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Ann Thorac Surg 2001;71:1813-1816
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema

^a Department of Thoracic Surgery, Glenfield Hospital, Leicester, United Kingdom

Accepted for publication January 19, 2001.

Address reprints requests to Dr Waller, Department of Thoracic Surgery, Glenfield Hospital, Leicester LE3 9QP, United Kingdom

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. We evaluated a technique of video-assisted thoracoscopic (VAT) decortication of the visceral cortex to reexpand entrapped lung in cases of chronic postpneumonic pleural empyema.

Methods. A prospective cohort study of 48 consecutive patients with multiloculated postpneumonic pleural empyema in whom visceral pleural decortication was required was studied. The effect of VAT decortication on perioperative outcome and factors affecting its success were assessed.

Results. Before the introduction of VAT decortication 12 patients were treated by thoracotomy (group T). In the subsequent 36 patients VAT decortication was attempted with success in 21 (group VS) but lung expansion was not observed in 15 patients (group VF) who required thoracotomy. There was no difference in the age or sex distribution of the 3 groups. Operating time was significantly longer in group T than group VS, mean difference 30.3 minutes (p = 0.001) and postoperative hospital stay was longer in group T than group VS, mean difference 2.9 days (p = 0.004). The success of VAT decortication was not related to either the delay between onset of symptoms or hospital admission and surgery; indeed the operating time decreased with increasing preoperative delay. However, success was related to increasing operative experience (p = 0.001).

Conclusions. VAT decortication is a feasible new technique to achieve lung reexpansion in chronic postpneumonic pleural empyema and has perioperative benefits over thoracotomy.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Fibrinopurulent pleural empyema may be successfully treated by video-assisted thoracoscopic surgical (VATS) debridement of multiloculated collections [1–3]. The use of VATS has not been advocated for an organized empyema, with an entrapped underlying lung, when open decortication of the lung by thoracotomy has been traditionally advocated [4]. However, partial thoracoscopic visceral pleural decortication has been reported in a single case of an infected hemothorax [5] but open surgery was advocated for a more advanced empyema. Several other authors have described thoracoscopic treatment of pleural empyema using pleural debridement and parietal pleural decortication but not referring to thoracoscopic removal of a visceral pleural cortex [6, 7].

We have prospectively evaluated a thoracoscopic method of visceral decortication in organized pleural empyema and the effects it has had on perioperative clinical outcomes. We have also analyzed factors influencing the success of the procedure.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patient selection
All patients referred to our thoracic surgical unit over a 3-year period with a multiloculated pleural empyema were considered for VATS. All patients had undergone chest radiography and either thoracic ultrasonography or computed tomography (CT) to confirm loculation. Evidence of pleural thickening was not a contraindication to VATS nor was prior intrapleural fibrinolysis. VATS was attempted irrespective of the etiology or chronicity of the empyema.

Surgical method
Double-lumen endotracheal intubation and single-lung ventilation were employed. All patients were initially evaluated by VATS using three 2-cm incisions without rib spreading. The first port site was placed in the fourth intercostal space in the anterior axillary line, at a site distant to the area of pleural collection to facilitate entry into the thoracic cavity. The remaining two incisions were placed in the line of the same intercostal space, usually the sixth or seventh, and the dissecting instruments were inserted under video guidance.

Initial pleural debridement was performed using directed suction with a modified 36F gauge intercostal tube combined with saline lavage. An assessment was then made of the ability to reexpand the underlying lung by ventilation to a positive pressure of 40 cmH₂O. If the lung was not seen to reexpand by direct vision then visceral pleural decortication was attempted. To facilitate removal of the visceral cortex continuous positive airways pressure (CPAP) was applied to the operative lung during dissection. The level of CPAP was variable and was dictated by the restricted space within the hemithorax.

An initial incision was made in the visceral cortex using endoscopic shears and proceeding in a radial direction across the lateral aspect of the trapped lobe. By grasping the edge of the cortex the plane between it and the visceral pleura was developed using blunt dissection with a mounted pledget. The elevated cortical sheet was then removed by a combination of traction and rolling (Fig 1).

View larger version (137K): [in this window] [in a new window]   Fig 1. Removal of visceral cortex from underlying lung by combined blunt dissection and traction from forceps.

Immediate intraoperative conversion to open decortication through a posterolateral thoracotomy was performed for failure to achieve apposition of the visceral and parietal pleural surfaces or excessive parenchymal air leak (judged subjectively on observation of the underwater seal drains).

All patients were electively extubated in the operating theater at the end of the procedure. They were then transferred to a High Dependency Unit for overnight intraarterial blood pressure monitoring.

Data analysis
Preoperative data were collected regarding the patients’ demographic details and delays to surgery from both onset of symptoms and initial hospital admission. Operating time and postoperative hospital stay were also recorded. Outcome during the first 6 months after surgery was monitored by both clinical and radiologic examination.

