Prognostic factors inﬂuencing the outcome of
empyema surgical management: prospective
study in a Moroccan University Center.
Sara Haﬁdi,M.D1*, Souheil Boubia,M.D1, Abdellah Fatene,M.D1, Najat Id El
ISSN: 0000-0000
Published 00 11 0000
Haj,M.D1, and Mohamed Ridai,M.D1
1Department of Thoracic Surgery, Ibn Rochd-Casablanca University Hospital, Morocco, Hassan
the 2nd University of Casablanca, Morocco
*Correspondence author: Email: haﬁdisara19@gmail.com Address : 1,Rue des
hopitaux,20360,Casablanca, Morocco ORCID : 0000-0002-4078-4001
O R I G I NA L
Abstract
Background: Pleural empyema is a public health problem, and is the most frequent complication of
pleural infection with signiﬁcant morbidity and mortality worldwide. Our study aims to highlight
the management of pleural empyema and evaluate its prognosis factors involved especially in
surgical treatment.
Patients and Methods: A prospective analysis of 53 patients who underwent surgical treatment
of pleural empyema, from January 2015 to December 2019 at the thoracic surgery department in
a tertiary referral university teaching hospital. Our study included patients who required surgical
treatment for pleural empyema and were excluded patients with destroyed lungs associated with
pyothorax.
Results: The mean age of patients was 39.24±15.89 years and 79,24% of them were males. In
85.7% of the cases, the etiology was undetermined in 34%, parapneumonic in 1.9%, of tuberculosis
in 54.71%, post-traumatic in 11, 3%, postoperative in 7.5% and iatrogenic in 1.9%. 45 patients
were treated with broad-spectrum antibiotics therapy adapted after antibiogram 14.38±21.76
days before the operation. A complete debridement and decortications were performed by VATS
in 28 and by PLT in 22 patients. No major complications occurred. At a mean term follow-up of
20 months (3months—3 years); all patients were alive with no recurrence. The analysis of the
results showed 4 factors of poor prognosis: delay of diagnosis and surgery (P = 0.02), chronic
alcoholism (P = 0.034), preoperative ventilation disorder/COPD (P = 0.04) and active tuberculosis
(P= 0, 05).
OPEN ACCESS
Conclusion: The success of surgical management of pleural empyema depends on several factors,
Edited by
which predict the prognosis, but can be prevented.
A.Hussain
Submitted 29 oct 2021
Keywords : Empyema, Pyothorax, Thoracic surgery, prognostic.
Accepted 29 Nov 2021
Citation
Introduction
S Haﬁdi ,S Boubia, A Fatene,
N Id El Haj, M Ridai.
Pleural Empyema or pyothorax, deﬁned as the presence of bacteria or pus in the pleural cavity, is a
Prognostic factors
serious infection. Despite adapted medical management, empyemas are still associated with high
inﬂuencing the outcome of
mortality and it ranges between 6%–24% in people with comorbidities with increasing incidence
empyema surgical
worldwide (1) . In our country (Morocco), it remains a real public health problem. The development
management: prospective
study in a Moroccan
of pyothorax is conditioned by the precocity and the quality of treatment, but also by the general
university
conditions in which they occur and the morbidity and mortality risk are highly reduced. In this
center:BJOSS::2021:(1);27-
prospective study, we report our 5 years of experience with pleural empyema.
34

Patients and Methods
This is a prospective descriptive and analytical study of 53patients; performed at the thoracic
surgery department of Ibn Rochd University Hospital Center, from January 2015 to December
2019. Our study included patients who required surgical treatment for pleural empyema and
were excluded patients with destroyed lung associated with pyothorax. All patients are initially
seen by a pulmonologist who sometimes determines the etiology of pyothorax and installs a
chest tube. The research of Koch’s Bacillus (BK) in the sputum was systematic and the patients
were operated on after their negativation. All patients underwent a check-up radiological ex-
amination performed with a standard chest x-ray and thoracic computed tomography (CT) scan.
Preoperative preparation was performed in all of our patients, with the placement of a chest
tube to allow an improvement of the respiratory functions and collect pleural eﬀusion samples
to perform microbiological and chemical examinations to set targeted antibiotic therapy and
incentive physiotherapy. Endoscopy was not performed systematically. The surgical indication
was retained due to the failure of medical treatment with the persistence of a trapped lung or
several locations of pleural ﬂuid or pleural thickening.
