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Source Control
Published in Firza Alexander Gronthoud, Practical Clinical Microbiology and Infectious Diseases, 2020
A 56-year-old male is on amoxicillin/clavulanic acid IV for a community-acquired pneumonia with empyema. He has a chest drain which is still producing pus. No samples have been sent to the microbiology laboratory. He is clinically improving, and the house officer asks you how long to continue antibiotic therapy. You advise to send drain samples for culture, continue antibiotics for at least 3 weeks post-drainage and then review. Oral stepdown depends on culture results or response to intravenous therapy. Complication of pneumonia, trauma or, less commonly, as a complication of thoracic surgical procedures.In the early stages, empyema is liquid and drainage via placement of a chest tube allows removal of pus and expansion of the lung.Percutaneous catheters have a failure rate of up to 20% when collections are extensive or multiloculated.If tube thoracostomy fails (e.g. in a later stage of the empyema when a thick fibrous peel has formed), video-assisted thoracic surgery (VATS) can be performed, allowing for decortication of empyema.
Thoracic and Chest Disease
Published in Stephen M. Cohn, Peter Rhee, 50 Landmark Papers, 2019
Empyema management has also moved to the less invasive route. Empyema exists in three stages, where each stage gets progressively more scars and is more difficult to evacuate. Without appropriate debridement of the infectious material and release of the lung, respiratory status will fail and sepsis will progress. Open thoracotomy with decortication has been the mainstay, but minimally invasive procedures have since been taken seriously in the last 15 years. Video-assisted thoracoscopic surgery (VATS) has gained popularity in its use for the decortication of stage 2 and 3 empyema. Tong et al. (2010) looked retrospectively over a 10-year period at their institution on VATS versus open decortication for benign disease. To date, they have one of the largest numbers of patients included in a study. Three hundred twenty-six VATS and 94 open decortication patients were identified, with an 11.4% conversion to open rate on the VATS patients. The VATS group was found to have shorter operative time, hospital length of stay (LOS), fewer complications, and lower mortality.
Successful Repair of Right Diaphragmatic Herniation with Recovery of Liver Function
Published in Wickii T. Vigneswaran, Thoracic Surgery, 2019
Christian Renz, Wickii T. Vigneswaran
This case describes a right-sided diaphragmatic defect with herniation of the entire liver and portions of the right colon, which is significant for various reasons. Right-sided diaphragmatic hernias are quite rare, partly because the liver occupies a majority of the space under the diaphragm on the right side, making it difficult for herniation to occur there [1]. However, in the above case, we see that our patient experienced complete herniation of the liver through the right-sided diaphragmatic defect. The etiology of his herniation is unclear; however, the remote history of the motor vehicle accident may have played a role in its development over the years. A tension-free repair of the hernia is mandatory for the repair to be successful. When there is a significant defect, it is necessary to repair the defect with a prosthetic material. The ideal material for repair is debatable. Many factors should be considered including cost and user handling properties. A tissue prosthetic such as a homograft or similar should be considered if there is any concern of infection. In our patient, in retrospect, we could postulate that he may have had a recent infection in his pleural space that might have necessitated the decortication and the middle lobe lung wedge resection. Fortunately, the wound infection appeared superficial layers and cleared with superficial debridement and vacu-dressing. If this involved deeper layers, it would have been necessary to remove the prosthetic material.
Lemierre’s syndrome treated operatively
Published in Baylor University Medical Center Proceedings, 2020
Allison T. Lanfear, Mohanad Hamandi, Joy Fan, Madison L. Bolin, Michael Williams, J. Michael DiMaio, John Waters
Pleural space disease may require additional interventions, such as tissue plasminogen activator, video-assisted thoracic surgery, and thoracotomy. The use of intrapleural tissue plasminogen activator to break down septations and minimally invasive surgery has been effective in cases of LS with bilateral parapneumonic effusions, cavitary pulmonary disease, and pleural effusions.6,10 When delayed diagnosis results in overwhelming sepsis, severe respiratory failure, and the presence of empyema, thoracotomy with decortication has been employed.11,13 In our patient, a severe right-sided pleural effusion resisted antibiotic treatment and intrathoracic lytic therapy. Thus, surgical decortication was performed, which proved effective.
Pleural tuberculosis
Published in Baylor University Medical Center Proceedings, 2019
Ashley Liou, Carlos E. Rodriguez-Castro, Abel Rodriguez-Reyes, Riyam Zreik, Shirley Jones, Whitney Prince
In our case, two acid-fast bacilli cultures from three different diagnostic methods came back positive, though timing from the thoracentesis allowed for earlier diagnosis. There were suggestions from the initial pleural fluid that pointed toward tuberculosis pleurisy. This included a predominant pleural fluid lymphocytosis and elevated lactate dehydrogenase.5 The distinctiveness of our case lies in a negative ADA and the sample used, because ultimately the pleural fluid was the first that grew acid-fast bacilli indicating the presence of M. tuberculosis. Not only is ADA a highly sensitive and specific test, but the negative predictive value of pleural ADA in a low-prevalence area for tuberculosis remains quite high.4,6 Because of delayed hypersensitivity in pleural tuberculosis, which occurs about 30% of the time, it can be difficult to isolate M. tuberculosis from pleural fluid samples.7 Samples obtained from bronchoscopy with bronchoalveolar lavage and VATS typically provide high and rapid diagnostic yield in undiagnosed exudative effusions, especially when there is associated parenchymal disease.5,8,9 Decortication also may have played a role in treatment, improving lung function and reducing residual pleural thickening.10
The role of pleurodesis in respiratory diseases
Published in Expert Review of Respiratory Medicine, 2018
Rachel M. Mercer, Maged Hassan, Najib M. Rahman
Pleurectomy and decortication are often used in combination but can be performed separately. A pleurectomy involves stripping the parietal and sometimes part of the visceral pleura; this is most commonly performed as part of a pleurectomy decortication for mesothelioma [64] or for a non-resolving pneumothorax. A visceral peel encasing the lung prevents lung expansion and therefore pleural apposition; this can be surgically removed in a procedure called decortication. In patients who are fit enough for surgical intervention, decortication can be undertaken to allow the lung to fully re-expand, to promote successful pleurodesis. This operation confers significant morbidity and is not commonly performed for pleurodesis alone as the patients are often palliative and the dyspnea can frequently be controlled after placement of an IPC.