Surgical versus non-surgical management of pleural empyema.

BACKGROUND: Pleural empyema is a collection of pus between the lungs and the chest wall. Approximately 50% of cases complicate pneumonia. There are a variety of treatment options ranging from intravenous antibiotics alone to open thoracotomy and debridement, depending in part on the stage of the empyema and the severity. The condition changes with time, becoming loculated and more difficult to drain. There is much debate about the most appropriate therapy particularly with the advent of new treatments such as fibrinolytic enzymes (e.g. streptokinase, urokinase) and video-assisted thoracoscopic surgery (VATS).

OBJECTIVES: To determine which is more effective for the management of empyema: surgical (e.g. thoracoscopy, thoracotomy) or non-surgical techniques (e.g. thoracocentesis, chest tube drainage) and to establish whether there is an optimum time for intervention.

SEARCH STRATEGY: The Cochrane Controlled Trials Register and DARE database were searched in addition to the Cochrane Acute Respiratory Infections Group's own register of trials. A specialised topic search with no language restrictions was used to search MEDLINE and EMBASE using Silverplatter. Bibliographies and the reference lists of identified studies and review articles were handsearched. Personal communication with authors and experts in the field is ongoing.

SELECTION CRITERIA: Randomised controlled trials (RCTs) of surgical techniques versus non-surgical approaches for treatment of pus in the pleural cavity in children and adults but not neonates. Studies of empyema associated with tuberculosis or malignancy were excluded.

DATA COLLECTION AND ANALYSIS: Trial quality was assessed using Jadad criteria as recommended by the ARI group (Jadad 1996). The primary outcomes were death or resolution of the empyema. Secondary outcomes addressed length of time chest tubes were required, pain, hospital stay and any complications.

MAIN RESULTS: Only one small randomised study was identified which met the inclusion criteria. It was conducted in a university thoracic surgery department. There were some methodological quality considerations which cast some doubt on validity ( patient selection, unclear allocation concealment and outcome assessor blinding) and it scored 'B' overall (Jadad score 3). The main results of the study were that when compared with chest tube drainage combined with streptokinase, the video-assisted thoracoscopic surgery (VATS) group had a significantly higher primary treatment success and spent less time in hospital. Each group suffered one mortality.

REVIEWER'S CONCLUSIONS: It would appear that for large, loculated pleural empyemas VATS is superior to chest tube drainage with streptokinase in terms of duration of chest tubes and hospital stay. However there are questions about validity and the study is also too small to draw conclusions. There are risks of complications (associated with all treatments) which may not apparent with small numbers. VATS is performed under general anaesthetic and one lung ventilation. Fibrinolytics are also associated with side effects. Further larger multicentre studies need to be conducted.