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Ann Thorac Surg 1997;64:1448-1450
© 1997 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Thoracoscopic Debridement of Empyema Thoracis

Department of Thoracic Surgery, Harefield Hospital, Harefield, Middlesex, United Kingdom

Accepted for publication May 28, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. The primary treatment of empyema thoracis remains intercostal tube drainage together with antibiotics. Failure of primary treatment has until recently been an indication for thoracotomy and decortication. Video-assisted thoracoscopic debridement (VATD) has increased the available treatment options but requires validation.

Methods. A retrospective analysis was undertaken of 44 consecutive patients who presented for surgical treatment of empyema thoracis over a 3-year period.

Results. Two patients were unsuitable for VATD and were treated with open decortication (OD). Thirty patients were successfully treated by VATD. Two patients were converted to OD at the first operation, and 10 patients required OD as a second procedure. The mean duration of preoperative symptoms before referral was 37.6 ± 11.8 days (VATD) and 40.1 ± 11.6 days (OD) (p = not significant). The mean duration of hospitalization before transfer was 13.7 ± 2.4 days (VATD) and 11.5 ± 3.4 days (OD) (p = not significant). Intercostal drainage was required for 4.0 ± 0.3 days (VATD) and 8.5 ± 2.0 days (OD) (p = 0.004). The postoperative hospital stay was 5.3 ± 0.4 days (VATD) and 10.3 ± 2.1 days (OD) (p = 0.001).

Conclusions. Primary surgical therapy with VATD should be considered for all patients with pleural empyema, irrespective of the duration of symptoms. This approach does not preclude OD as a secondary procedure or conversion to OD after initial thoracoscopic assessment. The major advantages of VATD over OD are a shorter duration of postoperative intercostal drainage and reduced postoperative hospitalization.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Empyema of the chest is a common condition that is associated with considerable morbidity and mortality, whether treated or untreated [1, 2]. Patients with empyema are initially seen by a variety of physicians because of pyrexia, chest pain, cough, shortness of breath, and general malaise. Symptoms are often masked by protracted antibiotic therapy. Patients can therefore be symptomatic for several weeks before they receive in-patient medical treatment. The initial in-patient medical treatment usually consists of intravenous antibiotics and drainage of the pleural cavity by needle aspiration or tube thoracostomy [3]. Nevertheless, 36% to 65% of patients are not cured of their empyema by medical therapy alone and require surgical intervention [4, 5].

Video-assisted thoracoscopic surgery is being increasingly used for a wide spectrum of thoracic procedures, including the treatment of recurrent pneumothorax [6], pleural effusions, hyperhydrosis, mediastinal tumors, bullous emphysema, hemothorax, chylothorax, and pericardial effusion, as well as for lung biopsy and the diagnosis of pleural tumors [7, 8]. It is a safe alternative to formal thoracotomy [9]. When successful, video-assisted thoracoscopic surgery results in less postoperative discomfort and a reduced hospitalization than that seen in patients who have a thoracotomy as a primary procedure. Video-assisted thoracoscopic debridement (VATD) needs to be formally clinically assessed in the context of empyema. We describe our experience with this technique over a 3-year period.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
From April 1993 to March 1996, 44 patients with empyema thoracis resistant to medical therapy were referred for surgical treatment. Patients were not excluded on the basis of the duration of symptoms before referral or the duration of their in-patient medical treatment. Two patients were considered unsuitable for a thoracoscopic operation because of a history of previous thoracic operations on the side of the empyema. The remaining 42 patients underwent VATD. All patients had a chest x-ray study and thoracic computed tomography done preoperatively.

The first thoracoscopic port was positioned one interspace below the angle of the scapula. The rigid telescope was introduced through this port. The second port was made more anteriorly and inferiorly, with the exact location dependent on the location of the cavity and the adhesions. If the intercostal space could not be easily defined, a 16-gauge needle was introduced through the chest wall and located with the telescope before insertion of the port. When this was not possible, the procedure was converted to an open decortication (OD).

Thoracoscopy was attempted but subsequent conversion to OD was required in 2 patients because of the presence of dense adhesions. The pleural cavity was thoracoscopically debrided in 40 patients using a blunt-ended metal sucker. The pus and fibrinous septae within the pleural cavity were aspirated and the space irrigated with normal saline solution. Thirty of these patients (75%) had no complications and were discharged home. The other 10 patients, however, required OD as a second procedure. Three of the 10 patients requiring OD were discharged home after VATD and were seen again because of recurrent symptoms.

We report on the 42 patients in whom VATD was attempted. Two groups were identified. One consisted of the 30 patients in the VATD group who were successfully treated by thoracoscopic debridement; the other consisted of the 12 in the OD group in whom VATD was unsuccessful and who underwent OD either after initial thoracoscopic assessment or as a second surgical procedure (Fig 1).

View larger version (16K): [in this window] [in a new window]   Fig 1. . Clinical management of patients with empyema thoracis. (OD = open debridement; VATD = video-assisted thoracoscopic debridement.)

