World Journal of Surgery

, Volume 40, Issue 5, pp 1121–1128 | Cite as

Intrapleural Fibrinolytic Therapy for Residual Coagulated Hemothorax After Lung Surgery

  • Dayu Huang
  • Deping Zhao
  • Yiming Zhou
  • Hongchen Liu
  • Xiaofeng Chen
Original Scientific Report



Many studies have described the use of intrapleural fibrinolytics for the treatment of complex pleural processes and traumatic hemothorax, but data are scarce regarding their use for hemothorax after lung surgery.


To evaluate the utility of intrapleural fibrinolytic therapy with urokinase for residual coagulated hemothorax (blood clot accumulation in the pleural cavity) after lung surgery.


From July 2009 to November 2013, 46 patients (33 males; mean age, 56.9 ± 10.7 years) were treated with intrapleural urokinase (250,000 IU per dose) for residual hemothorax after lung surgery. Complete response was defined as clinical improvement with complete drainage of the retained collection shown by chest X-ray, and partial response as substantial resolution with minimal residual opacity (<25 % of the thorax). Follow-up was at least 30 days.


The procedure was successful in 42 patients (91.3 %), with complete response observed in 35/46 patients (76.1 %) and partial response in 7/46 (15.2 %). These 42 patients did not require re-intervention for fluid accumulation in the pleural cavity. Treatment failed in 4 patients (8.7 %): one developed bronchopleural fistula that later resolved spontaneously and three (6.5 %) required thoracoscopic drainage for pleural cavity fluid accumulation and lung collapse. No patient required thoracotomy for total decortication. Intrapleural urokinase administration was not associated with serious adverse events, including bleeding complications or allergic reactions.


Intrapleural fibrinolytic agents should be considered a useful therapeutic option for the treatment of postoperative residual hemothorax. This method appears to be safe and effective in >90 % of patients with postoperative hemothorax.


Urokinase Streptokinase Bronchopleural Fistula Lung Surgery Fibrinolytic Agent 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We are grateful to all the patients who participated in this study. We thank all the staff involved in this study for their enormous efforts in collecting and ensuring the accuracy and completeness of the data. This scientific research project was supported by Huashan Hospital, Fudan University.

