Surgery for parapneumonic pleural empyema – What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome?☆
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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2017, Journal of Thoracic and Cardiovascular SurgeryCitation Excerpt :These patients often are unable to tolerate an extensive decortication with or without parenchymal resection or tissue flap placement for fistula control. The presence of a BPF may also create a grossly infected space that may need to be controlled before definitive operative repair with decortication and tissue flap placement.91,97,98,104 The creation of an open thoracic window allows for this infectious and fistula control either definitely or as part of a stepwise operative plan to definitive surgical treatment of the space.
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Presented at the Annual Meeting of the Society for Cardiothoracic Surgery in Great Britain & Ireland, Edinburgh, Scotland, March 10–12, 2014.