295 MED ARH 2009; 63(5) • ORIGINAL PAPERS Surgical Treatment of Pleural Empyema According to Disease Stage 1. INTRODUCTION Pleural empyema is deined as a col- lection of pus in the pleural space (1, 2, 3). Efusion in pleural area is a frequent occurrence during bacterial pneumo- nia. It is estimated that in 40% of cases efusion occurs. In 15% of cases, de- pending on the virulence of patho- gens, the immune status of patients and treatment start, efusion progresses in pleural empyema. Values of pH are be- tween 7.2 and 7.3 are proposed as a cru- cial point for drainage of bacterial neg- ative, non purulent, non localized ef- fusion. If the pH values are less than 7, the concentration of glucose that is less than 2.2 mmol/L and LDH value that is greater than 1000 U/L suggest para- pneumonic complicated efusion that must be drained. Sahn and Light state that the value of pH of 7.3 is an indica- tor of the favorable outcome of ther- apy with antibiotics without drainage, while in cases where the value is lower than pH 7.1 thoracic drainage is nec- essary in order to evacuate efusion. Pleural empyema exists and develops in three stages (1, 2, 3, 4, 5) Exudative or acute stage, Fibrinopurulent or intermedial stage which starts with transition of bacteria in pleural space, already 30 to 48 hours after the beginning of the in- fection. Organizing or chronic stage. Takes place during the period after 7 to 10 days from the beginning of the infec- tion in pleural space and resolves be- tween 4 and 6 weeks. Optimal treatment of pleural em- pyema requires • infection control, • evacuation of pus and • reestablished expansion of the lung parenchyma. Treatment of acute empyema is ori- ented in two directions, and includes: • hormonal therapy and • surgical procedures Pharmacological treatment is per- formed on the basis of the indings anti- biograms (when the cause is isolated) or on the basis of clinical assessment in re- lation to the probable cause of infection. Surgical therapy • Some of the modiications of tho- racic drainage, • classic surgical methods (Decor- tications of pleura). Pharmacological treatment is not suicient for deinitive cure of pleural empyema, so to inally achieve a cure surgical intervention is needed. Surgical treatment involves the ap- plication of some of the available mod- iications of thoracic drainage, applica- tion techniques and VATSIM thoracot- omy with decortications of the pleura. Optimal treatment of pleural empy- ema requires infection control, evacua- tion of pus and reexpansion of the lung parenchyma. In the early stages of in- fection evacuation of efusion can be performed by repeated thoracocente- ses, but early drainage of the thorax leads to faster recovery and reduced morbidity and mortality rates. In ibri- nopurulent stage evacuation of pus and reexpansion of the lung parenchyma can be achieved by thoracic drainage. Decortications of the lungs, in the or- ganizing stage is the optimal treatment, and therapeutic alternatives are thora- coplastic procedures and fenestration of the thorax. Data from literature show that in developed countries is somewhat lower percentage of the application of aggres- sive surgical procedures, which may be due to early diagnosis and appropriate initial antibiotic therapy. With respect to the large number of patients at clin- ics for thoracic surgery that are admit- ted in stage 3, is expected that surgical treatment which usually applied is de- cortications of the lungs. 2. GOALS To determine the stage of disease at admission of patients to the clinic. Based on the assessment of disease stages to determine the optimal surgi- cal procedure in the deinitive treat- ment of pleural empyema. 3. PATIENTS AND METHODS The study included 100 patients with clinical, laboratory and radio- logical indings, appropriate for para- pneumonic and metapneumoic pleu- ral empyema that were treated at the Clinic for horacic Surgery. In all pa- tients we registered the following data, which were used as criteria for inclu- sion in the study: • Age of the patient. • Gender, • he duration of treatment prior to admission to the Clinic for ho- racic Surgery, Clinical Center of Sarajevo University, • herapy that is applied prior to admission at the Clinic for ho- Surgical Treatment of Pleural Empyema According to Disease Stage Ilijaz Pilav, Safet Guska, Safet Musanovic, Kenan Kadric Clinic of horacic Surgery, Clinical Center of Sarajevo University, Bosnia and Herzegovina ORIGINAL PAPER SUMMARY Para pneumonic efusions are oten complications of bacterial pneumonia, occurring in 5-50% patients and in 15% cases it can progress into pleural empyema. Pleural empyema treatment includes drainage of pus, re-expan- sion of lung by using appropriate antibiotics. Surgical treatment covers implementation of certain thoracic drain- age modiications, use of VATS techniques and thoracotomy with pleura decortications. PATIENTS: Research has involved 100 patients with diagnosis and treatment of para pneumonic and meta pneumonic pleural empyema. RESULTS: Based on previously deined phase of pleural empyema it was determined which surgical procedures have been used in deinitive treatment of pleural empyema. In case of 31,17% (24/77) patients it has been found that pre-clinical treatment lasted 31 days and longer, and 49,35%(38/77) patients have been admited at Clinic ater 11 to 30 days of pre-clinic treatment. Only in 19.48% (15/77) patients pre-clinic treatment lasted up to 10 days. 79% (79/100) patients were in third phase of disease, 19% (19/100) patients were in second phase and 2% (2/100) patients were in irst stage of disease. Among patients with irst stage of disease 1 patient was subject to pleural drainage and 1 was subject to decortications. Among patients with second phase of disease 10 patients were subject to pleural drainage and 9 to decortications. Among patients with third phase of disease 20 patients were subject to pleural drainage and 49 to decortications, 4 patients were subject to pleural drainage with rib resection, and 2 were subject to combination of thoracoscopy and drainage, while in case of 4 patients it was necessary to perform additional drainage. CONCLUSIONS: Pleural drainage is irst procedure in surgical treat- ment of pleural empyema, but very oten it is not deinitive measure of treatment of patients with third phase of disease. Deinitive treatment of empyema in third phase is decortications of pleura carried out on 62% patients with this phase of disease. Eiciency of treatment determined on basis of mortality level is satisfactory. Keywords: pleural empyema, stage, surgical treatment