JEH Roberts (1881–1948): Pioneer thoracic surgeon

JEH Roberts was a leading figure in the new specialty of thoracic surgery before Second World War. His interest in this branch of surgery began during First World War when he served as a Major in a casualty clearing station and operated under local anaesthesia and without X-ray facilities. He reported a series of 199 cases of severe chest injury in which operation had been carried out in 67 patients – of whom 34 had made a complete recovery, a remarkable achievement in 1917. He was the first to use negative pressure suction drainage of the chest to encourage full expansion of the lung after thoracotomy, and he developed a plastic operation on the chest wall to treat chronic empyema. Together with HP Nelson, he described one-stage lobectomy for lung resection and developed a new lung tourniquet for use during this operation.

Objective Evaluation of Efficacy of Decortication in Chronic Pleural Empyema in Adult Patients

Background: Chronic pleural empyema (CPE) is the last phase of the triphasic process of pleural empyema development. Lung decortication is the corner stone in management of chronic empyema. This study aimed to objectively evaluate the efficacy of conventional decortication operation in chronic pleural empyema in adult patients. Also to prove that decortication of variable sizes of chronic empyema thoracis lesions is followed by improvement considering respiratory impairment. Methods: This prospective clinical study was conducted on 103 patients undergoing elective lung decortication operation for management of chronic empyema. All patients were subjected to the history taking, general examination, chest examination, computed tomography (CT), pulmonary function test and arterial blood gases. Postoperative evaluation was done in outpatient clinic 6 months post operatively including: Full clinical examination, investigations (acute phase reactants, CT chest, PFT and arterial blood gases. Results: Total leucocytic count, ESR 1st hour, ESR 2nd hour and CRP were significantly decreased in post than pre. FEV1 and FVC were significantly increased in post than pre (P <0.001). FEV1 / FVC Ratio was significantly decreased in post than pre (P <0.001). Transverse and antero-posterior diameters of affected hemithorax were significantly increased in post than pre (P <0.001, 0.019 respectively). Transverse and antero-posterior diameters of normal hemithorax were insignificantly different between post and pre. PaO2 and SpO2 were significantly increased in post than pre (P <0.001). PaCO2 was significantly decreased in post than pre (P <0.001). Conclusions: The improvement in the lung function, arterial blood gases, transverse and antero-posterior diameter of affected and normal hemithorax was proposed to have resulted from the decortication in chronic empyema thoracis. Decortication of variable sizes of chronic pleural empyema lesions is followed by objective improvement considering respiratory impairment.

Surgical Challenges of Chronic Empyema and Bronchopleural Fistula

Chronic empyema has always been a clinical challenge for physicians. There is no standard procedure or treatment to deal with the situation, and multi-modality approach is often necessary. Surgical intervention plays a very crucial role in the treatment of chronic empyema. Since bronchopleural fistula is often seen in chronic empyema patients, therefore it should also be mentioned. In this chapter, the focus will be on the different treatment options, various surgical approaches, and the rationale behind every single modality. Certain specific entity will be included as well, such as tuberculosis infection, post lung resection empyema, and intrathoracic vacuum assisted closure system application. Even with the advancement of technology and techniques, chronic empyema management is still evolving, and we look forward to less traumatic ways of approach with better outcome in the future.

Open thoracotomy and decortication for chronic empyema thoracis: Our experience

Empyema thoracis is defined as the presence of pus in the pleural space or a purulent pleural effusion. Chronic empyema is characterized by thickened visceral and parietal peels, which hamper the ability of the affected lung to re-expand and require definitive surgical intervention. In a resource constraint environment like ours, open thoracotomy and decortication is the treatment of choice. We review our experience with cases of chronic empyema thoracis that had thoracotomy and decortication. This is a descriptive, retrospective, and observational study. Medical records of patients who had thoracotomy and decortication on account of chronic empyema thoracis in the Cardiothoracic surgery unit of our hospital between 2012 and 2020 were retrieved and reviewed. The information obtained from the records included sex, age, premorbid conditions, aetiology of empyema, cultures of pleural fluids, histology results of the cortex removed, duration of chest tube drainage, duration of hospital stay, postoperative complications, and outcome. One hundred and eighty-five patients diagnosed with empyema thoracis were seen in the study period. Sixty-five patients had thoracotomy and decortication on account of chronic empyema thoracis while the remaining 120 (64.9%) had closed tube thoracostomy drain insertion. Male: female was 5:1, mean age at presentation 24.24 years with age ranging from 2 years to 70 years. Fourteen (23.33%) were in the paediatric age group while the remaining (76.67%) were adults. The aetiology of empyema was pneumonia in 36 (60%). Strept pneumoniae was the commonest organism isolated from pleural fluids of these patients accounting for 23.33%. All patients underwent thoracotomy and decortication. The mean duration before surgery was 17 days with a range of 2 days to 40 days. The average duration of surgery was 2 hours. Chest tube was removed after an average of 7 days (range 5 to 33 days. Twenty-one patients (35%) had complications. The average duration of drainage was 18.87 days and that of hospital stay was 36.74 days. There were 3 mortalities (5%). The mean duration of follow-up was 3 months. Chronic empyema thoracis is still common in our environment and presentation is usually very late. In our series, open thoracotomy and decortication was found to be an excellent procedure with low morbidity and mortality. The majority of our patients had good functional outcome with few complications.