The perioperative variables for the group of patients in whom the intention to treat was by VATS were compared with the immediately preceding cohort of consecutive patients treated intentionally by thoracotomy.

Statistical analysis
The statistical significance of differences in continuous variables between groups was assessed by unpaired t tests and in categorical variables by the ² test. Regression analysis was performed using the SPSS 9.0 for Windows statistical package (SPSS Inc, Chicago, IL). Statistical significance was assumed for p less than 0.05.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
We analyzed the records of 12 consecutive patients (group T) requiring open decortication of postpneumonic pleural empyema before the introduction of VAT decortication. In a subsequent series of 36 consecutive patients VAT decortication was attempted. The operation was successful in 21 of these patients (group VS) whereas the remaining 15 patients (group VF) required conversion to thoracotomy to achieve lung reexpansion after failed VAT decortication. All operations were performed by the authors.

Patient characteristics
As Table 1 shows, there were no significant differences in the age and sex distribution of the three groups, with patients being predominantly middle-aged males. The degree of preoperative lung collapse was similar among the groups. There was no significant intergroup difference in the underlying bacterial flora; the majority of intraoperative pleural cultures were sterile, reflecting the chronicity of the cases. All patients had primary bacterial pneumonia; there was no difference in underlying lung disease.

Treatment success
The likelihood of successful VAT decortication was not influenced by treatment delay (Table 1, Figs 2 and 3). There was no significant difference in the delay from either onset of symptoms or hospital admission to surgery in any of the groups. However, operating time in group VS decreased significantly with increased delay to surgery (r = 0.60, p = 0.005). The rate of successful VAT decortication was found to increase directly with greater operative experience (r = 0.96, p = 0.0007).

View larger version (11K): [in this window] [in a new window]   Fig 2. Effect of preoperative delay on operating time.

View larger version (9K): [in this window] [in a new window]   Fig 3. Learning curve for operative success.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Video-assisted thoracoscopic decortication is a feasible treatment of chronic pleural empyema when pleural debridement alone is insufficient. Using conventional instruments it is a safe, effective, and durable method of achieving reexpansion of the trapped underlying lung by removing the visceral cortex in the same way as in open surgery. Since our first successful operation we have now adopted a policy of attempted VAT decortication in all cases of pleural empyema irrespective of chronicity. The technique is subject to a learning curve as we have found with VATS in spontaneous pneumothorax [8]. Our success rate is still increasing with experience and stands at 58.3% (21 of 36 cases). Our main reason for conversion was inability to access the cavity. As the empyema becomes more organized, it also becomes more difficult to introduce the thoracoscope owing to fibrous bands between the visceral and parietal surfaces.

We have found previously, unlike some reports [7], in cases of earlier pleural empyema the success of VAT debridement is reduced by increased delay in surgical intervention [9]. Others have also found that successful VATS is more likely after shorter duration of medical management [10]. Injudicious use of intrapleural fibrinolytic therapy may contribute to a delay in surgical intervention and thus preclude successful VAT treatment. Fibrinolytics, ie, streptokinase, are best suited for complicated parapneumonic effusions and have been shown to reduce the need for surgery in these cases [11]. However, they are less successful in treating more chronic thick-walled empyemas [4, 12]. Although we support the opinion that prolonged courses of fibrinolysis or subsequent observation should be avoided [13], there may be an argument for initial treatment with these agents to allow empyema drainage and control of infection. VAT decortication may then be applied to obtain lung reexpansion, as we have not found its outcome to be adversely affected by preoperative delay.

VAT decortication has many perioperative benefits over open surgery in our practice. Patients have a shorter period of general anesthesia because of the time saved in avoiding opening and closure of the thoracotomy. Postoperative stay is shorter than after open surgery owing to reduced requirement for invasive pain control (thoracic epidural) and earlier mobilization. The durability of the technique has been shown by the excellent clinical and radiologic results obtained, such that most patients have not required follow-up in excess of 6 months.

Our experience of the benefits of VAT decortication has allowed us to extend its application to treat patients with poor respiratory reserve more definitively. Rather than being restricted to the standard option of a simple open thoracostomy and empyema drainage [4], we have been able to achieve greater lung expansion by VAT decortication without the detrimental effects of thoracotomy.

A further application of this technique is in managing empyema associated with malignant pleural disease, which is often iatrogenic associated with repeated pleural aspiration. We have been able to release the malignant visceral pleural sheet and allow lung reexpansion even in patients with malignant mesothelioma, in which case pleurodesis alone would not have been effective.

The development of visceral decortication adds a further stage to the technique of pleural debridement already described, thereby extending the role of VATS in the treatment of chronic postpneumonic pleural empyema. Its success is subject to a learning curve, however, which must be appreciated. The early involvement of a thoracic surgeon in the management of patients with postpneumonic pleural empyema is advocated.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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