Renner H, Gabor S, Pinter H, Maier A, Friehs G, Smolle-Juettner F M
Department of Thoracic and Hyperbaric Surgery, University Medical School of Graz, Austria.
Eur J Cardiothorac Surg. 1998 Aug;14(2):117-22. doi: 10.1016/s1010-7940(98)00165-1.
High risk and a long hospitalization time are often quoted as negative aspects of aggressive surgery in pleural empyema. We did a retrospective analysis evaluating outcome and duration of hospitalization in patients treated according to an aggressive schedule.
Since 1989 we have treated 101 patients with pleural empyema (72 males, 29 females; mean age 50.3 years, range 11-91 years; 77 metapneumonic empyema, 24 empyema following trauma or abdominal surgery). Sixty-nine patients had had unsuccessful conservative pre-treatment (antibiotics, thorcozentses, drainage/irrigation, VATS). Thirty-one were critically ill patients. In eight cases a seropurulent stage of empyema was present, 17 patients had fibrinous membranes, 30 an organizing stage with and 46 without well identifiable dissection plane. Eighty-five patients proceeded to thoracotomy. Pulmonary abscesses or indurative pneumonia necessitated wedge-resection, lobectomy, or pneumonectomy in 29 cases. In the presence of gross necroses or callosities not amenable to decortication primary open-window thoracostomy (n = 22) was carried out. In six cases a secondary open-window thoracostomy was carried out because of persisting putrid secretion and sepsis persisting after decortication or after drainage. The thoracostomy was closed when clean granulative tissue developed. Sixteen patients underwent only drainage and irrigation because of an early stage or because of a general condition not permitting thoracotomy.
Three patients died due to severe sepsis not responding to treatment, one had fatal bleeding from a duodenal ulcer (mortality rate 3.9%). The others were able to resume their preoperative activities. The median duration of hospitalization was 14 days (mean 21.1 days; SEM 1.7 days).
Aggressive surgery for pleural empyema beyond the seropurulent stage ensures rapid relief from sepsis at a low mortality rate even in very ill patients.
高风险和较长的住院时间常被视为胸膜脓胸积极手术的负面因素。我们进行了一项回顾性分析，评估按照积极治疗方案治疗的患者的治疗结果和住院时间。
自1989年以来，我们共治疗了101例胸膜脓胸患者（男72例，女29例；平均年龄50.3岁，范围11 - 91岁；77例为肺炎旁脓胸，24例为创伤或腹部手术后脓胸）。69例患者保守治疗前效果不佳（使用抗生素、胸腔穿刺、引流/冲洗、电视辅助胸腔镜手术）。31例为重症患者。8例处于脓胸的浆液脓性阶段，17例有纤维膜，30例处于机化阶段，其中30例有可明确辨认的剥离平面，46例没有。85例患者接受了开胸手术。29例因肺脓肿或硬结性肺炎需要进行楔形切除术、肺叶切除术或全肺切除术。对于存在严重坏死或胼胝体且无法进行剥脱术的情况，进行了一期开放式胸廓造口术（n = 22）。6例患者因剥脱术或引流后持续存在恶臭分泌物和败血症而进行了二期开放式胸廓造口术。当出现清洁的肉芽组织时，关闭胸廓造口。16例患者因处于早期或全身状况不允许开胸而仅接受了引流和冲洗。
3例患者因严重脓毒症治疗无效死亡，1例因十二指肠溃疡大出血死亡（死亡率3.9%）。其他患者能够恢复术前活动。住院时间中位数为14天（平均21.1天；标准误1.7天）。
对于浆液脓性阶段后的胸膜脓胸进行积极手术，即使在病情非常严重的患者中，也能确保以低死亡率快速缓解脓毒症。
