Hollaus P H, Lax F, Wurnig P N, Janakiev D, Pridun N S
Department of Thoracic Surgery, Pulmologisches Zentrum Vienna, Austria.
Eur J Cardiothorac Surg. 1999 Sep;16(3):283-6. doi: 10.1016/s1010-7940(99)00224-9.
Simple irrigation has proven to be an efficient method to treat postpneumonectomy empyema provided that bronchopleural fistula is not present or successfully closed. However, with this treatment modality, infected material inside the thoracic cavity is not removed and this can be a potential source of empyema recurrence if the patient's immune system is compromised. The removal of the infected material should result in a lower recurrence rate.
As soon as diagnosis of postpneumonectomy empyema was established, a chest tube drainage was inserted. A concomitant bronchopleural fistula was evaluated bronchoscopically. If the fistula was smaller than 3 mm, bronchoscopic sealing with fibrin glue (Tissucol, Immuno, Vienna) was initiated. Fistulas closed surgically were excluded from this analysis. The thoracic cavity was cleared of infected material by videothoracoscopy and bacteriological samples were taken. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection; WBC and CRP were controlled.
Nine patients (five men, four women) between 55 and 72 years (mean 61, SD 6), all initially operated on for malignancy, were successfully treated with this regimen. In three cases a concomitant bronchopleural fistula was successfully closed before videothoracoscopy. The interval between primary operation and empyema was between 7 and 436 days (mean 93, SD 141). There was no postoperative mortality and no procedure related morbidity. Operating time ranged from 45 to 165 min (mean 92.7, SD 36.6), the suction volume (consisting of blood, debris and pus) was 300 to 1000 ml (mean 880, SD 600). Duration of thoracic drainage was 12-38 days (mean 22, SD 9), duration of hospital stay after videothoracoscopy 21-46 days (mean 29, SD 9). During the follow-up period of 204-1163 days (mean 645, SD 407) no recurrence of tumour or empyema was observed.
Videothoracoscopic debridement of the postpneumonectomy space with postoperative antibiotic irrigation of the pleural space is an efficient method to treat postpneumonectomy empyema, provided that a concomitant bronchopleural fistula can be closed successfully. No early empyema or fistula recurrence were observed. However, late recurrence may occur many years after operation, therefore close follow-up is indicated.
事实证明，单纯冲洗是治疗肺切除术后脓胸的一种有效方法，前提是不存在支气管胸膜瘘或已成功闭合。然而，采用这种治疗方式时，胸腔内的感染物质无法清除，如果患者免疫系统受损，这可能是脓胸复发的潜在根源。清除感染物质应能降低复发率。
一旦确诊肺切除术后脓胸，即插入胸管引流。通过支气管镜评估是否存在合并的支气管胸膜瘘。如果瘘口小于3mm，则开始用纤维蛋白胶（Tissucol，Immuno，维也纳）进行支气管镜封堵。手术闭合的瘘口排除在本分析之外。通过电视胸腔镜清除胸腔内的感染物质并采集细菌学样本。术后立即根据培养药敏结果，通过单根胸管引流每天两次进行抗生素冲洗。注入抗生素后，引流管夹闭3小时。每周采集两次培养样本。如果连续三次培养均未发现细菌生长，则认为脓胸已根除。拔除引流管后，患者再住院一周，观察是否有感染的临床症状；监测白细胞和C反应蛋白。
9例患者（5例男性，4例女性），年龄在55至72岁之间（平均61岁，标准差6），均因恶性肿瘤接受了初次手术，采用该方案治疗成功。3例患者在电视胸腔镜检查前成功闭合了合并的支气管胸膜瘘。初次手术至脓胸的间隔时间为7至436天（平均93天，标准差141）。无术后死亡病例，也无与手术相关的并发症。手术时间为45至165分钟（平均92.7分钟，标准差36.6），吸出量（包括血液、碎屑和脓液）为300至1000毫升（平均880毫升，标准差600）。胸腔引流持续时间为12至38天（平均22天，标准差9），电视胸腔镜检查后住院时间为21至46天（平均29天,标准差9）。在204至1163天（平均645天，标准差407）的随访期内，未观察到肿瘤或脓胸复发。
电视胸腔镜下对肺切除术后胸腔进行清创，并在术后对胸腔进行抗生素冲洗，是治疗肺切除术后脓胸的一种有效方法，前提是合并的支气管胸膜瘘能够成功闭合。未观察到早期脓胸或瘘口复发。然而，术后多年可能会发生晚期复发，因此需要密切随访。
