Video-assisted thoracoscopic surgery (VATS) for the management of parapneumonic pleural empyema

Parapneumonic pleural empyema has been classified by international societies and by pleural diseases experts into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, Light has classified pleural empyema according to radiological, physical and biochemical characteristics, and the American College of Chest Physicians (ACCP) has categorised patients with pleural empyema according to the risk of a poor outcome. According to these classifications, the management of the pleural empyema is based on the stage of the disease. The recommended treatment options in (ATS) stage I disease (Light classes I-III, ACCP categories I and II) are therapeutic thoracentesis or tube thoracostomy and antibiotics when necessary. In (ATS) stage II disease (Light classes IV-VI, ACCP category III), thoracoscopy (VATS) is the treatment of choice because it has a higher efficacy than treatment strategies that utilise tube thoracostomy or catheter-directed fibrinolytic therapy alone, whereas in (ATS) stage III disease (Light class VII, ACCP category IV), decortication via thoracoscopy or thoracotomy is the treatment of choice.     

Continuous pleural lavage may decrease postoperative morbidity in patients undergoing thoracotomy for stage 2 thoracic empyema.

OBJECTIVE: To assess the impact of postoperative continuous pleural lavage (PCPL) after thoracotomy for the treatment of stage 2 pleural empyema in relation to postoperative length of stay and morbidity. METHODS: Stage 2 pleural empyema was diagnosed with computer tomography. Conservative treatment including antibiotics and pleural aspiration was introduced. 89 patients treated for stage 2 pleural empyema by thoracotomy, pleural discharge evacuation and irrigation after pleural decortication were identified after unsuccessful conservative treatment for 10 days. Whenever pleural discharge remained opaque after operation, PCPL was administered daily through the cranial chest tube and discharge evacuated through the caudal pleural suction (10-15 mmHg) tube. Risk factors related to pleural pus and patient outcome were sought for. RESULTS: Seventy-seven out of 89 patients (86.5%) had clear empyema discharge immediately after pleural decortication and irrigation. Pleural discharge remained opaque despite surgery in 12 out of 89 patients (13.5%) and PCPL was introduced. Presence of a combination of risk factors for pleural empyema, such as dental caries, alcohol abuse or previous inflammatory reaction, was predictive for persistence of opaque pleural discharge after operation (P<0.05). Need for re-thoracotomies (in 11 cases, P=ns) and postoperative deaths (P<0.05) were related with patients who did not have PCPL. The length of the hospital treatment was 20.1+/-3.1 (days+/-SEM) among patients with PCPL and 19.2+/-1.8 without PCPL before possible re-thoracotomy, respectively (P=ns). CONCLUSIONS: Early postoperative (1 day-11 months) mortality was statistically associated with patients having fibrinopurulent empyema but no PCPL. PCPL is a feasible method to clear pleural pus discharge without prolongation of hospitalization and may be recommended after thoracotomy for patients with fibrinopurulent stage 2 empyema.     

Minimally invasive surgery in the treatment of empyema: intraoperative decision making

BACKGROUND: Pneumonia, parapneumonic effusions, and empyema continue to be significant health problems, especially in elderly individuals. Minimally invasive thoracic surgery in the treatment of empyema has been demonstrated but has not been well defined. Furthermore, it has not been determined how to choose patients who can be treated with thoracoscopy versus thoracotomy. We report the results of a strategy in which all patients were initially approached with thoracoscopy and converted to open decortication only if the lung could not be inflated to fill the chest. METHODS: A total of 172 patients underwent decortication for empyema over a 5-year period. Thoracoscopic decortication was attempted in all patients; patients were converted to open decortication if access to the pleural space was not possible, or if the lung could not be mobilized sufficiently to reach both the chest wall and the diaphragm. Proportions were compared using the chi(2) test. RESULTS: Of the 172 patients, 66 successfully underwent decortication with thoracoscopic techniques only. The remaining 106 patients required complete thoracotomy. No difference was found in the reoperation rate; 3 of 106 open thoracotomy patients underwent reexploration for recurrent empyema, whereas two of 66 thoracoscopy patients required reoperation for hemothorax (p = 0.347). There was a tendency for thoracoscopic patients to require reoperation for bleeding (p = 0.08); both patients taken back to the operation room for bleeding had undergone thoracoscopic pleurectomy. Eleven of 166 patients (all explored with open thoracotomy) died after decortication, for a mortality rate of 6.6%. All of these patients had gone to surgery from the intensive care unit. CONCLUSIONS: Using the criteria of complete expansion of the lung surface to the chest wall and diaphragm allowed accurate selection of patients who could undergo complete thoracoscopic decortication without risk of recurrent empyema. Computed tomographic scans did not help to predict which patients would require open procedures. Thoracoscopic patients were more likely to require reoperation for bleeding if thoracoscopic pleurectomy was performed.     

