Ergebnisse der stadienadaptierten chirurgischen Therapie von Pleuraempyemen

Zusammenfassung

Hintergrund: Die chirurgische Therapie von Pleuraempyemen sollte stadien- und patientenadaptiert erfolgen. Zielsetzung der Studie war die Auswertung der Behandlungsergebnisse der chirurgischen Therapie von Patienten mit einem Pleuraempyem. Patienten und Methoden: Retrospektive Analyse aller zwischen 01/2008 und 12/2013 chirurgisch therapierten Patienten mit Pleuraempyem. Primärer Endpunkt der Studie war die stationäre Letalität. Sekundäre Endpunkte waren die stationäre Aufenthaltsdauer, die Therapieart (chirurgisch/konservativ), der Erregernachweis sowie Art, Wechsel und Dauer der Antibiotikatherapie. Ergebnisse: Von 359 Patienten hatten 0,8 % (n = 3) ein Pleuraempyem im Stadium I, 50,4 % (n = 181) ein Stadium II und 48,7 % (n = 175) ein Stadium III. Zu den am häufigsten vorkommenden Ursachen (32,4 %) zählten eine akute Pneumonie (parapneumonisches Pleuraempyem), eine (zumeist thoraxchirurgische) Operation in 18,0 % und eine abgelaufene Pneumonie (postpneumonisches Pleuraempyem) in 15,4 %. Eine Operation erfolgte in 86 % der Fälle (OP-Verfahren: offene Thorakotomie 85 %, VATS15 %). Der stationäre Aufenthalt betrug im Stadium II und III durchschnittlich 20 Tage. Die Ausheilung nach VATS war im Stadium II signifikant kürzer im Vergleich zur Thorakotomie (p = 0,022). Die Krankenhausletalität umfasste 7,0 % (25 Patienten). Im Stadium II lag die Letalität bei 5,5 % (10/185), im Stadium III bei 8,6 % (15/175). Patienten mit Erregernachweis hatten mit 9,8 % über alle Stadien eine deutlich schlechtere Letalitätsrate als Patienten ohne Erregernachweis (4,0 %; p = 0,034). Alter, maligne Grunderkrankung, Multimorbidität, Immunsuppression, Wechsel der Antibiose sowie Sepsis stellten signifikante Risikofaktoren dar. Schlussfolgerung: Die stationäre Letalität von Patienten mit einem Pleuraempyem korreliert mit dem Stadium. Positiver Erregernachweis, Sepsis, höheres Alter, Multimorbidität, eine maligne Tumorerkrankung, Immunsuppression und Antibiotikawechsel sind negative Prognosefaktoren.

Abstract

Background: The surgical treatment of pleural empyema should be carried out depending on the stage of the disease and the patientʼs symptoms. The aim of this study was to evaluate the outcomes of surgical pleural empyema treatment. Patients and Methods: Retrospective analysis of all patients with pleural empyema treated surgically between January 2008 and December 2013. The primary endpoint of the study was inpatient lethality. Secondary endpoints included duration of inpatient stay, type of treatment (surgical/conservative), proof of pathogen and type, alteration and duration of antibiotic therapy. Results: Of 359 patients, 0.8 % (n = 3) had stage I empyema, 50.4 % (n = 181) had stage II and 48.7 % (n = 175) had stage III. The most frequent causes (32.4 %) included acute pneumonia (parapneumonic pleural empyema), surgery (usually thoracic) in 18.0 % of cases and previous pneumonia (postpneumonic pleural empyema) in 15.4 %. Surgery was performed in 86 % of cases (operative procedures: open thoracotomy 85 %, VATS 15 %). The average duration of inpatient stay was 20 days for stages II and III. Recovery following VATS was significantly shorter in stage II compared to thoracotomy (p = 0.022). Hospital lethality amounted to 7.0 % (25 patients). The lethality rate was 5.5 % (10/185) in stage II and 8.6 % (15/175) in stage III. Patients with confirmed pathogens had a significantly worse mortality rate across all stages (9.8 %) than patients with no confirmed pathogens (4.0 %, p = 0.034). Age, malignant underlying disease, multiple comorbidities, immunosuppression, a change in antibiotic regimens and sepsis were significant risk factors. Conclusion: The inpatient lethality of patients with pleural empyema correlates with the stage of the condition. Positive confirmation of pathogens, sepsis, a higher age, multiple comorbidities, malignant tumour disease, immunosuppression and a change of antibiotics are negative prognostic factors.

