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Surgery first improves empyema outcomes

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – The first procedure performed to treat empyema patients has a key impact on outcomes, new research shows. In particular, patients fare better when initial therapy is thoracotomy or video-assisted thoracic surgery (VATS) rather than simple drainage.

As reported in the Annals of Thoracic Surgery for May, Dr. Douglas E. Paull, from the Department of Veterans Affairs, Ann Arbor, Michigan, and colleagues assessed the outcomes of 104 consecutive patients who were treated for empyema at two centers from 2000 to 2006.

The main outcomes were the need for additional drainage procedures and death. Success was defined as survival without the need for additional drainage procedures.

Overall, 84% of patients had advanced empyema, based on a modified American Thoracic Society stage of IIA or higher. Tube thoracostomy was the common procedure, performed in 37 patients, followed by thoracotomy in 36.

The treatment success rates with the two surgical operations, thoracotomy and VATS, were 89% and 81%, respectively. By contrast, pigtail drainage and tube thoracostomy yielded success rates of just 40% and 38%, respectively.

On multivariate analysis, a poor Karnofsky performance status and failure of the first drainage procedure were significant predictors of death, the report shows. When the first procedure was either pigtail drainage or tube thoracostomy, the likelihood of first procedure failure increased by 11.1-fold (p = 0.00004).

The results indicate that “operative intervention with VATS or thoracotomy is the optimal initial approach for patients with advanced empyema,” the investigators conclude. Even after adjustment for confounding variables, the choice of first treatment for empyema is “critical.”

Ann Thorac Surg 2009;87:1525-1531.