Video-assisted evacuation of empyema is the preferred procedure for management of pleural space infections

BACKGROUND: Empyema remains a cause of morbidity and mortality. Thoracoscopy has proved its versatility in the management of pleural space disorders. The suitability of video-assisted thoracic surgery (VATS) for decortication in the management of the fibrotic stage of empyema is unclear. METHODS: VATS evacuation of empyema and decortication was performed on seventeen patients presenting with pleural space infections. A retrospective review was performed and constitutes the basis of this report. RESULTS: VATS evacuation of empyema and decortication was successfully performed in 13 of 17 patients. Blood loss was 325 +/- 331 cc. Mean hospital stay was 18 +/- 10 days. Postoperative hospitalization was 11 +/- 7 days. Chest tubes remained in place for 7 +/- 3 days. There were no operative mortalities. CONCLUSIONS: Video-assisted evacuation of empyema and decortication is an effective modality in the management of the exudative and fibrinopurulent stages of empyema. An organized empyema should be approached thoracoscopically, but may require open decortication.     

Pleural empyema and lung abscess: current treatment options

Parapneumonic pleural empyema has been classified into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, Light has classified pleural empyema according to the radiological, physical and biochemical characteristics, and the American College of Chest Physician (ACCP) has categorised the patients with pleural empyema according to the risk of a poor outcome. According to this classification the management of the pleural empyema is based on the stage of the disease. Therapeutic strategies include chest tube, chest tube with fibrinolysis, thoracoscopic debridement and decortication in open or minimally invasive techniques. Primary lung abscesses develop in previously healthy lung parenchyma and are caused by aspiration. In addition, abscess formation can occur without aspiration, and important differences relate to community-acquired, nosocomial abscesses and those in the immunosuppressed host. 90 % of all lung abscesses can be cured with antibiotic treatment alone, 10 % have to be treated with an interventional catheter or chest tubes and only 1 % require thoracic surgery because of complications independent of the former conservative or interventional treatment strategies.     

Video-assisted thoracoscopic surgery for children with stage II empyema

Children with stage II empyema often fail traditional medical management, frequently succumbing to the effective albeit morbid clutches of thoracotomy. Video-assisted thoracoscopic surgery (VATS) has been recently introduced as a viable and potentially less morbid alternative to open thoracotomy. We review our VATS experience in children with empyema, assessing surgical outcome. Between August 1996 and March 1999, 13 patients at our institution with stage II empyema that did not respond to conventional medical management underwent a modified VATS with decortication. Data from retrospective chart review reflects intraoperative findings and postoperative course, including average time to defervescence, removal of thoracostomy tube, and hospital discharge. VATS was completed in all 13 patients. All intraoperative cultures of pleural fluid and fibrinopurulent debris obtained at VATS showed no growth. The average time to defervescence was 2.2 days (range, 0-4 days) and to removal of thoracostomy tube 3.6 days (range, 2-5 days). Average total chest tube days in patients with pre-VATS thoracostomy (n = 6) was 14.5 days (range, 8-37 days) versus 3.1 days (range, 2-5 days) in patients (n = 7) who underwent primary VATS (t test, p < 0.05). The average time to surgical discharge after VATS was 5.8 days (range, 3 to 19 days). All patients were well on follow-up clinic visits without delayed complications. VATS can be performed safely and effectively in children with stage II empyema, thus avoiding the morbidity of open thoracotomy and decortication. Importantly, early application of VATS significantly relieves patients of unnecessary days of thoracostomy drainage.     

