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Empyema and Ruptured Lung Abscess in Adults' Thorax: first published as 10.1136/thx.19.6.492 on 1 November 1964. Downloaded from Thorax (1964), 19, 492. Empyema and ruptured lung abscess in adults' ROWAN NICKS From the Thoracic Surgical Unit, Page Chest Pavilion, Royal Prince Alfred Hospital, Melbourne This brief annotation concerns 18 adult patients TABLE II with empyema complicating the rupture of a lung RESULTS OF TREATMENT abscess into the pleural cavity who were referred to my service during the period 1957 to 1962. No. Cure No Cure Medical treatment By different methods of treatment all these Antibiotics .. 18 patients have been returned to health, but in some Primary surgical treatment earlier cases the illness was painful and prolonged Drainage: Infected .9 2 7 and multiple operations were necessary to attain Sterile. I a final cure. Primary decortication These are compared with patients treated Non-infected 5 5 recently in whom convalescence has been rapid, Infected .. 2 I I uncomplicated, and without loss of tissue. Primary pleuro-resection .. 1 Total .. .. 18 10 8 CLINICAL MATERIAL Particulars relevant to the treatment of 18 patients A cure followed simple drainage in three copyright. of comprising the series are summarized in Table I. 10 patients. Five sterile cases treated by primary decortica- TABLE I tion were cured, and, of two infected cases, one EMPYEMA COMPLICATING INTRAPLEURAL RUPTURE OF recurred. LUNG ABSCESS IN ADULTS, 1957 TO 1962 In the one with a localized empyema treated Total no. of cases 18 by pleurolobectomy and thoracoplasty, a curehttp://thorax.bmj.com/ Died. 0 resulted. Final cure .. .. .. 18 Primary surgery failed to achieve a cure in eight Culture: Sterile. 7 patients, and secondary procedures were Infected .. .. .. 1 1 performed for these (Table III). Organisms isolated Pneumococcus .. 2 Staphylococcus aureus 4 TABLE III Haemolytic streptococcus 2 RESPONSE TO SECONDARY SURGICAL PROCEDURES Mixed Streptococcus viridans and albus .. 3 Staphylococcus No. Cure No Cure on September 29, 2021 by guest. Protected Secondary treatment All patients were treated by antibiotics to which Total cases .. 8 sensitivity had been ascertained. It was not Decortication 5 2 3 Pleuro-pneumonecton-y 2 1 I possible to differentiate those in whom the Pleuro-lobectomy I abscess resulted from aspiration from those in Tertiary treatment whom it complicated a pneumonic infection. Saucerization, closure of fis- tula and muscle graft .. 3 3 Eleven were infected at the time of presentation Pleuro-pneumonectomy .. 2 2 were From infected cases and seven sterile. the Quarternary treatment a mixed variety of pathogenic organisms were Thoracoplasty .. .. 2 cultured. Procedure 5 RESULTS Muscle graft and closure of fistula.2 2 The results of treatment are summarized in Table II. Of five patients subjected to decortication, two were cured; in both, the fistula was closed and I Delivered to the General Scientific Session, Royal Australasian College of Surgeons, Melbourne, in May 1963 the abscess cavity was marsupialized with the 492 Thorax: first published as 10.1136/thx.19.6.492 on 1 November 1964. Downloaded from Empyema and ruptured lung abscess in adults 493 chest wall. Of three patients submitted to It is significant that simple drainage was un- pleuroresection, one of two was cured by successful in seven of nine persistently infected pleuropneumonectomy and one failed with cases. pleurolobectomy. Decortication was successful in five uninfected In tertiary treatment, saucerization of a cases (including three with an open abscess cavity localized empyema, followed after an interval by and fistulae at the time of operation) and in one suture of the fistulae and the insertion of a of two infected cases. In this latter group, dTbride- vascular muscle graft, was finally successful in all ment of the necrotic abscess, closure of the patients. fistulae, and marsupialization of the closed abscess Pleuropneumonectomy was not successful in above a soft drainage tube withdrawn through the two patients due to re-infection and to the chest wall was performed. Healing took place occurrence of a broncho-pleural fistula in one of without complication. Treatment of one other these. patient treated in this way failed because of the In the patients referred to above, total thoraco- development of osteomyelitis in a rib bared at plasty was palliative, and cure was only achieved operation. by saucerization and closure of the fistulae by Drainage and saucerization are wisely used as suture and muscle grafting as described (Fig. 1). temporary procedures in doubtful cases until the infection has subsided and it is possible to study COMMENT the architecture of the remaining lung. It appears that pleurolobectomy or pleuro- The rupture of a lung abscess complicating a pneumonectomy should be reserved for localized staphylococcal pneumonia or aspiration is not an lesions with lobar or pulmonary suppuration. uncommon event. Convalescence is often long and Secondary closure of fistulae in healthy complicated. granulating tissue supported by a