A complete debridement and decortication by VATS approach was the preferred procedure
but thoracotomy was due to intolerance to selective intubation or lack of complete evacuation
or complete lung expansion. the evolution was considered favorable in view of the complete
peroperative pulmonary re-expansion, the stay in intensive care not exceeding 24 hours, the
disappearance of the infectious signs, the absence of atelectasis and prolonged air leakage in
the immediate postoperative, improvement of respiratory function, absence of sequelae pleural
thickening or recurrence of pyothorax, and weight gain in the long-term course. The information
was collected from a data collection sheet completed since admission, during hospitalization,
and in postoperative. The qualitative values are presented by numbers and percentages. The
quantitative values are presented by the medians, the means, and standard deviations. For
univariate analyses, the Chi-square test and Fisher’s exact test were used, when appropriate.
For the outcome analyses, the above-mentioned potential prognostic factors were included in
a multiple logistic regression analysis using a backward selection technique SPSS version 17.0
software (SPSS, Inc., Chicago, IL, USA). The level of signiﬁcance was set at p 0.05.
Results
The mean age of patients was 39.24±15.89 years and 79, 24% of them were males. The main
demographical and clinical characteristics of the patients are reported in ( Table 1). Chest pain
was the main symptom in the 66%(n=35) of the series, 50,94%(n=27)patients presented dys-
pnea, cough 16,2%(n=30) high fever 22,6%(n=12), overall health deterioration 18,9%(n=10) ,
purulent sputum 13,2%(n=7), hemoptysis 9,4%( n=5)and Fluid eﬀusion syndrome 73.9% (n=39)
at the admission.chest x-ray was performed in all patients showing gaz level 37.7%(n=20 ),Free
pleural eﬀusion35.8% (n= 19),Septic pleurisy 18.9% (n=10),Thickened pleura1.9% (n= 1),Pleural
calciﬁcations1.9%(n= 1)Lung abscess 1.9%(n= 1).
All patients were treated with antibiotic therapy and subsequent target therapy (after determi-
nation of responsible germs by bronchoalveolar lavage in 9 cases or analysis of pleural eﬀusion
in 23 cases) for 14.38±21.76 days prior to operation. The duration of antibiotic therapy de-
pended on the condition of infectious disease of the patient; C-reactive protein(CRP), the eﬃcacy
and response of the treatment. The main etiologic agents were: Streptococcus pneumonia and
Mycobacterium tuberculosis. All patients needed the placement of a chest tube until the eﬀu-
sion was completely drained, and was guided by ultrasound in 18,9% ( n=10). The median time
from admission to drainage was 4 days (range 1 – 10 days), No ﬁbrinolytic therapy had been
administered.
A preoperative CT chest for the evaluation of condition was achieved in all patients.42 patients
(79.24%) stage II, 8 patients (15.09%) presented with stage III and 3 patients (5.66%) stage I
empyema ( Figure 1). In 43.4% (n=23), the etiology was of tuberculous origin,undetermined in34%
(n=18),post traumatic in 11,3% (n=6), postoperative in 7.5% (n=4) and post iatrogenic in 1.9%
n=(1), parapneumic in 1.9% (n=1).The overage delay between onset of symptoms and surgery
28/34

was 67.5 days (range 15-120).
For the operation, all patients were under general anesthesia with the use of double-lumen
endotracheal tubes for selective ventilation and then placed in the lateral position. A complete
debridement and decortications were performed in 50 cases by VATS in 28cases and by PLT
in 22cases and pleuropneumonectomy in 3cases after the ﬁrst decortication through PLT. The
mean operation time was 180min. The intraoperative and 30-day mortality was null. The average
length of stay in intensive care was 36 +/- 18 hours. Incentive respiratory physiotherapy was
performed on all our patients. The last drainage was removed after 7.13±9.05 days and patients
were discharged after 15.37±8.67days. Antituberculosis treatment was administered to patients
in whom tuberculosis was diagnosed histologically in the postoperative period. The regimen was
isoniazid and rifampin for 6 months, with ethambutol and pyrazinamide for the ﬁrst 2 months.
The outcome was favorable in 90.56% of cases but the following postoperative complications
were noted: Persistent pyothorax in 1,88% prolonged air leakage in 7,54% of patients and these
ﬁve patients had trapped lung were not responsive to surgical treatment of which 2 cases kept
the chest drain for an average of 30.45/-15 days and 3 patients were treated with Open window
thoracostomy with good evolution. At a mean follow-up of 20 months(3months—3 years), all
patients were alive with no recurrence. The univariate analysis of the results of the surgery
allowed to determine 4 factors of bad prognosis: delay between onset of symptoms and surgery>
45 days (P = 0.02),history of chronic alcoholism(P = 0.034), preoperative ventilation disorder:
COPD (P = 0.04),active tuberculosis (P=0, 05)( Table 2).