Empyema thoracis

Early recognition of empyema is of prime importance. Accurate assessment of stage is crucial in planning management. Exudative empyema (stage I) should be treated by aspiration or tube thoracostomy. Fibrinopurulent empyema (stage II) can be treated effectively by video-assisted thoracic surgery (VATS). Debridement and decortication are the main components of surgical treatment of stage III empyema. It is worthwhile assessing most cases by video-assisted thoracoscopy.     

Behandlung des Pleuraempyems

Pleural empyema remains a frequently encountered clinical problem and is responsible for significant morbidity and mortality worldwide. Its diagnosis may be difficult; delays in diagnosis and treatment may contribute to morbidity, complications, and mortality. The management of parapneumonic effusion and empyema depends on timely, stage-dependent therapy and the underlying etiology. Thoracentesis and antibiotics remain the cornerstones of treatment in stage I disease. In the early fibrinopurulent phase (stage II) thoracoscopic methods should be considered. As treatment strategy for this stage, fibrinopurulent pleural empyema entails thorough debridement of multiloculated collections from the pleural cavity by video-assisted thoracic surgery. After evacuation of multilocular effusions and the removal of fibrin deposits with drainage by two intercostal chest tubes, irrigation treatment helps to achieve clarity of the pleural discharge. Open thoracotomy and decortication are reserved for organized, multiloculated empyema with lung entrapment (stage III disease). Early drain removal may lead to rapid symptomatic recovery and complete resolution.     

Video-thoracoscopic and open surgical management of thoracic empyema

PURPOSE: To evaluate the outcomes of video-thoracoscopic and open surgical management of patients with thoracic empyema. METHODS: We studied 122 patients retrospectively who underwent surgery for thoracic empyema in our hospital between January, 1999 and January, 2005. Patients' medical records, surgical procedures, and outcomes were reviewed. The study identified 97 affected men and 25 affected women with a mean age of 54 years (range 16-78 years). The empyema was parapneumonic in 95 patients (78%). RESULTS: Forty-four patients who had stage II empyema underwent video-assisted thoracic surgery (VATS). The procedure was converted to thoracotomy in 13 patients (29.5%); the morbidity and mortality rates of VATS were 13% and 0, respectively. Seventy-eight patients had stage III empyema and, along with those 13 who were converted, underwent thoracotomy for decortication. The associated morbidity rate was 12%, and the mortality rate was 6.6%. Thoracotomy was considered successful in 90 of 91 patients (99%); one patient needed a reoperative thoracotomy for an organ space/surgical site infection with pus in the pleural cavity. CONCLUSIONS: Many treatment modalities are available for thoracic empyema, depending on the results of appropriate clinical and laboratory investigations. In fibrinopurulent empyema, VATS debridement is safe and effective, with minimal morbidity and no deaths. Lung decortication via thoracotomy is the only option for organized empyema and is associated with a substantial mortality rate.     

Primary thoracoscopic treatment of empyema in children

OBJECTIVE: The optimal treatment of pediatric empyema remains controversial. The objective of this study is to compare the use of conventional management versus primary thoracoscopic drainage and decortication in children with empyema. METHODS: Conventional management has consisted of chest drain insertion under general anesthesia plus intravenous antibiotics. Thoracoscopic drainage and decortication has consisted of primary thoracoscopic drainage and decortication plus antibiotics. The clinical course of 54 patients treated conventionally between 1989 and 1997 was compared with that of 21 patients treated by means of thoracoscopic drainage and decortication between September 2000 and September 2001. RESULTS: Results of the study demonstrated that patients in the drainage-decortication group had fewer invasive interventions per patient than those in the conventional management group (1.0 vs 1.26). Patients undergoing thoracoscopic drainage and decortication also had significantly shorter durations of intravenous antibiotic therapy (7.6 +/- 1.2 vs 18.2 +/- 7.5 days), chest tube drainage (4.0 +/- 0.5 vs 10.2 +/- 6.1 days), and hospital stays (7.4 +/- 0.8 vs 15.4 +/- 7.4). Moreover, there were no open thoracotomies and decortications in the thoracoscopic drainage and decortication group, whereas in the conventional management group 39% (21/54) of patients underwent an open procedure. CONCLUSION: Although the 2 groups were not prospectively randomized and they were treated in different time periods, the results of this study support the use of thoracoscopic surgery as the primary therapeutic modality in children presenting with pleural empyema. This strategy appears to offer significant benefits over conventional treatment in terms of duration of treatment and the need for more invasive surgery.     

