Elsevier

The Surgeon

Volume 14, Issue 2, April 2016, Pages 69-75
The Surgeon

Surgery for parapneumonic pleural empyema – What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome?

https://doi.org/10.1016/j.surge.2014.05.002Get rights and content

Abstract

Objective

Pleural empyema is a critical condition. In the western world the share of sufferers with multiple comorbidities and advanced age is rapidly increasing.

Methods

This retrospective study comprises all patients who underwent surgery for parapneumonic pleural empyema at a major center for thoracic surgery in Germany between January 2006 and April 2013.

Results

A total of 335 patients (mean age 60.4 years) were included. The average ASA grade was 2.8. Empyema stage 1, 2 and 3 (classification of the American Thoracic Society) was encountered in 30, 230 and 75 cases, respectively. The most common comorbidities were cardiac disorders (124), diabetes mellitus (76), COPD (66) and alcoholism (54). The mean Charlson index of comorbidity score was 2. Minimally invasive surgery was feasible in 290 cases. A total of 88 patients sustained pulmonary sepsis. The overall mortality was 29/335 (8.7%).

The occurrence of pulmonary sepsis (OR: 17.95; 95% CI: 6.38–62.69; p < 0.001), respiratory failure (OR: 23.08; 95% CI: 8.52–73.35; p < 0.001) and acute renal failure (OR: 8.20; 95% CI: 3.18–20.80; p < 0.001) and Charlson score ≥ 3 (OR: 6.65; 95% CI: 2.76–17.33; p < 0.001) were associated with higher mortality. On the other hand, very elderly sufferers (≥80 years) showed neither higher odds for pulmonary sepsis (OR: 0.78) nor for fatal outcome (OR: 0.92; 95% CI: 0.22–2.86; p = 1).

Conclusions

Parapneumonic pleural empyema is still associated with considerable morbidity and mortality. Pre-existing comorbidity, the occurrence of pulmonary sepsis and sepsis related complications have a determining influence on the results whereas advanced age itself shows no higher risk for adverse outcome. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.

Introduction

Parapneumonic pleural empyema is a critical condition with reported mortality between 10% and 20%.1, 2, 3, 4, 5 The timely and appropriate management of pleural space infections remains a most challenging issue in modern thoracic surgery.6, 7 Recent population based data has shown an increasing incidence of parapneumonic pleural empyema in North America as well as in Europe.8, 9, 10, 11, 12 A rising share of sufferers with multiple comorbidities and advanced age further complicates the situation. Geriatric patients are much more frequently affected by lower respiratory tract infections and pneumonia as young persons. Current population based data from the United Kingdom showed that the incidence of community-acquired pneumonia increases markedly with age.13 Those aged 85–89 years had seven times more community-acquired pneumonia episodes than those aged 65–69 years. Moreover, the study, which included a total of 1.534.443 patients (all aged ≥ 65 years), revealed an increase in the overall incidence of lower respiratory tract infections as well as of community-acquired pneumonia over the study period (1997–2011).13

In addition to advanced age, the presence of comorbid conditions (chronic heart, renal, liver or respiratory disease) as well as chronic alcoholism and smoking are considered to be major risk factors for community-acquired pneumonia.14 At the same time, advanced age and multimorbidity are also associated with higher risk for parapneumonic pleural empyema.6, 10 The outcome of these sufferers is often poor with mortality rates of approximately 20% and a similar share of patients who have to be transferred to institutional care facilities postoperatively. Therefore, the increasing incidence of pneumonia as well as of parapneumonic empyema and the simultaneously rising number of very elderly sufferers with multiple comorbidities are one of the most pressing health care problems today. Currently, lower respiratory tract infections are the fourth most common cause of death globally.15

Against this background, we report on our experience with surgery for pleural empyema in a population with considerable prevalence of multimorbidity and a large share of geriatric patients. Aim is not only to show the current results of surgical management but also to identify strategies for further improvement.

Section snippets

Material and methods

The outcomes of all patients who underwent surgery for parapneumonic pleural empyema at the Department of General and Thoracic Surgery at the Klinikum Nuremberg between January 2006 and April 2013 were retrospectively analyzed. Our institution is one of Germany's largest tertiary referral hospitals and a major center for thoracic surgery in southern Germany. Only cases of primary, parapneumonic empyema were included whereas empyema secondary to thoracic surgery was generally excluded.

Results

The study comprises a total of 335 consecutive patients, who underwent surgery for parapneumonic pleural empyema. There were more men (234) than women (101) and the mean age was 60.4 years (17–95 years; SD ± 16.88 years) (Fig. 1). Empyema stage 1, 2 and 3 (classification of the American Thoracic Society) was observed in 30, 230 and 75 cases, respectively. The average ASA grade reached 2.8. ASA grade 1, 2, 3 and 4 was encountered in 8, 90, 208 and 29 cases, respectively.

Heavy pre-existing

Discussion

The incidence of parapneumonic pleural empyema is on the rise – in Europe as well as in North America.8, 9, 10, 11, 12 Several contemporary population-based studies confirm this trend. For example, the analysis of a statewide administrative database of all hospitalizations for pleural space infections in Washington State (USA) showed that the incidence rate increased 2.8% per year (95% CI: 2.2–3.4%; p < 0.001) from 1987 to 2004.8 A similar result was obtained from an analysis of the Nationwide

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