muscle graft It is fortunate that the infecting organisms are on the surface has been found to be a safe and sensitive to antibiotics in most cases. satisfactory operation (Fig. 1). copyright. http://thorax.bmj.com/ a b C on September 29, 2021 by guest. Protected L~~~~~~~~~~~~~ d e f 9 FIG. 1. Diagrammatic representation of operation for sealing of bronchial fistula: (a) Incision, (b) saucerization of empyema cavity, cuffing of the fistulae; (c) suture of fistulae in two layers; (d) muscle flap as a secondary seal; (e) final closure with small drainage tube in position; (f)pressure pad; (g) arm in sling. Thorax: first published as 10.1136/thx.19.6.492 on 1 November 1964. Downloaded from AC9A Rowan Nicks PRECIS OF ILLUSTRATIVE CASE HISTORIES Fluid aspirated from the chest was inflammatory and sterile on culture. Ruptured hydatid cyst was CASE 1 S. McH., aged 34 years. Diagnosis: Ruptured suspected but the hydatid complement fixation and right lung abscess, d6bridement, decortication, and Casoni tests were negative. Thoracotomy performed marsupialization (Fig. 2). shortly after admission revealed intrapleural rupture She was seven months pregnant when she devel- of a gangrenous lung abscess in the anterior segment oped right chest pain and rigors. The condition was of the right lung. diagnosed as pneumonia and she was treated for this The outer necrotic abscess wall was excised and all with broad-spectrum antibiotics. She developed gangrenous tissue was removed. Several large fistulae sudden dyspnoea one week later. were closed with catgut, and the lung was decorti- On examination when admitted to the Page Chest cated. The abscess cavity was partially closed about a Pavilion on July 4, 1962, she was toxic and breath- soft catheter which was withdrawn through the chest less. The chest radiograph showed collapse of the wall, and the lung was sutured to the parietal pleura right lung and a pleural effusion. at the point of exit. The chest was closed in the ..-aVW ..e... ... ..... | | :S.:.: ..:.. :.''..::. l. ... s * . ,=-e > t i ' copyright. http://thorax.bmj.com/ E) on September 29, 2021 by guest. Protected FIG. 2. Case 1. (a) Right pleuro-pneumonia with cavitation ofthe right upper lobe; (b) right tension pneumothorax and empyema; (c) after decortication and debridement and marsupialization. The catheter is in position; (d) sinogram showing obliteration of the cavity and small bronchial fistulae which sealed spontaneously on withdrawal. Thorax: first published as 10.1136/thx.19.6.492 on 1 November 1964. Downloaded from Einpyema and riiptured lung abscess in aduilts 495 (a) (b) copyright. http://thorax.bmj.com/ on September 29, 2021 by guest. Protected (') (d) FIG. 3. Case 2. (a) Left pneumothorax and empyema; (b) recurrent pyopneumothorax; (c) after decortication, debridement, and marsupialization. The catheter is in position; (d) final radiograph with restoration of lung. usual way with two tubes connected to underwater CASE 2 K. R., aged 40 years. Diagnosis: Ruptured suction. The lung expanded and the wound healed lung abscess, debridement, decortication, and mar- by first intention. Premature labour pains were con- supialization (Fig. 3). trolled successfully by diuadilan. The drainage from This patient was admitted to the Page Chest Pavi- the intracavitary tube soon ceased. After verifying by lion on September 29, 1962, with an infected lung a sinogram that there was no abscess cavity and that abscess and empyema thoracis. the trace merely led to small pulmonary fistulae, the He had had a pyrexial illness 10 days before admis- tubes were removed. She remains well and without sion for which he was treated by broad-spectrum anti- symptoms. biotics. He developed sudden dyspnoea four days 2R Thorax: first published as 10.1136/thx.19.6.492 on 1 November 1964. Downloaded from 496 Rowan Nicks later and was treated for spontaneous pneumothorax found in the left lower lobe. Decortication was per- by an apical intercostal catheter connected to under- formed, and the necrotic top of the abscess in the water drainage. lower lobe was removed, the fistulae were sutured, On admission the chest radiograph showed an and the wall was closed about a soft drainage tube empyema in the left lower chest with an air fluid which was withdrawn through the chest wall and level indicating a bronchopleural fistula. Pus grew sutured to the parietal pleura to prevent an escape mixed organisms from which Staphylococcus albus, of air into the pleural cavity. Streptococcus viridans, and non-haemolytic strepto- The chest was closed by two underwater drainage cocci were isolated. tubes. The lung expanded, and finally the marsupial- At operation, apart from a thick-walled fibrous ized tube was removed. Three weeks later the dis- empyema, an abscess with bronchial fistulae was charge stopped, the culture was sterile, and the FIG. 4. Case 3. (a) Ruptured right lung abscess with pyopneumothorax; (b) bronchogram showing abscess in apical segment of the lower lobe; (c) deibridement and marsupialization; (d)final bronchogram which is essentially normal.
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