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The mean patient age was 50.8 ± 3.7 years in the VATD group and 53.3 ± 6.2 years in the OD group (p = not significant). Twenty-one of the 30 VATD patients (70%) had either a chest drain inserted or had undergone needle aspiration of the collection before transfer. This was also the case for 8 of the 12 patients in the OD group (66.7%) (p = not significant). Similarly, 21 (70%) patients in the VATD group were receiving intravenous antibiotics at the time of transfer (p = not significant), versus 8 (66.7%) in the OD group.

The mean duration of preoperative symptoms before referral was 37.6 ± 1.8 days in the VATD group and 40.1 ± 11.6 days in the OD group (p = not significant). The mean duration of hospital treatment before transfer was 13.7 ± 2.4 days in the VATD group and 11.5 ± 3.4 days in the OD group (p = not significant).

Organisms were identified in the pleural collections in only 13 (43%) of the VATD patients and 4 (33%) of the OD patients. No specific organism was identified predominantly in either group (Table 1).

There was no 30-day mortality in either group. All patients were followed up and discharged from the clinic at 6 to 12 weeks. Patient data and the results are summarized in Table 2.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

Earlier referral for VATD may be expected to enhance the success of the treatment. However, we cannot support this contention on the basis of the findings in our study. The difficulty lies in defining those patients in whom OD should be undertaken as the primary surgical procedure. We note, however, that all the patients in this study, except 1, were referred within 30 days of hospital admission, and this would be compatible with referral before the onset of the chronic (organizing) phase of the empyema.

Antibiotic treatment prescribed by community physicians is in part responsible for the delayed presentation of these patients to hospital physicians, which ultimately delays referral to thoracic surgeons. This time before surgical referral may be lessened in the future once the availability of thoracoscopy and the need for early intervention becomes more widely recognized. Antibiotic therapy may also account for the inability to culture organisms from the empyema cavity in 17 of the 30 (56.6%) VATD patients and 8 of the 12 (66.7%) OD patients (see Table 1).

The video-assisted thoracoscopic approach facilitates the evacuation of multilocular effusions and the division of fibrinous septae. Although it is not our practice to routinely irrigate the empyema space, this has been employed by Hutter and associates [12]. After completion of the debridement, intercostal drains may be positioned in apical and basal locations under thoracoscopic vision. The VATD patients required reduced intercostal drainage (4.0 days versus 8.5 days). The difference in patients who had undergone OD was the result of persistent alveolar leaks. As a result, the VATD patients could be mobilized earlier and subsequently discharged before the OD patients (5.3 days versus 10.3 days).

However, it is important also to focus on the failures of VATD. Ten patients required OD as a second procedure, in 4 because their lungs failed to expand, in 3 because a recurrent fluid level was seen on the chest x-ray study, and in 3 because their symptoms recurred. Of these 10 patients, 2 were discharged home with long-term intercostal drains in situ. No clinical or radiologic features were identified that were unique to this group of patients. It may, however, be expected on the basis of the natural history of empyema thoracis that VATD would probably fail in patients who are in an advanced stage of the disease with thicker cortices.

We conclude that thoracoscopic debridement is a valuable addition to the surgical armamentarium for the treatment of empyema thoracis. It should be considered in all patients referred for surgical treatment of this condition. The 30 patients treated successfully with VATD remain well and free of recurrent symptoms (mean follow-up period, 18.2 months). Although we were unable to show a difference in outcome attributable to prolonged in-patient treatment consisting of conservative measures, we note that all but 1 patient was referred within 30 days of hospital admission. This may reflect a growing understanding on the part of thoracic physicians of the benefits of early thoracoscopic debridement. We have shown that, in 75% of the patients with empyema thoracis, thoracoscopic decortication spares the patient a painful thoracotomy and patients can be discharged 5 days earlier than those undergoing OD. Even when VATD fails to prevent the need for a thoracotomy, the patient may still benefit from the VATD because it limits the risk of toxic episodes and stabilizes the patient's condition before formal thoracotomy.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Lawrence, c/o Mr S.K. Ohri, Department of Thoracic Surgery, Harefield Hospital, Middlesex UB9 6JH, United Kingdom (e-mail: drl{at}romesh.demon.co.uk).

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Muskett A, Burton NA, Karwande SV, Collins MP. Management of refractory empyema with early decortication. Am J Surg 1988;156:529–32.[Medline]
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4. Lemmer JH, Botham MJ, Orringer MB. Modern management of adult thoracic empyema. J Thorac Cardiovasc Surg 1985;90:849–55.[Abstract]
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8. Coltharp WH, Arnold JH, Alford AC. Video thoracoscopy: improved technique and expanded applications. Ann Thorac Surg 1992;53:776–9.[Abstract]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David R. Lawrence Edward R. Townsend Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lawrence, D. R. Articles by Fountain, S. W. Search for Related Content PubMed PubMed Citation Articles by Lawrence, D. R. Articles by Fountain, S. W.