Centre of General Thoracic Surgery, Clinic of Infectious and Chest Diseases, Dermatovenerology and Allergology, Faculty of Medicine, Vilnius University, Vinius, Lithuania.
Department of General Thoracic Surgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania.
Eur J Cardiothorac Surg. 2017 Jul 1;52(1):70-75. doi: 10.1093/ejcts/ezx054.
Thoracoscopy is an effective treatment method for pleural empyema; however, it is still not well defined as to which patient subgroups could benefit from it the most. The aim of the study was to identify preoperative factors that could facilitate selecting appropriate surgical intervention and to evaluate early postoperative period.
Seventy-one patients were prospectively included in the study, which was conducted from January 2011 to June 2014. Thoracoscopic surgery for Stage II/III pleural empyema was performed in all patients. Thoracoscopy failed in 18 (25.4%) patients, requiring conversion to thoracotomy. The preoperative factors that could possibly predict conversion were analysed.
Obliterated pleural space (12 patients) and failure to achieve lung re-expansion (6 patients) were the main reasons for conversion. Multivariable logistic regression analysis demonstrated that each day of illness [odds ratio 1.1 (95% confidence interval 1.0-1.2], P = 0.004] and frank pus [odds ratio 4.4 (95% confidence interval 1.2-15.3), P = 0.021] were independent predictors of conversion. Using receiver-operating characteristic analysis, it was determined that the duration of illness had a high predictive value for conversion [area under the curve 0.8 (95% confidence interval 0.7-0.9), P < 0.001]. The cut-off value for duration of illness was 16 days (sensitivity 94.4%, specificity 54.7%). The conversion group had a significantly greater need for postoperative intensive care unit stay ( P = 0.022) but a lower rate of reoperations ( P = 0.105).
Duration of illness and frank pus discovered during thoracocentesis can help in selecting the patient for appropriate intervention. Earlier surgery for pleural empyema can reduce the rate of conversion and reoperation.
胸腔镜是治疗脓胸的有效方法；然而，对于哪些患者亚组最能从中受益，仍未明确界定。本研究的目的是确定术前因素，以便有助于选择适当的手术干预，并评估术后早期。
71 例患者前瞻性纳入本研究，研究时间为 2011 年 1 月至 2014 年 6 月。所有患者均行 II/III 期脓胸胸腔镜手术。18 例（25.4%）患者胸腔镜手术失败，需转为开胸手术。分析可能预测转换的术前因素。
胸腔镜手术失败的主要原因为胸腔粘连（12 例）和未能实现肺复张（6 例）。多变量逻辑回归分析表明，患病天数[优势比 1.1（95%置信区间 1.0-1.2），P=0.004]和脓性胸腔积液[优势比 4.4（95%置信区间 1.2-15.3），P=0.021]是转换的独立预测因素。使用受试者工作特征分析，确定患病时间对转换具有较高的预测价值[曲线下面积 0.8（95%置信区间 0.7-0.9），P<0.001]。患病时间的截断值为 16 天（敏感性 94.4%，特异性 54.7%）。转换组术后需要入住重症监护病房的时间明显更长（P=0.022），但再次手术的比例较低（P=0.105）。
胸腔穿刺时发现的患病时间和脓性胸腔积液有助于选择合适的干预措施。早期手术治疗脓胸可降低转换和再次手术的发生率。