Table 1. Demographical and clinical characteristics of the patients
Characteristics
N=53(%)
Age (years) Gender
39.24±15.89
Male
42(79,24)
Female
11(20,75)
Smoking
23(43,3)
Chronic Alcoholism
2(3,8)
COPD
20(37,73)
Heart Disease
2(3,8)
Arterial Hypertension
3(5,66)
Diabetes
6(11,3)
TBK
29(54,71)
Progressive Neoplasm
3(5,7)
Lung Cancer
1(1,9)
Thoracic Traumatism
6(11,3)
Preoperative White Blood Cell Count
13(24,5)
Preoperative
C-reactive
Pro- 8(15,2)
tein(>100mg/L)
Empyema Stage
I
3(5,66)
II
42(79,24)
III
8(15,09)
Surgical Approach
PLT
25(47,17)
VATS
28(52,83)
Operating Time (min) Side
120
Right
25(47,16)
Left
28(52,83)
Number Of Chest Tubes
2(100)
Length Of Hospital Stay(days)
15.37 +/-05,67
29/34

Table 2. the prognostic factors of our series
Prognostic Factors
Favourable Evolu- Unfavourable Evolu- P Value
tion
tion
Diabetes
35(67,6%)
17(32,7%)
0,349
Progressive Neoplasia
35(66%)
18(34%)
0,234
Old Tuberculosis
35(66%)
18(34%)
0,475
Active Tuberculosis
35(66%)
18(34%)
0,05
Lung Cancer
35(66%)
18(34%)
0,359
Smoking
35(66%)
18(34%)
0,634
Chronic Alcoholism
35(66%)
18(34%)
0,034
Thoracic Surgery
33(66%)
17(34%)
0,685
Delay Between Onset Of
0,02
Symptoms And Surgery
>45 Days
Pleural thickening
31(64,6%)
17(34%)
0,347
Preoperative Ventilation 35(66,7%)
18(34%)
0,04
Disorder:COPD
Discussion
Pyothorax or pleural empyema is a health care problem in many regions of the world; its incidence
has increased since 1990, and it has aﬀected more than 65,000 patients each year in the United
States and the United Kingdom (2; 3). From 1996 to 2008, the hospitalization for pyothorax
increased from 3.0 to 5.9 per 100,000 in the United States population. Pyothorax in recent years
might be associated with an increasingly aging, high morbidity in a population (4), the average
age of our population was young 39.24±15.89 years which has a good prognostic factor with a
low rate of comorbidities ( Table 1). Treatment of these pus collections include surgical drainage
and intra-pleural ﬁbribnolytic agents.
Postpneumonic pleural empyema, which is the most common form of pleural empyema (60%),
is increasing in North America and Europe and is recognized as a major cause of morbidity and
prolonged hospital stay. The second most common cause of pleural empyema is postsurgical
(30%), in our study, In 43.4%, the etiology was due to tuberculosis ,undetermined in34% ,post-
traumatic in 11,3%, postoperative in 7.5% (5), and post iatrogenic in 1.9% (1), parapneumonic in
1.9%.
In our series, 43.3% were active smokers with a preoperative ventilatory disorder/COPD (P =
0.004) in 37.73% and a history of chronic alcoholism (P = 0.034) in 3.8%. We retained them as 2
signiﬁcant poor prognosis factors. Unlike simple pleural eﬀusion, empyema shows a rapid clinical
progression, and any delay initiating eﬀective drainage may result in increased morbidity and
mortality. The importance of early surgical involvement in the management of lobulated pleural
eﬀusion and empyema has been reported in many recent studies. According to these studies,
early application of VATS drainage or decortication has shown better early results than those in
cases managed with ﬁbrinolytic or thoracotomy alone. Presently, VATS has become one of the
most important treatment modalities in the management of early stages of empyema, especially
during the ﬁbrinopurulent stage. However, because of the lack of suﬃcient data regarding the
optimal timing of operation in the management of loculated pleural eﬀusion and empyema, many
physicians and surgeons are still debating when to perform surgical interventions in these patients.
In most clinical situations the decision for surgical intervention is based solely on the patient’s
clinical status (for example, fever, leukocytosis, chest X-ray, and chest CT), and mainly relies on
the physician’s clinical experience and subjective opinion. Consequently, delays in the decision
to perform surgical intervention may lead to deterioration in the patient’s status and a worse
postoperative outcome (4). In our series, the average delay between the onset of symptoms
and surgery was 54,36+/-65,55 days and was retained as a factor of poor prognosis when it’s
exceeded 45 days with a P=0,02.
