Chirurgische Therapie des Pleuraempyems bei Kindern

Zusammenfassung

Das Pleuraempyem ist definiert als infizierter parapneumonischer Erguss in der Pleurahöhle. Durch die Aktivierung der Gerinnungskaskade kommt es zu ausgeprägter Fibrinabscheidung mit Septierung und Kammerung der Pleurahöhle. Die Einteilung des Pleuraempyems erfolgt nach Größe und Stadium. Die Diagnosestellung erfolgt radiologisch und sonografisch. Alle großen (sonografisch >2 cm) Pleuraempyeme Stadium I sollten drainiert werden. Die Primärtherapie der Wahl des Pleuraempyems Stadium II ist die fibrinolytische Therapie über eine Thoraxdrainage. Kleinlumige Pigtaildrainagen sind dabei den konventionellen, großlumigen Thoraxdrainagen gleichgestellt. Bei Therapieversagen muss eine thorakoskopische Ausräu-mung des Pleuraempyems in Erwägung gezogen werden. Für die Therapie des Pleuraempyem Stadium III kann keine evidenzbasierte Empfehlung ausgesprochen werden. Die Indikation zur Thorakotomie und Dekortikation wird symptomabhängig gestellt. Da die Indikation zur chirurgischen Therapie häufig kurzfristig gestellt werden muss, ist eine interdisziplinäre Betreuung der Patienten vom Zeitpunkt der Diagnosestellung an obligat.

Summary

Pleural empyema is defined as infected parapneumonic effusion of the pleural cavity. Activation of the coagulation cascade leads to deposition of fibrin and purulent material followed by fibrinous loculations and septations of the pleura. The main criteria for classification of pleural empyema are size and stage of the disease. Chest X-ray and sonography are the most important imaging modalities to diagnose pleural empyema. All large (>2 cm) pleural effusions should be drained. The primary therapy of pleural empyema stage II is fibrinolysis which is applied through a chest tube. Small bore pigtail chest tubes do not bear any disadvantages as compared to conventional surgical thoracic drains. If failure of fibrinolytic therapy occurs, thoracoscopic debridement needs to be done. No evidence based recommendation can be given for pleural empyema stage III. The indication for thoracotomy and decortication should be made according to the severity of symptoms. A primary interdisciplinary approach is mandatory, since the indication for surgical therapy of pleural empyema may be given at any stage of the disease.

Schlüsselwörter

Pleuraempyem - Thorakoskopie - Thorax -drainage - Fibrinolyse

Keywords

Pleural empyema - VATS - Chest tube - fibrinolysis

• Literatur

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