However, in many of the cases in which empyema developed, there was evidence of premature tube removal before the hemothorax was fully evacuated and full pulmonary re-expansion had occurred. Over the past decade there has been some disagreement over the management of acute empyema. There have been advocates for open- or closed-drainage procedures7- s while others have favored early thoractomy. 910 In a recent editorial on this problem, Langston11 focused on two major errors of management: (1) overly long persistence in closed drainage, and (2) overenthusiasm for early decortication at formal thoracotomy. Six patients in this series underwent early thoracotomy for mechanical cleansing of the pleural cavity, and empyema recurred in all cases. Although no compliance studies have been performed, personal observation in Vietnam at open thoracotomy indicates an increased stiffness in the contused lung immediately after a high velocity wound. Radiologic evidence of this pulmonary contusion usually persists 3 to 6 weeks after wounding. It seems probable that the major reason for failure of early decortication in these cases of a high-velocity injury to the lung is the inability to obtain complete pulmonary re-expansion in the early postoperative period. Adequate open drainage continues to remain the most successful therapeutic procedure in the treatment of post-traumatic empyema. In 76 per cent of the patients treated in this manner, no further operative intervention was necessary. In addition, five out of the six treatment failures of early thoracotomy for empyema responded to open drainage. As soon as the diagnosis of post-traumatic empyema is suspected, pleural aspiration fol-
lowed by bacterial evaluation and the administration of appropriate antibiotics constitute the initial steps in treatment. If this therapy proves to be inadequate, as judged by the reaccumulation of fluid in the pleural space, closed drainage by tube thoracostomy is instituted. The frequently associated bronchopleural fistula may be evident at this juncture and should be evaluated by bronchography in individuals in whom a formal thoracotomy is anticipated. When the need for prolonged drainage of the pleural space becomes evident, conversion to an open system is effected by using the same tube site or by rib resection to ensure adequate dependent egress of pleural accumulations. Formal thoracotomy with decortication is indicated when there is lack of progressive cavity closure or the persistence of a bronchopleural fistula. Summary A series of 25 patients with pleural empyema complicating treatment for chest wounds sustained in Vietnam is reported. The following observations have been made. 1. Early thoracotomy directed toward elimination of the infected pleural space did not appear to reduce morbidity; continued pleural drainage was necessary in each of 6 patients so treated. 2. Ultimate establishment of open pleural space drainage was sufficient to relieve 76 per cent of these patients of their empyema. REFERENCES 1 The Medical Department of The United States Army in the World War, Washington, D. C , 1925, U. S. Government Printing Office, Vol. 15, p. 2. 2 Burford, T. H., Parker, E. P., and Samson, P. C : Early Pulmonary Decortication in the Treatment of Post-traumatic Empyema, Ann. Surg. 122: 163, 1945. 3 Valle, A. R.: Management of War Wounds of the Chest, J. THORACIC SURG. 24: 457,
1952.
4 The Medical and Surgical History of the War of the Rebellion (1861-1865), edited by Barnes, J. K., Washington, D. C , 1870, U. S. Government Printing Office, Part I, pp. 526-606. 5 Patterson, L. T., Schmitt, H. J., and Armstrong, R. G.: Intermediate Care of War
6 34
The Journal of
Levitsky, Annable,
Thomas
Thoracic and Cardiovascular Surgery
Wounds of the Chest, J. THORAC. CARDIOV. SURG. 55: 16,
1968.
6 Military Surgical Practices of the United States Army in Vietnam in Current Problems in Surgery, November, 1966, p. 34. 7 Bryant, L. R., Chicklo, J. M., Crutcher, R., Danielson, G. K., Malette, W. G., and Trinkle, J. K.: Management of Thoracic Empyema, J. THORAC. CARDIOV. SURG. 55: 850,
1968.
8 Humphrey, E. W.: Therapy of Acute Empyema, Surgery 59: 661, 1966.
9 Mayo, P., and Mc Elvain, R. B.: Early Thoracotomy for Pyogenic Empyema, Ann. Thorac. Surg. 2: 649, 1966. 10 Yeh, T. J., Hall, D., and Ellison, R. G.: Empyema Thoracis: A Review of 110 Cases, Am. Rev. Resp. Dis. 88: 785, 1963. 11 Langston, H. T.: Empyema Thoracis, Ann. Thorac. Surg. 2: 766, 1966.