Schlüsselwörter

Empyem - Thoraxchirurgie - Thorakoskopie - Überleben - Vakuumbehandlung - Ergebnisqualität

Key words

vacuum-assisted treatment - empyema - thoracic surgery - thoracoscopy - outcome - survival

• Literatur

• 1 Haas AR, Sterman DH. Advances in pleural disease management including updated procedural coding. Chest 2014; 146: 508-513
• 2 Hofmann HS. Modern management of empyema thoracis. Semin Thorac Cardiovasc Surg 2013; 25: 287-291
• 3 Molnar TF. Current surgical treatment of thoracic empyema in adults. Eur J Cardiothorac Surg 2007; 32: 422-430
• 4 Andrews N, Parker E, Shaw R et al. Management of nontuberculous empyema. A statement of the ATS subcommittee on surgery. Am Rev Respir Dis 1962; 85: 935-936
• 5 Schweigert M, Solymosi N, Dubecz A et al. Surgery for parapneumonic pleural empyema – What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome?. Surgeon pii: S1479-666X(14)00069-9 [Epub ahead of print]
• 6 Ozol D, Oktem S, Erdinc E. Complicated parapneumonic effusion and empyema thoracis: microbiologic and therapeutic aspects. Respir Med 2006; 100: 286-291
• 7 Helfritzsch H, Lesser T, Seifert S et al. Stage-adapted therapy of pleural empyema. Results during 1992–1998. Zentralbl Chir 2000; 125: 454-458
• 8 Yim AP. Paradigm shift in empyema management. Chest 1999; 115: 611-612
• 9 Rahman NM, Kahan BC, Miller RF et al. A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural infection. Chest 2014; 145: 848-855
• 10 Marks DJ, Fisk MD, Koo CY et al. Thoracic empyema: a 12-year study from a UK tertiary cardiothoracic referral centre. PLoS One 2012; 7: e30074
• 11 Hsieh MJ, Liu YH, Chao YK et al. Risk factors in surgical management of thoracic empyema in elderly patients. ANZ J Surg 2008; 78: 445-448
• 12 Schweigert M, Solymosi N, Dubecz A et al. Surgical management of pleural empyema in the very elderly. Ann R Coll Surg Engl 2012; 94: 331-335
• 13 Bar I, Stav D, Fink G et al. Thoracic empyema in high-risk patients: conservative management or surgery?. Asian Cardiovasc Thorac Ann 2010; 18: 337-343
• 14 Sziklavari Z, Ried M, Neu R et al. Mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. Eur J Cardiothorac Surg 2015; 48: e9-e16
• 15 Chung JH, Lee SH, Kim KT et al. Optimal timing of thoracoscopic drainage and decortication for empyema. Ann Thorac Surg 2014; 97: 224-229
• 16 Tsang KY, Leung WS, Chan VL et al. Complicated parapneumonic effusion and empyema thoracis: microbiology and predictors of adverse outcomes. Hong Kong Med J 2007; 13: 178-186
• 17 Mwandumba HC, Beeching NJ. Pyogenic lung infections: factors for predicting clinical outcome of lung abscess and thoracic empyema. Curr Opin Pulm Med 2000; 6: 234-239
• 18 Okiror L, Coltart C, Bille A et al. Thoracotomy and decortication: impact of culture-positive empyema on the outcome of surgery. Eur J Cardiothorac Surg 2014; 46: 901-906
• 19 Tasci S, Ewig S, Lüderitz B. Diagnose und Therapie von parapneumonischen Pleuraergüssen und Empyemen. Dtsch Ärztebl Int 2004; 101: A638-648
• 20 Niederman MS, Mandell LA, Anzueto A et al. American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001; 163: 1730-1754
• 21 Brims FJ, Lansley SM, Waterer GW et al. Empyema thoracis: new insights into an old disease. Eur Respir Rev 2010; 19: 220-228
• 22 Cardillo G, Carleo F, Carbone L et al. Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication. Eur J Cardiothorac Surg 2009; 36: 914-918
• 23 Cassina PC, Hauser M, Hillejan L et al. Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome. J Thorac Cardiovasc Surg 1999; 117: 234-238
• 24 Shahin Y, Duffy J, Beggs D et al. Surgical management of primary empyema of the pleural cavity: outcome of 81 patients. Interact Cardiovasc Thorac Surg 2010; 10: 565-567
• 25 Vyas KS, Saha SP, Davenport DL et al. Trends and practice patterns in the management of thoracic empyema. Asian Cardiovasc Thorac Ann 2014; 22: 455-459
• 26 Waller DA, Rengarajan A. Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema. Ann Thorac Surg 2001; 71: 1813-1816
• 27 Wurnig PN, Wittmer V, Pridun NS et al. Video-assisted thoracic surgery for pleural empyema. Ann Thorac Surg 2006; 81: 309-313
• 28 Ried M, Graml J, Großer C et al. [Para- and postpneumonic pleural empyema: current treatment strategies in children and adults]. Zentralbl Chir 2015; 140 (Suppl. 01) S22-S28
• 29 Schneiter D, Grodzki T, Lardinois D et al. Accelerated treatment of postpneumonectomy empyema: a binational long-term study. J Thorac Cardiovasc Surg 2008; 136: 179-185