Compliance with ethical standards

Potential and real conflict of interest



  1. 1.
    Harpole DH Jr, DeCamp MM Jr, Daley J et al (1999) Prognostic models of thirty-day mortality and morbidity after major pulmonary resection. J Thorac Cardiovasc Surg 117(5):969–979CrossRefPubMedGoogle Scholar
  2. 2.
    Sirbu H, Busch T, Aleksic I et al (1999) Chest re-exploration for complications after lung surgery. Thorac Cardiovasc Surg 47(2):73–76CrossRefPubMedGoogle Scholar
  3. 3.
    Szwerc MF, Landreneau RJ, Santos RS et al (2004) Minithoracotomy combined with mechanically stapled bronchial and vascular ligation for anatomical lung resection. Ann Thorac Surg 77(6):1904–1909 (discussion 1909–1910) CrossRefPubMedGoogle Scholar
  4. 4.
    Krasna MJ, Deshmukh S, McLaughlin JS (1996) Complications of thoracoscopy. Ann Thorac Surg 61(4):1066–1069CrossRefPubMedGoogle Scholar
  5. 5.
    McKenna RJ Jr (2005) New approaches to the minimally invasive treatment of lung cancer. Cancer J 11(1):73–76CrossRefPubMedGoogle Scholar
  6. 6.
    Solaini L, Prusciano F, Bagioni P et al (2001) Video-assisted thoracic surgery major pulmonary resections. Present experience. Eur J Cardiothorac Surg 20(3):437–442CrossRefPubMedGoogle Scholar
  7. 7.
    Solaini L, Prusciano F, Solaini L et al (2011) Video-assisted thoracoscopic surgery for postoperative hemothorax. Thorac Cardiovasc Surg 59(8):475–478CrossRefPubMedGoogle Scholar
  8. 8.
    Ali HA, Lippmann M, Mundathaje U et al (2008) Spontaneous hemothorax: a comprehensive review. Chest 134(5):1056–1065CrossRefPubMedGoogle Scholar
  9. 9.
    Navsaria PH, Vogel RJ, Nicol AJ (2004) Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg. 78(1):282–285 (discussion 285–286) CrossRefPubMedGoogle Scholar
  10. 10.
    Inci I, Ozcelik C, Ulku R et al (1998) Intrapleural fibrinolytic treatment of traumatic clotted hemothorax. Chest 114(1):160–165CrossRefPubMedGoogle Scholar
  11. 11.
    DuBose J, Inaba K, Demetriades D et al (2012) Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study. J Trauma Acute Care Surg 72(1):11–22 (discussion 22-14; quiz 316) PubMedGoogle Scholar
  12. 12.
    Tillett WS, Sherry S (1949) The effect in patients of streptococcal fibrinolysin (streptokinase) and streptococcal desoxyribonuclease on fibrinous, purulent, and sanguinous pleural exudations. J Clin Investig 28(1):173–190CrossRefPubMedCentralGoogle Scholar
  13. 13.
    Moulton JS, Benkert RE, Weisiger KH et al (1995) Treatment of complicated pleural fluid collections with image-guided drainage and intracavitary urokinase. Chest 108(5):1252–1259CrossRefPubMedGoogle Scholar
  14. 14.
    Ozcelik C, Inci I, Nizam O et al (2003) Intrapleural fibrinolytic treatment of multiloculated postpneumonic pediatric empyemas. Ann Thorac Surg 76(6):1849–1853 (discussion 1853) CrossRefPubMedGoogle Scholar
  15. 15.
    Ahmed AH, Yacoub TE (2010) Intrapleural therapy in management of complicated parapneumonic effusions and empyema. Clin Pharmacol. 2:213–221PubMedPubMedCentralGoogle Scholar
  16. 16.
    Ben-Or S, Feins RH, Veeramachaneni NK et al (2011) Effectiveness and risks associated with intrapleural alteplase by means of tube thoracostomy. Ann Thorac Surg 91(3):860–864CrossRefPubMedGoogle Scholar
  17. 17.
    Skeete DA, Rutherford EJ, Schlidt SA et al (2004) Intrapleural tissue plasminogen activator for complicated pleural effusions. J Trauma 57(6):1178–1183CrossRefPubMedGoogle Scholar
  18. 18.
    Careaga G, Esparza J, Riera C et al (2001) Treatment with intrapleural streptokinase for coagulated hemothorax after cardiac surgery with cardiopulmonary bypass. Rev Esp Cardiol 54(3):294–298CrossRefPubMedGoogle Scholar
  19. 19.
    Erdeve O, Atasay B, Arsan S et al (2009) Intrapleural streptokinase treatment for postoperative coagulated hemothorax in a newborn. Pediatr Int 51(2):307–309CrossRefPubMedGoogle Scholar
  20. 20.
    Sivrikoz MC, Tuncozgur B, Iyikesici T et al (2005) Practice of early-stage fibrinolytic therapy at postoperative clotted hemothorax. Respir Med Extra 1(1):9–11CrossRefGoogle Scholar
  21. 21.
    Boersma WG, Stigt JA, Smit HJ (2010) Treatment of haemothorax. Respir Med 104(11):1583–1587CrossRefPubMedGoogle Scholar
  22. 22.
    Richardson JD, Miller FB, Carrillo EH et al (1996) Complex thoracic injuries. Surg Clin North Am 76(4):725–748CrossRefPubMedGoogle Scholar
  23. 23.
    Richardson JD, Spain DA (2001) Lesiones de pulmón y pleura. In: Mattox KL, Feliciano DV, Moore EE (eds) Trauma, 4 Spanish edn. México, McGraw-Hill Interamericana, pp 559–580Google Scholar
  24. 24.
    Hsu LH, Soong TC, Feng AC et al (2006) Intrapleural urokinase for the treatment of loculated malignant pleural effusions and trapped lungs in medically inoperable cancer patients. J Thorac Oncol. 1(5):460–467CrossRefPubMedGoogle Scholar
  25. 25.
    Litle VR, Swanson SJ (2006) Postoperative bleeding: coagulopathy, bleeding, hemothorax. Thorac Surg Clin 16(3):203–207CrossRefPubMedGoogle Scholar
  26. 26.
    Oguzkaya F, Akcali Y, Bilgin M (2005) Videothoracoscopy versus intrapleural streptokinase for management of post traumatic retained haemothorax: a retrospective study of 65 cases. Injury 36(4):526–529CrossRefPubMedGoogle Scholar
  27. 27.
    Cameron R, Davies HR (2008) Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst Rev 2:CD002312PubMedGoogle Scholar
  28. 28.
    Moulton JS, Moore PT, Mencini RA (1989) Treatment of loculated pleural effusions with transcatheter intracavitary urokinase. AJR Am J Roentgenol 153(5):941–945CrossRefPubMedGoogle Scholar
  29. 29.
    Misthos P, Sepsas E, Konstantinou M et al (2005) Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study. Eur J Cardiothorac Surg 28(4):599–603CrossRefPubMedGoogle Scholar
  30. 30.
    Jerjes-Sanchez C, Ramirez-Rivera A, Elizalde JJ et al (1996) Intrapleural fibrinolysis with streptokinase as an adjunctive treatment in hemothorax and empyema: a multicenter trial. Chest 109(6):1514–1519CrossRefPubMedGoogle Scholar
  31. 31.
    Pollak JS, Passik CS (1994) Intrapleural urokinase in the treatment of loculated pleural effusions. Chest 105(3):868–873CrossRefPubMedGoogle Scholar
  32. 32.
    Blom D, van Aalderen WM, Alders JM et al (2000) Life-threatening hemothorax in a child following intrapleural administration of urokinase. Pediatr Pulmonol 30(6):493CrossRefPubMedGoogle Scholar
  33. 33.
    Frye MD, Jarratt M, Sahn SA (1994) Acute hypoxemic respiratory failure following intrapleural thrombolytic therapy for hemothorax. Chest 105(5):1595–1596CrossRefPubMedGoogle Scholar
  34. 34.
    Thommi G, Nair CK, Aronow WS et al (2007) Efficacy and safety of intrapleural instillation of alteplase in the management of complicated pleural effusion or empyema. Am J Ther 14(4):341–345CrossRefPubMedGoogle Scholar
  35. 35.
    Froudarakis ME, Kouliatsis G, Steiropoulos P et al (2008) Recombinant tissue plasminogen activator in the treatment of pleural infections in adults. Respir Med 102(12):1694–1700CrossRefPubMedGoogle Scholar
  36. 36.
    Banerjee A, Chisti Y, Banerjee UC (2004) Streptokinase—a clinically useful thrombolytic agent. Biotechnol Adv 22(4):287–307CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2015

Authors and Affiliations

  • Dayu Huang
    • 1
  • Deping Zhao
    • 2
  • Yiming Zhou
    • 2
  • Hongchen Liu
    • 2
  • Xiaofeng Chen
    • 1
  1. 1.Department of Cardiothoracic SurgeryHuashan Hospital of Fudan UniversityShanghaiChina
  2. 2.Department of Thoracic SurgeryShanghai Pulmonary Hospital of Tongji UniversityShanghaiChina

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