Transpleural Сontralateral Occlusion of the Left Main Bronchus Stump in a Patient with Bronchopleural Fistula and Chronic Pleural Empyema

Bronchopleural fistula (BPF) is a pathological communication between the bronchial tree and the pleural cavity, the most common complication of anatomical lung resection.BPF rarely closes spontaneously and almost always requires surgical or bronchoscopic interventions.The main methods of treatment are sanitation of the pleural cavity with the development of empyema and re-occlusion of the bronchial stump. The development of this complication in the postoperative period is accompanied by an increase in hospitalization time, a high risk of chronic pleural empyema, exacerbation of chronic diseases and death. The mortality rate ranges from 18 to 67%. Most often, BPF is manifested after removal of the right lung (8-13%), compared with the left side (1-5%), which is due to the anatomical features of the main bronchus.The presented clinical case describes a non-standard surgical approach in the treatment of bronchopleural fistula and chronic empyema of the residual pleural cavity in a young patient.

Salvage Treatment of Acute Respiratory Failure after Transcomposite Myocutaneous Flaps Transplantation for Chronic Empyema Combined with Chest Wall Sinus: A Case Report

BackgroundChronic empyema with chest wall sinus is a complex and refractory disease caused by multiple factors.It may be combined with bronchopleural fistula, residual bone and other necrotic tissue,causing local infection difficult to control, and the disease is a vicious circle.Case presentationThis paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 11 years ago and began to develop empyema with purulent sinus in the anterior chest wall 3 years ago. Therefore, he was admitted to our medical center for further treatment. Chest computed tomography (CT) showed the right pleural effusion with the chest wall rupture sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the large empyema cavity,the patient should be treated with free vastus lateralis musculocutaneous flap combined with pedicled pectoralis major muscle flap transplantation.After the operation, acute respiratory failure occurred due to left lung aspiration pneumonia.ConclusionsAfter a series of treatment measures such as tracheal intubation, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, he was finally rescued and cured.Follow-up after discharge showed that the tissue flap survived and empyema was eliminated.

Salvage Treatment of Acute Respiratory Failure after Transcomposite Myocutaneous Flaps Transplantation for Chronic Empyema Combined with Chest wall sinus: A Case Report

BackgroundChronic empyema with chest wall sinus is a complex and refractory disease caused by multiple factors.It may be combined with bronchopleural fistula, residual bone and other necrotic tissue,causing local infection difficult to control, and the disease is a vicious circle.Case presentationThis paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 11 years ago and began to develop empyema with purulent sinus in the anterior chest wall 3 years ago. Therefore, he was admitted to our medical center for further treatment. Chest computed tomography (CT) showed the right pleural effusion with the chest wall rupture sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the large empyema cavity,the patient should be treated with free vastus lateralis musculocutaneous flap combined with pedicled pectoralis major muscle flap transplantation.After the operation, acute respiratory failure occurred due to left lung aspiration pneumonia.ConclusionsAfter a series of treatment measures such as tracheal intubation, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, he was finally rescued and cured.Follow-up after discharge showed that the tissue flap survived and empyema was eliminated.

Salpingopharyngeus fistula by means of videosurgery to treat horse bilateral gutural pouch chronic empyema – a case study

The aim of this paper is to report the Salpingopharyngeus fistula technique by means of videosurgery through a natural orifice (NOTES) in order to treat bilateral empyema. A mare was seen at the Large Animal Sector of UFPR, with a history of bilateral purulent nasal discharge associated with dysphagia lasting for ninety days. The animal was submitted to endoscopy, showing a moderate amount of purulent secretion in both guttural pouches. With no improvement on the clinical treatment, we opted for surgical treatment by endoscopy through Salpingopharyngeus fistula made with the aid of a device containing an electrical scalpel developed to perform this technique. It consisted of making an incision in the pharyngeal recess in order to access the guttural pouches and subsequently drain the purulent content. The patient was discharged at the same day and returned to work 30 days after the procedure. Surgical treatment for cases of guttural pouch empyema is indicated when the clinical resolution has not been effective, and the minimally invasive technique is indicated due to the reduction of risks and the easiness of postoperative management. Until this moment, there are no reports of the salpingopharyngeal fistula technique through video surgery for the treatment of guttural pouch empyema, which has proved to be efficient for the treatment of the disease.

Uniportal thoracoscopic surgery for difficult late stage empyema: Case series

Early, aggressive, and minimally invasive approach is an advanced surgical approach for chronic empyema management. The traditional video-assisted technique is considered superior over open thoracotomy for empyema management; however, with further modification, the uniportal video-assisted thoracoscopic surgery (UVATS) has greater advantage for surgeons, providing better anatomical view of target tissues, allowing bimanual instrumentation similar to open approach, and nullifying the creation of dihedral angle by instruments that are not favorable in traditional VATS. The present case series describes different clinical scenarios including chronic empyema secondary to traumatic hemothorax, recurrent tubercular empyema following postoperative open decortication, and methicillin-resistant staphylococcus aureus chronic empyema in pediatric patient, which are effectively managed with UVATS approach.

Comparison of video assisted thoracoscopic surgery with thoracotomy for treatment of chronic empyema: a systematic review study

The article's abstract is not available.