Options for High-Risk Surgical Patients

In this two-part episode our team debates management of complex pleural effusions and empyema. Our surgical team is joined by Dr. Jed Gorden, an interventional pulmonologist, as we explore the nuances of deciding on fibrinolytic therapy (part 1) versus surgical management (part 2).

Part 1: https://behindtheknife.org/podcast/clinical-challenges-in-thoracic-surgery-complex-pleural-effusions-empyema-part-1-of-2/

Learning Objectives:

-Discuss the pros and cons of small bore versus large bore chest tubes for complex pleural effusions 
-Review the evidence for fibrinolytic therapy for management of complex pleural effusions
-Describe the surgical management of a complex pleural effusion including VATS, open thoracotomy, empyema tube, Eloesser flap, and Clagett window
-Create a framework for shared-decision making with patients regarding management of a complex pleural effusion

Hosts:

Kelly Daus MD, Peter White MD, Jed Gorden, MD and Brian Louie MD

Referenced Material

https://pubmed.ncbi.nlm.nih.gov/15745977/
Maskell NA, et al. First Multicenter Intrapleural Sepsis Trial (MIST1) Group. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005 Mar 3;352(9):865-74. doi: 10.1056/NEJMoa042473. Erratum in: N Engl J Med. 2005 May 19;352(20):2146. PMID: 15745977.

https://pubmed.ncbi.nlm.nih.gov/21830966/
Rahman NM, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011 Aug 11;365(6):518-26. doi: 10.1056/NEJMoa1012740. PMID: 21830966.

https://pubmed.ncbi.nlm.nih.gov/35830586/
Wilshire CL, et al. Comparing Initial Surgery versus Fibrinolytics for Pleural Space Infections: A Retrospective Multicenter Cohort Study. Ann Am Thorac Soc. 2022 Nov;19(11):1827-1833. doi: 10.1513/AnnalsATS.202108-964OC. PMID: 35830586.

https://pubmed.ncbi.nlm.nih.gov/37043201/
Wilshire CL, et al. Effect of Intrapleural Fibrinolytic Therapy vs Surgery for Complicated Pleural Infections: A Randomized Clinical Trial. JAMA Netw Open. 2023 Apr 3;6(4):e237799. doi: 10.1001/jamanetworkopen.2023.7799. PMID: 37043201; PMCID: PMC10098968.

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