Benefits of early aggressive management of empyema thoracis

BACKGROUND: The end-target of the management of thoracic empyema is to obtain early rehabilitation by re-expansion of the trapped lung resulting from intrapleural infected material. Our aim was to shorten the hospitalization time and to prevent a possible thoracotomy by using video-assisted thoracoscopy initially. METHODS: Seventy patients with parapneumonic empyema were prospectively studied between January 1997 and June 2004. The patients were randomly divided into two groups. In group I (n = 35 patients), a chest tube was inserted into the patients after pleural content was evacuated and fibrins were debrided using video-assisted thoracoscopy. In group II (n = 35 patients), tube thoracostomy was carried out without using a video-assisted thoracoscope. Both groups were compared in terms of hospitalization time, open surgery for decortication and complications. RESULTS: There was no statistically significant difference between the groups from the point of view of age and sex (P > 0.05). In group I, 17.1% of the patients underwent open decortication, whereas in group II, 37.1% of the patients underwent the same procedure (P < 0.05). Whereas average hospital stay in group I was 8.3 days (range, 7-11 days), it was 12.8 days in group II (range, 10-18 days; P < 0.05). There was one bronchopleural fistula in group I, and there was one bronchopleural fistula and one death in group II. CONCLUSION: Video-assisted thoracoscopic evacuation and chest tube insertion in situ is a new therapeutic approach for pleural empyema that shortens hospital stay and reduces the necessity of open decortication.     

Surgical strategy of complex empyema thoracis.

BACKGROUND: The optimal treatment of empyema thoracis has been widely debated. Proponents of pleural drainage alone, drainage plus fibrinolytic therapy, video-assisted thoracoscopic surgical (VATS) debridement, and open thoracotomy each champion the efficacy of their approach. METHODS: This study examines treatment of complex empyema thoracis between June 1, 1994, and April 30, 1997. Twenty-one men and 9 women underwent 30 drainage/decortication procedures (14 open thoracotomies and 16 VATS) in treatment of their disease. Effusion etiology was distributed as follows: infectious-14; neoplastic-associated-7; traumatic-3; other-6. RESULTS: The mean preoperative hospital stay was 14 +/- 8.8 days, (11.4 +/- 6.5 days for VATS vs 16.8 +/- 10.2 days for thoracotomy). Hospital stay from operation to discharge for thoracotomy patients was 10.0 -/+ 7.2 days (median 8.5 days) and for VATS patients 17.6 -/+ 16.8 days (median 11 days). These differences were not statistically significant. Duration of postoperative thoracostomy tube drainage was 8.3 -/+ 4.6 days for thoracotomy patients and 4.7 -/+ 2.8 days in the VATS group (p = 0.01). Operative time for the thoracotomy group was 125.0 -/+ 71.7 minutes, while the VATS group time was only 76.2 -/+ 30.7 minutes. Estimated blood loss for the thoracotomy group was 313.9 -/+ 254.0 milliliters and for the VATS group 131.6 -/+ 77.3 milliliters. Three of the 30 patients (10.0%) required prolonged ventilator support (>24 hours). Morbidity included one diaphragmatic laceration (VATS group) and one thoracic duct laceration (thoracotomy). Two VATS procedures (6.7%) required conversion to open thoracotomy for thorough decortication. CONCLUSIONS: The surgical approach to empyema thoracis is evolving. In the absence of comorbid factors, the significantly lower requirement for chest tube drainage time in the VATS patients suggests that this modality is an attractive alternative to thoracotomy in the treatment of complex empyema thoracis.     

