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Ann Thorac Surg 1996;61:1626-1630
© 1996 The Society of Thoracic Surgeons
Division of Thoracic Surgery, British Hospital, Buenos Aires, Argentina
Accepted for publication January 30, 1996.
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
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Methods. Sixty-four cases of postpneumonic fibrinopurulent empyema were operated on at our institution: 33 cases (group I) by means of a formal thoracotomy and 31 cases (group II) by thoracoscopy. In the thoracoscopic subset the data were collected prospectively since 1992. These results were compared with those of a historical series treated by thoracotomy between 1985 and 1991. Both populations were similar in terms of age (mean, 49 years), number of cases (33/31), sex (2.1 male/female), and comorbid status.
Results. Mean preoperative length of the medical management (11.5 versus 17 days) (p = 0.03) and chest tube removal (4.3 versus 6.1 days) were shorter in group II than in group I (p = 0.02). Morbidity and mortality were identical: one death and five complications in each group. Mean operative time was similar in both groups, and hospital stay was shorter in the video-assisted thoracic surgery group (6.8 versus 11.2 days) (p = not significant). Three patients from group II needed utilitary thoracotomies for debridement completeness (10% conversion rate).
Conclusions. We conclude that video-assisted thoracic surgical treatment has the same rate of success as open thoracotomy but offers substantial advantages over thoracotomy in terms of resolution of the disease, hospital stay, and cosmesis. A prospective and randomized study is needed to confirm the findings of this nonrandomized initial experience.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Ever since Hippocrates (200 BC), empyema thoracis has been a well-recognized disease. Its occurrence is most commonly associated with pneumonia [1]. During the First World War, empyema cases among United States military forces resulted in an almost two thirds mortality (61%). This fact led to the creation of the "Empyema Commission" made up of distinguished doctors, among whom was young Evarts Graham [2]. The final recommendation of the Commission was that closed surgical drainage was the most appropriate treatment, lowering the lethal outcome to 9.5%. There are approximately 1.2 million new cases of pneumonia every year in the United States. About 40% of them will have an accompanying pleural effusion; 35% will resolve "ad integrum" with antibiotic treatment (stage I), and 5% (around 60,000 patients) will be contaminated by bacterial infection and develop fibrinopurulent effusion (stage II), complicated effusion [3], or empyema.
The gold-standard treatment for these complicated effusions has been early drainage, either by means of a chest tube or through a limited thoracotomy and debridement in the fibrinopurulent stage (phase II of Light [4]). Organization of the fibrinous clots into fibrotic peel causes lung encasement (phase III of Light), which requires a major thoracotomy and open decortication. Delay in draining these pleural effusions has resulted, even recently, in as much as a 22% mortality rate [5].
The introduction of video-assisted thoracic surgery (VATS) in 1991 has offered a less traumatic alternative by means of closed chest debridement of fibrinopurulent loculated cases (early decortication). The purpose of this presentation is to assess the role of VATS debridement in the treatment of postpneumonia fibrinopurulent empyema (phase II) and to compare its results with those of a previous similar series dealt with by open thoracotomy and debridement.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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. In all cases the diagnosis was established (1) on clinical grounds (fever, cough, dyspnea, and chest pain), (2) by thoracocentesis (pH less than 7.00, glucose level less than 40 mg/dL, and lactate dehydrogenase level greater than 1,000 IU/L), and (3) by computed tomographic (CT) scans showing a loculated effusion. In the first group only 28 of 33 were studied by CT scans. The 5 remaining patients underwent thoracotomy before our institution had a scanner, so they had linear tomographic evaluation instead.
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Patients from both series were sent either to the intensive care unit or to the room floor depending only on the degree of illness, not on the procedure itself. Antibiotics were administered for at least 3 weeks; clinical course, body temperature, leukocyte count, and duration of chest tube were always recorded. Chest roentgenograms were obtained at different intervals, from immediately postoperative up to 6 months later, when patients were definitively discharged.
Statistical Analysis
Results are expressed at mean values ± standard deviation. Student's t test for paired data was employed for quantitative variables and either the 
2 or Fisher's test for qualitative variables. Statistical significance was determined at a p value of less than 0.05.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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compares for both groups: the length of preoperative treatment and postoperative chest tube duration, hospital stay, operating time, bacteriology, and morbidity and mortality. Six patients in each group were treated preoperatively by unsuccessful chest drainage during a mean period of 6.3 days in group I (range, 1 to 12 days) and 6.3 days in group II (range, 2 to 13 days) (p = not significant). The mean preoperative duration of the effusion was longer in the thoracotomy subset (17.5 days versus 11.4 days).
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Culture and gram staining revealed bacteria in 31.2% of the whole series (33.3% in group I and 29% in group II). Table 3 shows the identified bacteria in both groups.
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In the VATS subset an 83-year-old man, severely ill with bilateral parapneumonic empyema, died 4 days after VATS debridement on the right side and chest tube drainage on the left. The complications were requirement of mechanical respiratory assistance for 5 days postoperatively in a 63-year-old woman with bilateral debridement, 2 cases of prolonged febrile syndrome (>7 days), and 2 cases of mild wound infection. In no case did empyema recur after VATS technique was applied. All complications in both groups resolved well without further consequences.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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After reviewing the medical literature, several facts emerge clearly: (1) Operation should be indicated early [4–10]. (2) Conservative treatments using lytic agents are of little value and are associated with long hospitalizations and greater morbidity and mortality than operation [11]. (3) There are few publications regarding the use of VATS for treatment of loculated pleural empyema [12–15].
