title: Choice of first intervention is related to outcomes in the management of empyema.
abstract: BACKGROUND
  The study determined whether the first procedure; simple drainage (tube thoracostomy, pigtail catheter) or operation (video-assisted thoracic surgery [VATS], thoracotomy) was related to outcomes in the management of empyema.
  
  
  METHODS
  Data were collected from 104 consecutive patients with empyema. Primary outcomes were additional procedures and death. Predictor variables included age, delay, Karnofsky performance status (KPS), Charlson comorbidity index (CCI), serum albumin, malignancy, Acute Physiology and Chronic Health Evaluation II score, loculations on computed tomography scan, empyema stage, and first procedure choice.
  
  
  RESULTS
  Advanced empyema (> or = stage IIA) was present in 84% of patients. Overall treatment success rates (no death, no additional drainage procedures) among evaluable patients for pigtail drainage, tube thoracostomy, VATS, and thoracotomy were 40% (4 of 10), 38% (14 of 37), 81% (13 of 16), and 89% (32 of 36), respectively. Five patients underwent miscellaneous procedures. Univariate variables associated with hospital death included KPS, CCI, and drainage as the first procedure. In multivariate analyses, KPS (coefficient, -0.06, p = 0.002) and failure of the first procedure (odds ratio [OR], 6.76; 95% confidence interval [CI], 1.45 to 31.4, p = .01) were independent predictors of death. Simple drainage as the first procedure was a strong, independent predictor of failure of the first procedure (OR, 11.1; 95% CI, 3.51 to 34.9; p = .00004).
  
  
  CONCLUSIONS
  The choice of the first procedure is critical in the outcome for treatment of empyema, even with adjustment for confounding variables. VATS or thoracotomy as initial therapy for advanced empyema is associated with better outcomes.
authors.affiliation: Department of Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA.
authors.forename: Curtis J
authors.initials: CJ
authors.lastname: Wozniak
authors.forename: Douglas E
authors.initials: DE
authors.lastname: Paull
authors.forename: Jazbieh E
authors.initials: JE
authors.lastname: Moezzi
authors.forename: Rosalyn P
authors.initials: RP
authors.lastname: Scott
authors.forename: Mark P
authors.initials: MP
authors.lastname: Anstadt
authors.forename: Virginia V
authors.initials: VV
authors.lastname: York
authors.forename: Alex G
authors.initials: AG
authors.lastname: Little
mesh_terms: D018806:APACHE; D001419:Bacteria / Q000145:classification / Q000302:isolation & purification; D015897:Comorbidity; D004322:Drainage; D016724:Empyema, Pleural / Q000209:etiology / Q000382:microbiology / Q000401:mortality / Q000628:therapy*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013907:Thoracostomy; D013908:Thoracotomy; D016896:Treatment Outcome