30/34

Before surgery it is mandatory, to have the correct empyema stage assessment, which must be
done with a clear description of the radiographic aspect and with a CT scan, which can help
to locate the presence of a thick pleura, which is a pathognomonic sign of stage 3 empyema
( step, it begins with the installation of a chest tube. This attitude must be a rule before any
surgical intervention, in our series, all the patients received preoperative thoracic drainage. it is
the therapeutic key in the management of pyothorax and constitutes a therapeutic emergency.
Its interest lies above all in the control of the local and general infectious state to avoid per-
and postoperative septicemia which can be life-threatening. VATS debridement or decortications spent less time in the hospital, and the conversion rate
to open procedure for stage III empyema was only 19%, which encourages considering VATS
debridement/decortication as a ﬁrst-choice treatment. The guidelines produced by the British
Thoracic Society suggest surgical treatment in patients with nonresolved pleural empyema with
a maximum period of 7 days without resolution. Early referral to surgery is a key factor for
a successful operation of pleural empyema by the VATS approach. Conversion from VATS to
thoracotomy range from 5.6% to 61% but increases from 22% to 86% between day 12 and day
16 of presentation, and patients with a symptom duration of fewer than 4 weeks had better
early results compared with a symptom duration of more than 4 weeks. Stefani and colleagues
demonstrated that the probability of thoracotomy increased from 28% to 81% if the operation
was performed within 10 days or after a delay of 30 days to 40 days

The guidelines proposed by the European Association for Cardio-Thoracic Surgery preferred VATS
in patients with stages II to III pleural empyema with the omission of stage III empyema with
more than 5 weeks symptomatic clinical history.VATS decortication has also been reported to
successfully manage tuberculous empyema. Irrespective of the pleural empyema stage, some
patients have a hidden chest malignancy. (10; 11; 12) According to The American Association for
Thoracic Surgery (AATS) consensus guidelines for the management of empyema, the choice of the
initial approach in stage III of empyema is dictated based on the condition of the patient, pleural
space, and underlying lung parenchyma (13). The development of pyothorax is conditioned by the
precocity and the quality of treatment, but also by the underlying lesions and general conditions in
which they occur, several factors including predisposing diseases, delay in targeted antimicrobial
or surgical treatment, the choice of treatment, and the bacterial aetiology may aﬀect the outcome.
A short delay in the diagnosis and treatment of pleural empyema is associated with a superior
outcome and a low mortality rate of 4.3 –15%. A diﬀerence in mortality from 3.4% to 16% has
been described with a delay in chest tube drainage of more than 3 days, and the detrimental eﬀect
on the outcome of a further 1-day delay in chest tube drainage has been shown in animal models.
Towe and his colleagues noticed that every daily surgery was delayed from admission to day 5 of
hospitalization was associated with a 20% relative increase in mortality in these patients. (14) To
improve unnecessary delays in patients receiving the most appropriate interventions, surgeons
should extend widely their scope of responsibility beyond the operating room. Thoracic surgeons
have an obligation to defend the management of empyema in the establishments where they
practice and guide early treatment decisions to improve outcomes and reduce resource use in this
clinically complex area disease. Thus recent guidelines have concluded that a multidisciplinary
approach is recommended (15).
The evolution was favorable in 88.67% of our patients, the outcome was unfavorable in 5 patients
who presented postoperative complications, either 9.5% of cases (persistent pyothorax, prolonged
air leakage) and the mortality rate was zero.
In our series, the predictors of unfavorable evolution were: long delay between the onset of
symptoms and surgery>45 days p = 0.02, chronic alcoholism p = 0.034, active tuberculosis p =
0.05, and ﬁnally a preoperative ventilation disorder: COPD p = 0.04.
Figure 1. VATS decortication in pleural empyema stage III of tuberculous origin. A,B)
Pre-operative CT of the thorax; and C,D) operative views with thick fibrin layer over the parietal
pleura and cortex overlying the lung.
Conclusion
Pleural empyema remains a major complication of pleural infection with a great challenge for
physicians for its treatment. The morbidity and mortality are high in elderly people and patients
with co-morbidities but can be reduced to zero in the young population without co-morbidities
and risk factors when diagnosis and therapeutic management are made at early time.
32/34

Availability of data and materials
Data available on request from the authors
Abbreviations
VATS: Video-assisted thoracic surgery, PLT: Postero lateral thoracotomy, COPD: Chronic obstruc-
tive pulmonary disease
Acknowledgements
Not applicable
Funding
The authors disclose no sources of funding for research.
Competing interests
The authors declare that they have no competing interests.
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