Experiences in stage-adapted therapy of pleural empyema]

INTRODUCTION: Up till now the phases adapted treatment of a pleural empyema unfortunately is still not obvious, but recently the operative spectrum has been widened in the field of video-assisted thoracoscopic surgery (VATS) of the pleural empyema. PATIENTS AND METHODS: In the present study we examined all our patients with a pleural empyema and we followed them for a postoperative period of 4 years analysing our therapy-efficacy and our treatment concept of pleural empyema. RESULTS: 52 out of 102 patients--who suffered from a pleural empyema in the last 10 years--were reexamined postoperatively. In 96% of the 102 cases we found a phase II-III empyema. Initially all patients were treated with a closed-chest-tube drainage, followed by an operation in 78%. In 6 cases a video-assisted-thoracoscopic evacuation of the cavity with an early decortication was performed. All the 52 patients who were treated in an early phase showed the best functional results 4 years later. CONCLUSION: Especially in phase III the open operative revision of a pleural empyema is the method of choice. In the fibrinopurulent phase the drainage therapy may be sufficient. If the empyema cavity is divided we recommend the early video-assisted-thoracoscopic revision of the thoracic empyema.     

Current treatment of pediatric empyema

Pneumonia with complicated parapneumonic effusion and empyema is increasing in incidence and continues to be a source of morbidity in children seen in our institution. Current diagnostic modalities include chest radiographs and CT scanning with ultrasound being helpful in some situations. Exact management of empyema remains controversial. Although open thoracotomy drainage is well accepted in children, video-assisted thoracoscopic surgery (VATS) drainage has become more prevalent in the current era. Over the last 4 years, we have treated 58 children with intrapleural placement of pigtail catheters and administration fibrinolytics consisting of tissue plasminogen activator (tPA). Successful drainage and resolution of 54 of the 58 effusions was achieved with percutaneous methods alone. There was no mortality or 30-day recurrence. Mean hospital stay was 9.1 days (range 5 to 21) and mean chest catheter removal was 6 days post placement (range 1.5 to 20). Of the four patients that failed percutaneous tube therapy, 3 underwent video assisted thoracic surgery (VATS), and one had open thoracotomy with decortication. Based on our experience, tPA administered through a small bore chest tube for drainage of complicated parapneumonic effusions has become our standard practice. We reserve VATS for treatment failures and open thoracotomy and decortication for patients with VATS failure.     

Thoracoscopic debridement for acute pediatric empyema: efficacy of ultrasonic surgical device.

Few studies have examined thoracoscopic treatment for pediatric empyema. We encountered three children with thoracic empyema successfully treated by thoracoscopic debridement. Patients were a 3-year-old girl, a 17 month-old boy and a 13-year-old girl who developed thoracic empyema during therapy for pneumonia. We performed dissection and debridement under thoracoscopy and resolved fibrinopurulent collections using an ultrasonic surgical device in two cases to search the dissection plane while minimizing injury to the lung parenchyma. Ultrasonic surgical device (USUTM) is very useful for performing effective debridement and irrigation with minimal pleural damage. Thoracoscopic debridement performed early in the course of therapy is recommended even for acute pediatric empyema and could prevent the unnecessary open surgical intervention or decortication.     

Comparison between irrigation and conventional treatment for empyema and pneumonectomy space infection.

A new method of treating pleural empyema or pneumonectomy space infection by irrigation was evaluated in 11 patients. The infected cavities were filled with an antibiotic or antiseptic solution for three hours, and allowed to drain for one hour. This cycle was repeated every four hours for seven to 10 days. When cultures of the infected cavity became sterile the irrigation tube was removed and the wound sealed. Using this method, infection was eradicated after an average of 11 days in five of six patients with pleural empyema and in all five patients treated for an infected pneumonectomy space, including one with a bronchopleural fistula. The results of treating 58 similar cases of intrapleural sepsis over a 10-year period by the standard methods of aspiration, open drainage, decortication, or thoracoplasty were compared with the results of irrigation. In general, cyclical irrigation resulted in a shorter hospital stay and a shorter period of wound drainage than other methods.     

Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) for decortication or debridement in the management of empyema thoracis has increased the available treatment options but requires validation. We present and evaluate our technique and experience with thoracoscopic management of pleural empyema, irrespective of chronicity. METHODS: From May 1, 2000, to April 30, 2002, VATS debridement and decortication in 70 consecutive patients presenting with pleural space infections was performed with endoscopic shaver system. A retrospective review was performed and the effect of this technique on perioperative outcome was assessed. RESULTS: The VATS evacuation of infected pleural fluid and decortication was successfully performed in 65 of 70 patients. The mean duration of preoperative symptoms before referral was 23 +/- 1.8 days. The mean duration of hospitalization before transfer was 13.5 +/- 1.5 days. Blood loss was 330 +/- 200 mL. Intercostal drainage was required for 5 +/- 3 days. The postoperative hospital stay was 5 +/- 0.7 days. There were no operative mortalities. CONCLUSIONS: Video-assisted thoracoscopic decortication with endoshaver system is a simple and effective method in the management of the fibropurulent or organic pleural empyema.     

Video-Assisted Thoracoscopic Surgery in the Management of Pediatric Empyema

Background:

Management of empyema in children has progressed from open thoracotomy to video-assisted thoracoscopic surgery (VATS). The purpose of the present study was to evaluate the efficacy and safety of VATS in children with multiloculated empyemas.

Methods:

Nine children (mean age, 4 years; range, 21 months to 13 years) with empyema, in whom multiple loculations were found on computed tomography, were treated with VATS from January, 1994, to November, 1996. All patients underwent VATS under general anesthesia, with drainage of the empyemas, decortication, and placement of chest tubes under direct vision.

Results:

In all nine patients, VATS was successful. Average operating time was 120 minutes. Blood loss was insignificant, except in one patient who needed an intraoperative blood transfusion. This child required extensive decortication, with blood oozing from raw areas. All patients recovered well, with no recurrences to date. An algorithm for the use of VATS in the treatment plan for children with empyema was established.

Conclusion:

VATS provides safe and effective treatment in the management of pediatric empyema. Moreover, it avoids lengthy hospitalization, prolonged intravenous antibiotic therapy, and unnecessary pain and stress secondary to placement of chest tubes without anesthesia.     

电视胸腔镜在脓胸治疗中的应用体会

目的探讨胸腔镜在脓胸治疗中的价值。方法 2002年1月至2011年11月对98例确诊脓胸在胸腔镜下清理和刮除脓苔,剥离纤维膜;对病程稍长,纤维粘连不易剥离者,胸腔镜辅助下小切口,术后彻底冲洗脓腔。结果 71例胸腔镜手术,18例辅助小切口手术,9例中转开胸手术。手术时间50～180min,平均80min;胸腔引流3～35d,平均12d。出院前胸片复查肺复张良好,无脓胸复发及并发症。结论胸腔镜手术或辅助小切口手术治疗脓胸安全、有效、微创。能达到清除病因、闭合脓腔、恢复肺功能的目的 ,特别是对病程较长、心肺功能差的患者尤为适合。     

Video-Assisted Thoracoscopic Surgery in the Treatment of Chronic Empyema Thoracis

We prospectively analyzed the surgical results in chronic organizing empyema thoracis utilizing a video-assisted thoracoscopic technique, particularly in debilitated patients. From January 1999 to September 2000, ten patients with stage III empyema thoracis underwent video-assisted thoracoscopic surgery for decortication (VATD). The mean age of the patients was 53.2 years, and they included one female and nine male patients. Four patients were regarded as not suitable for open thoracotomy. After the procedure, all patients had one infusion tube and two 32-F chest tubes inserted, the former for irrigation with saline solution and the latter for drainage. The mean operation time was 178 min. There was no mortality. The mean time to remove the infusion tube was 3.3 days. The mean time to remove the first chest tube was 7.1 days and the second chest tube 9.7 days. The mean hospitalization time after the operation was 14.9 days. The mean follow-up was 14.9 months. A restoration of lung function was ascertained in nine patients, with a 17.6% mean increase in forced vital capacity. There was no recurrence of empyema during the follow-up. Nevertheless, a reaccumulation of pleural effusion occurred in one patient 1 month after the procedure, which thus necessitated further treatment. VATD is considered to be a feasible surgical modality for the treatment of stage III empyema thoracis in selected patients. Received: January 22, 2001 / Accepted: July 17, 2001