Low-pH (<7.00) parapneumonic effusions with or without positive bacterial cultures and radiologic evidence of fibrinous loculation are likely to evolve into fibrotic organization resulting in lung encasement. This is the fibrinopurulent stage, Light phase II complicated effusion or empyema. Light [3] makes a distinction between complicated effusion and empyema depending on whether bacterial cultures are negative or positive. Because the lower pH seems to be caused [16] by both leukocyte phagocytosis and bacterial metabolism, it constitutes in our view a consistent indirect evidence of pleural fluid infection. By far, most of these patients have been treated previously with antibiotics, which may prevent bacterial isolation, making pleural fluid Gram stains negative. Consequently we prefer the term "empyema" because it is indicative of pleural fluid infection; it also suggests more strongly the indication for early operation even when the bacterial cultives are negative. The evolution of a parapneumonic pleural effusion from the exudative stage to the fibrotic encasement represents a continuous spectrum and has no sharply defined boundaries. Fibrin deposition within the pleural cavity is variable and may take only a few days [17]. This variability would depend on individual biological reaction, but seems to be earlier and more pronounced when anaerobic bacteria alone or in combination with aerobic germs are the causative agents [18]. This explains the similar surgical findings in both series having different preoperative lengths.
The most suggestive sign of empyema on a chest radiograph is an encapsulated effusion in an atypical position. On CT scans empyemas usually are encapsulated and biconvex, showing thickening of the parietal pleura and the endothoracic fascia along with increased contrast uptake of the parietal pleura as shown by Kirsh and colleagues [19]. In their experience CT scans were unable to differentiate between early and late phases of empyema.
Strictly speaking, many of these loculated effusions or empyemas contain no frank pus but a lot of fibrin clots and membranes forming several compartments filled with seropurulent fluid. Whether frank pus exists or not, the final outcome will be the same: fibroblast invasion and fibrotic peel lung encasement. Therefore, early operation remains the gold standard of treatment.
Long before we started the series described here we had developed the concept that any loculated empyema will not respond to tube thoracostomy. In those cases the indication was a limited lateral thoracotomy, long enough to introduce one hand and perform a rather blind debridement to achieve (1) complete evacuation of fibrin clots, septae, and fluid from the pleural cavity including fissures and recesses; (2) a fully expansible lung; and (3) proper positioning of dependent tube drainage. If fibrotic peel was found, the thoracotomy was extended as much as necessary to allow a complete pulmonary decortication.
In 1992 we realized that these same goals could be obtained by the use of VATS instead of a limited thoracotomy but with the following advantages: (1) more accurate magnified inspection of the whole pleural cavity, (2) direct vision for all surgical maneuvers, and (3) avoidance of a thoracotomy and its sequelae. Modified liposuction cannulas angled in different curvatures attached to a high negative pressure source are the most effective tools that permit expeditious removal of parietal and visceral debris without injuring the lung parenchyma. On comparing the results of both series the superiority of the VATS treatment (group II) over the thoracotomy approach becomes evident. Definitive resolution was obtained in all patients in group II, whereas in group I 4 patients (12%) had to be retreated for debridement completion. Three patients in the VATS group required the extention of one port up to 10 cm as a utilitary thoracotomy (10% conversion rate) because of firmly adherent fibrinous membranes; earlier referral of patients to operations could have avoided this undesirable contingency. Mean operative time, morbidity, and mortality were identical in the two groups.
Pain was not assessed in either group; nevertheless, clinical impression would favor group II. Cosmetic results were far better in group II. The most striking difference between the two surgical modalities was the duration of the entire process, resulting from the sum of the preoperative length of medical management plus the postoperative hospital stay. The data so collected rendered a mean value of 33.72 days for thoracotomized patients and 18.3 days for the thoracoscopy group (p < 0.001). This difference was due to a much quicker acceptance of operation by both the referring physician and the patient when a mini-invasive procedure was proposed. In general, when comparing VATS technique versus traditional open procedures, higher cost is one of the main objections to this mini-invasive approach. This is not true in empyema, where expenses are in fact lower than in the thoracotomy group because (1) no special instruments are needed (cheap reusable cannulas and forceps are the most appropriate tools), (2) operative time is equal, (3) there is no need for or fewer intensive care unit admissions, (4) hospital stay is shorter, and (5) patients return to work earlier.
Even though these two series are not strictly comparable because of their chronologic difference and the lack of randomization, we conclude that for the treatment of fibrinopurulent low-pH empyema (1) complete surgical debridement has proved to be the most successful treatment, (2) CT scans are the best method to detect fibrin septae and must be obtained early whenever a pleural effusion complicates any pneumonic process, and (3) VATS debridement offers results equal to those of thoracotomy in terms of resolution of the disease but seems to be more advantageous in terms of surgical sequelae, cosmesis, costs, and labor impediment. At our institution, VATS is at present the treatment of choice for loculated postpneumonic empyema (Fig 1). A prospective and randomized multiinstitutional study is needed to confirm the findings of our initial experience.
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Address reprint requests to Dr Angelillo Mackinlay, Hospital Británico de Buenos Aires, Perdriel 74, 1280 Buenos Aires, Argentina.
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References |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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