Risk factors influencing postoperative pleural empyema in patients with pleural mesothelioma: a retrospective single-centre analysis

Our plain-English summary of Risk factors influencing postoperative pleural empyema in patients with pleural mesothelioma: a retrospective single-centre analysis, by P. Henschke, L.C. Guglielmetti, S. Hillinger, et al (European Journal of Cardio-thoracic Surgery, 2024).

The study

• Authors: P. Henschke, L.C. Guglielmetti, S. Hillinger, G.M. Monsch, D. Schneiter, I. Opitz, O. Lauk
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2024;65(4)
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objectives: Postoperative empyema is a severe, potentially lethal complication also present, but poorly studied in patients undergoing surgery for pleural mesothelioma. We aimed to analyse which perioperative characteristics might be associated with an increased risk for postoperative empyema.

Methods: From September 1999 to February 2023 a retrospective analysis of consecutive patients undergoing surgery for pleural mesothelioma at the University Hospital of Zurich was performed. Uni- and multivariable logistic regression was used to identify associated risk factors of postoperative empyema after surgery.

Results: A total of 400 PM patients were included in the analysis, of which n = 50 patients developed empyema after surgery (12.5%). Baseline demographics were comparable between patients with (Eyes) and without empyema (Eno). 39% (n = 156) patients underwent extrapleural pneumonectomy (EPP), of whom 22% (n = 35) developed postoperative pleural empyema; 6% (n = 15) of the remaining 244 patients undergoing pleurectomy and decortication (n = 46), extended pleurectomy and decortication (n = 114), partial pleurectomy (n = 54) or explorative thoracotomy (n = 30) resulted in postoperative empyema. In multivariable logistic regression analysis, EPP (odds ratio 2.8, 95% confidence interval 1.5-5.4, P = 0.002) emerged as the only risk factor associated with postoperative empyema when controlled for smoking status. Median overall survival was significantly worse for Eyes (16 months, interquartile range 5-27 months) than for Eno (18 months, interquartile range 8-35 months).

Conclusions: Patients undergoing EPP had a significantly higher risk of developing postoperative pleural empyema compared to patients undergoing other surgery types. Survival of patients with empyema was significantly shorter.

© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.

In plain English

This retrospective review of medical records covered 400 patients who had surgery for pleural mesothelioma at the University Hospital of Zurich, Switzerland, between September 1999 and February 2023. It studied a surgical complication, infection of the chest cavity (pleural empyema), not asbestos exposure. Fifty patients (12.5%) developed empyema. Of 156 patients who had extrapleural pneumonectomy (removal of the pleura and the whole lung), 35 (22%) developed empyema, compared with 15 (6%) of the other 244 patients. In the adjusted analysis, extrapleural pneumonectomy was the only factor significantly linked to empyema. The article's table gives an odds ratio of 2.260 (95% confidence interval 1.130 to 4.521). The text reports 2.8 (1.5 to 5.4), which matches the table's unadjusted figure. Median survival was 16 months with empyema and 18 months without, a difference the authors reported as statistically significant. Four patients developed empyema soon after radiotherapy, which the authors did not test statistically. The authors concluded their findings support favouring lung-sparing operations over extrapleural pneumonectomy. They cautioned that having only 50 empyema cases limited interpretation.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective single-centre analysis of medical records, using univariable and multivariable logistic regression and Kaplan-Meier survival curves
• Who was studied: 400 consecutive patients who underwent surgery for pleural mesothelioma at the University Hospital of Zurich, Switzerland, between September 1999 and February 2023. Patients who had partial pleurectomy or explorative thoracotomy were excluded from the regression analysis.
• Exposure: The factor studied was type of surgery, not asbestos; the article does not discuss asbestos exposure. Operations were extrapleural pneumonectomy (EPP, n = 156), pleurectomy and decortication or extended pleurectomy and decortication (n = 160), partial pleurectomy (n = 54) and explorative thoracotomy (n = 30). Other variables tested were smoking, diaphragm replacement, tumour and nodal stage, gender, blood loss, sarcomatoid histology and induction therapy.
• Main results:
  • Of all 400 patients, 50 (12.5%) developed pleural empyema after surgery. Of these, 15 (30%) were early (within 30 days) and 35 (70%) were late (more than 30 days after surgery).
  • Of the 156 patients who underwent EPP, 35 (22%) developed empyema, compared with 15 (6%) of the remaining 244 patients who had other operations. No patient who had partial pleurectomy or explorative thoracotomy developed empyema.
  • In the multivariable model, which also included current smoking and diaphragm replacement, EPP was the only statistically significant risk factor. Table 1 gives an odds ratio of 2.260 (95% CI 1.130 to 4.521, P = 0.021). The univariable odds ratio for EPP was 2.796 (1.458 to 5.363, P = 0.002). Current smoking was not statistically significant (multivariable odds ratio 2.299, 0.931 to 5.678, P = 0.071).
  • Of the 156 EPP patients, 14 (9%) developed a bronchopleural fistula. Of the 50 patients with empyema, 13 (26%) developed empyema following a bronchopleural fistula.
  • Median overall survival for all patients was 18 months (IQR 8 to 34). It was 16 months (IQR 5 to 27) for patients with empyema and 18 months (IQR 8 to 35) for patients without (logrank P = 0.045). In a subgroup of 316 patients that excluded partial pleurectomy and explorative thoracotomy, survival was also worse with empyema (logrank P = 0.013).
  • Four of the 35 late-empyema patients (11%) developed empyema right after adjuvant radiotherapy; 88 patients received adjuvant radiotherapy without developing empyema. This possible link was not analysed statistically.
• The authors' conclusion: The authors concluded that patients undergoing EPP had a significantly higher risk of postoperative empyema than patients having other operations, and that survival was shorter for patients with empyema. They stated that their findings support the current standard of care favouring pleurectomy and decortication or extended pleurectomy and decortication over EPP. They said their data suggest a possible connection between adjuvant radiotherapy and empyema, and that further research is needed for risk stratification.
• Limitations the authors state:
  • The study covered more than two decades, during which diagnosis and treatment changed significantly.
  • The authors urged caution because there were only 50 empyema cases.
  • The retrospective design allowed no time-dependent analysis.
  • The study could not determine whether empyema caused the earlier deaths or was the result of other factors responsible for shorter survival.
  • Quality of life was not evaluated with quality-of-life questionnaires.

Topics

Medical terms in this study, explained in our Lexicon: Empyema, Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Thoracotomy, Odds Ratio, confidence interval, Median Overall Survival.

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