Coşkun ÖZCAN, AHMET ÇELİK, Güliz ERGÜN, HAKKI ATA ERDENER

Çocuklarda ampiyemin torakoskopik tedavisi

Torakoskopik debridman (TD), plevral sıvının lokule veya koyu kıvamda olduğu ve bu nedenle toraks tüpü ile temizlenemediği ampiyem hastalarında uygulanabilecek bir tedavi seçeneği olarak önerilmektedir. Bu çalışmada TD uygulanan çocuklarda tedavinin sonuçları ve yöntem ile ilgili deneyimlerimiz sunulmuştur. Yaş ortalaması 4 (1-7) yıl olan 14 hastaya TD uygulandı. Radyolojik incelemelerde tüm hastalarda ampiyemin tipik bulguları, 4 hastada ek olarak akciğer parankiminde kavitasyonlar ve/veya pnömotoraks saptandı. Radyolojik incelemelerinde lokule ya da koyu plevral sıvı saptanan ya da torasentez ile sıvı alınamayan 9 hastaya ilk tedavi olarak TD uygulandı. Diğer 5 hastaya ise ilk olarak tüp torakostomi yapıldı ancak tedaviye rağmen akciğerin açılmaması ve ampiyemin klinik ve radyolojik bulgularının devam etmesi üzerine TD uygulandı. Operasyonda plevral boşluğa bir endoskop yerleştirilerek, direkt görüş altında septasyonlar parçalandı, plevra koyu sıvı, püy ve fibrinlerden temizlendi ve bol izotonik solüsyon ile yıkandı. Port giriş yerlerinden birinden geçirilen bir toraks tüpü plevral boşluğa yerleştirildi. Drenajın durduğu gün toraks tüpü çekildi. Bir hasta dışında operasyondan ortalama 2 (1-4) gün sonra hastaların klinik bulgularında düzelme gözlendi. Parankimde kavitasyonların olduğu 4 hastada bronkoplevral fistule bağlı olarak uzun süre toraks tüpüne gereksinim oldu (ortalama 16,5, 11-21 gün). Bu hastalardan birinde ikinci kez yapılan torakoskopik girişimle, bir olguda ise torakotomi ile fistülün kapatılması gerekti. Diğer 10 hastada ise TD' dan ortalama 3,4 (3-5) gün sonra toraks tüpleri çekildi. Hastaların hiçbirinde geç dönemde yapılan kontrollerde plevrada kalınlaşma ya da akciğerde kollaps saptanmadı. TD, plevranın fibrin ve püyden temizlenmesini kolaylaştırarak klinik bulgularda hızlı bir düzelme sağlar ve tüp torakostomi süresini kısaltır. Ancak parankimal kavitasyonların olduğu olgularda bronkoplevral fistule bağlı olarak operasyon sonrası tüp torakostomi süresi uzamakta ve ikinci bir girişim olasılığı artmaktadır.

Anahtar Kelimeler:

Toraks cerrahisi işlemleri, Ampiyem, Torakoskopi, Çocuk, Radyoloji

Thoracoscopy in the management of empyma in children

Treatment with tube thoracostomy may fail in children with fibrinopurulent empyema since there are loculations in pleural cavity and/or the pleural fluid is too dense to be easily drained through a chest tube. Thoracoscopic debridment (TD), recently, has been suggested as an alternative therapy in such patients. This study describes our experience with TD at the fibrinopurulent stage of empyema in children.Fourteen children were treated by TD. The patients were aged between 1 and 7 years (mean, 4 years). All children had typical clinical and radiological findings ofempyema; 4 also had intraparenchymal cavitations and 3 had pneumothorax. Nine children underwent TD as an initial therapy since there are loculations and/or thick pleural fluid on preoperative radiologie investigations. TD was performed in the remaining 5 patients who had persistent empyema despite an initial tube thoracostomy. At the operation, an endoscope was inserted into the pleural cavity, loculi were disrupted, and gelatinous debris was evacuated. The pleural cavity was irrigated with saline and a chest tube was placed under direct vision. Clinical improvement was observed at 1 to 4 days (mean, 2 days) postoperatively in all except one patient. Four patients with intraparenchymal cavitations required prolonged tube thoracostomy (mean 16.5 days, range 11 to 21 days) because of bronchopleural fistula and one of them required a second thoracoscopy while the other required thoracotomy for the closure of the fistula. In the remaining 10 patients, chest tubes were removed at 3 to 5 days (mean, 3.4 days) after TD. There were no pleural thickening or lung collapse on chest radiographs in the follow-up. TD is useful for the evacuation of thick debris and results in rapid clinical improvement in children with fibrinopurulent empyema. However, chest tube drainage may prolonge and a second surgical intervention may be required because of bronchopleural fistulas in patients with intraparenchymal cavitations.

