Clinical Challenges in Thoracic Surgery: Complex Pleural Effusions & Empyema - Part 2 of 2

Aug 17, 2023

Complex pleural effusions and empyema take center stage, as the surgical team discusses management strategies with Dr. Jed Gorden. Discover the debate between fibrinolytic therapy and surgical options, including VATS and open thoracotomy. Key insights include choosing between small versus large bore chest tubes and factors influencing surgical decisions. Learn about innovative techniques like the Eloesser flap and Clagett window, as well as management options for high-risk patients. Clinical outcomes and successful recovery stories wrap up the conversation.

Ask episode

AI Snips

Chapters

Transcript

Episode notes

ADVICE

Always Put A Tube First

Always place a chest tube first to assess drainage before choosing lytics or surgery.
Use antibiotics and tube drainage as initial source control while you plan next steps.

INSIGHT

Start Minimally Invasive When Possible

Start VATS when feasible because it often matches outcomes of open decortication with less morbidity.
Convert to open thoracotomy if exposure is inadequate or anatomy dictates.

ADVICE

When To Consider Open Thoracotomy

Lean toward open thoracotomy if prior ipsilateral thoracotomy, talc pleurodesis, trauma, or suspected bronchopleural fistula exist.
Counsel patients about high conversion risk when attempting VATS in these settings.

Get the Snipd Podcast app to discover more snips from this episode

Get the app

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.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out more thoracic surgery episodes here: https://behindtheknife.org/podcast-category/cardiothoracic/