Keywords:

Thoracic Surgical Procedures, Empyema, Thoracoscopy, Child, Radiology,

PDF

___

1. Hoff SJ, Neblett WW, Edwards KM, ve ark. Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections. Pediatr Infect Dis J 1991; 10: 194-199.
2. Meier AH, Smith B, Raghavan A, ve ark. Rational treatment of empyema in children. Arch Surg 2000; 135: 907-912,
3. Kercher KW, Attorri RJ, Hoover JD, Morton D. Thoracoscopic decortication as first-line therapy for pediatric parapneumonic empyema. A case series. Chest 2000; 118: 24-27.
4. Kern JA, Rodgers BM. Thoracoscopy in the management of empyema in children. J Pediatr Surg 1993; 28: 1128-1132.
5. Doski JJ, Lou D, Hicks BA, ve ark. Management of parapneumonic collections in infants and children. J Pediatr Surg 2000; 35: 265- 270.
6. Rodriguez JA, Hill CB, Loe WA, ve ark. Video-assisted thoracoscopic surgery for children with stage II empyema. Am Surg 2000; 66: 569-574.
7. Foglia RP, Randolph J. Current indications for decortication in the treatment of empyema in children. J Pediatr Surg 1987; 22: 28- 33.
8. Chen LE, Langer JC, Dillon PA, ve ark. Management of late-stage parapneumonic empyema. Pediatr Surg 2002; 37: 371-374.
9. Lemmer JH, Botham MJ, Orringer MB. Modern management of adult thoracic empyema. J Thorac Cardiovasc Surg 1985; 90: 849- 855.
10. Chan W, Keyser-Gauvin E, Davis GM ve ark. Empyema thoracis in children: a 26-year review of the Montreal Children's Hospital experience. J Pediatr Surg 1997; 32: 870-872.
11. Şencan A, Günşar C, Süzek D ve ark. Çocukluk çağı ampiyemlerinin tedavisi. Pediatrik Cerrahi Dergisi 2001; 15:120-124.
12. Stovroff M, Teauge G, Heiss KF ve ark. Thoracoscopy in the management of pediatric empyema. J Pediatr Surg 1995; 30: 1211- 1215.
13. Patton RM, Abrams RŞ, Gauderer MWL. Is thoracoscopically aided pleural debridement advantageous in children? Am Surg 1999; 65:69-72.
14. Klena JW, Cameron BH, Langer JC, ve ark. Timing of video-assisted thoracoscopic debridement for pediatric empyema. J Am Coll Surg 1998; 187:404-408.
15. Rescorla FJ, West KW, Gingalewski CA, ve ark. Efficacy of primary and secondary video-assisted thoracic surgery in children. J Pediatr Surg 2000; 35:134-138.
16. Subramaniam R, Joseph VT, Tan GM, ve ark. Experience with video-assisted thoracoscopic surgery in the management of complicated pneumonia in children. J Pediatr Surg 2001; 36: 316-319.
17. Andrews NC, Parker EF, Shaw RR ve ark. Management of nontuberculous empyema: A statement of the subcommittee on surgery. Am Rev Respir Dis 1962; 85: 935-936.
18. Göçmen A, Kiper N, Toppare M, ve ark. Conservative treatment of empyema in children. Respiration 1993; 60:182-185.
19. Kılıç N, Çelebi S, Gürpınar A, ve ark. Management of thoracic empyema in children. Ped Surg Int 2002; 18: 21-23.
20. Robinson LA, Moulton AL, Fleming WH, ve ark. Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas. Ann Thorac Surg 1994; 57: 803-813.
21. Chin NK, Lim TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest 1997; 111: 275-279.
22. Kosloske AM, Cushing AH, Shuck JM. Early decortication for anaerobic empyema in children. J Pediatr Surg 1980; 15: 422-426.
23. Kosloske AM, Cartwright KC. The controversial role of decortication in the management of pediatric empyema. J Thorac Cardiovasc Surg 1988; 96: 166-170.
24. Demirbilek S, Atayurt HF, Uysal G, ve ark. Early decortication in the treatment of pleural empyema in childhood: Indications and results. Pediatrik Cerrahi Dergisi 1999; 13: 22-28.
25. Rızalar R, Somuncu S, Saraç A, ve ark. Postpnömonik ampiyemierde erken dekortikasyon. Pediatrik Cerrahi Dergisi 1993; 7: 6-9.
26. Wait MA, Sharma S, Hohn J, ve ark. A randomized trial of empyema therapy. Chest 1997; 111: 1548-1551.
27. Hoffer FA, Bloom DA, Colin AA, Fishman SJ. Lung abscess versus necrotising pneumonia: implications for interventional therapy. Pediatr Radiol 1999; 29: 87-91.