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Ann Thorac Surg 2006;81:309-313
© 2006 The Society of Thoracic Surgeons

Original article: General thoracic

Video-Assisted Thoracic Surgery for Pleural Empyema

Peter N. Wurnig, MD * , Victoria Wittmer, MD, Nestor S. Pridun, MD, Peter H. Hollaus, MD

Department of Thoracic Surgery, Otto-Wagner Hospital, Vienna, Austria

Accepted for publication June 24, 2005.

* Address correspondence to Dr Wurnig, Department of Thoracic Surgery, Otto-Wagner Hospital, Sanatoriumstrasse 2, 1140 Vienna, Austria (Email: peter.wurnig{at}wienkav.at).


   Abstract
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 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 The Thoracic Surgery Foundation...
 References
 
BACKGROUND: After we gained considerable experience with video-assisted thoracic surgery (VATS) and became familiar with its advantages, we started to use it for the treatment of thoracic empyema.

METHODS: We treated 130 patients with pleural empyema in whom chest tube drainage and antibiotic therapy had failed to produce a satisfactory result. Six months after surgery they had clinical and radiologic assessment and spirometry.

RESULTS: Video-assisted surgery was performed in all patients. Mean operative time was 93 minutes (range, from 55 to 180 minutes), mean duration of postoperative chest tube drainage was 10 days (range, from 5 to 32 days), and mean hospital stay was 16 days (range, from 3 to 56 days). The rate of conversion to open thoracotomy was 3.1%. Complications for which reoperation was necessary occurred in 9% of patients. At follow-up after six months, the mean forced expiratory volume in 1 second was 87.7% (range, from 69.5% to 105.9%), the mean postoperative vital capacity was 84.4%, (range, from 59.9% to 97.9%). There were no postoperative or procedure-related deaths.

CONCLUSIONS: Video-assisted thoracic surgery is a safe and effective treatment option for fibropurulent empyema with low morbidity and mortality. Conversion to thoracotomy should be used if necessary to remove all of the fibropurulent material and achieve complete expansion of the lung to insure a good outcome.


   Introduction
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Patients and Methods
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 The Thoracic Surgery Foundation...
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Pleural empyema affects a large number of patients each year. As defined by the American Thoracic Society in 1962 [1], pleural empyema may pass from an exudative form through a fibropurulent phase before becoming organized. The principles of surgical treatment of pleural empyema were outlined by Muskett and colleagues [2]. Jacobeus [3, 4] is generally credited with being the first to use an endoscope to explore the thoracic cavity, a procedure which he called "Thorakoscopie." Vecchio and colleagues [5] and Hoksch and colleagues [6] described some attempts at thoracoscopy before Jacobeus. We report our experience with thoracoscopic debridement of thoracic empyema in 130 patients treated since 1993.


   Patients and Methods
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This retrospective study was approved by our Institutional Review Board. Informed consent was obtained for all patients.

From 1993 to 2003, 130 patients with empyema thoracis resistant to medical therapy were treated endoscopically. Inclusion criteria were unsuccessful medical treatment, multiloculated empyema diagnosed by computed tomographic (CT) scan and ultrasound, fever and C-reactive protein over 100 (regular value is 1 to 10), and high leukocyte level (over 10.000 per unit). Previous thoracic surgery destroyed lung, diagnosed bronchopleural fistulas, the presence of a thickened visceral pleura peel, or a shrunken hemithorax on CT scan were exclusion criteria. The patients' data are presented in Table 1. All patients had a preoperative chest x-ray and CT scan (Fig 1). Under general anesthesia, with one lung ventilation in the side up position, the first port was positioned so that the empyema was not touched, normally in the third intercostal space in the axillary region (Fig 2). From this camera port we are able to resolve adhesions bluntly with fingertips after a first look into the thoracic cavity by thoracoscope. After having enough space we place a second and third port, normally below the first one. In some cases more than 3 ports are necessary. The exact position depends on the local intrathoracic situation. Now, with a camera port and 2 or more working ports, the empyema may be safely approached because of perfect visualization. We debride the whole lung, especially the base, which seems to us of importance. With regular suction, blunt cherry (Ethicon Inc, Somerville, NJ), and other blunt instruments, we clean the thoracic cavity and the surface of the lung so that reexpansion of the lung becomes possible. The final step is irrigation with antiseptics and inspection for bleeding and airleaks.After the previous step, two chest tubes are positioned. During the postoperative period the thorax was flushed with antiseptic irrigation (Varidase: the agent of Varidase is a mixture of streptokinase and streptodamase in the ratio 4:1 dissolved in liquid) to dissolve a postoperative hematoma, which was visible in the postoperative chest x-ray. Irrigation was repeated up to three times if the drainage volume was higher in the following 24 hours. Follow-up consisted of spirometry (percent predicted values based upon patient's height, age, and sex) and chest x-ray for six months postoperatively in addition to clinical investigation. Preoperative lung function was not measured. Intraoperative bacteriology, duration of drainage, intraoperative and postoperative course, and postoperative complications were recorded. Outcome is classified following the classification according to Siemon [7], which classifies lung function into three groups: excellent (FEV1, 100-90% of predicted value), good (FEV1, 90 –70% predicted value), or poor (< 70% of predicted value).


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  		Table 1. Patients' Demographic Data
 


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  		Fig 1. Computed tomographic scan (left) and chest X-ray (preoperative) (right).

 


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  		Fig 2. Port placement.

 

   Results
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One hundred and thirty patients (98 male and 32 female) with a mean age of 45 years (18–82 years) were treated. Bacteriologic examination at the beginning of the operation was sterile in 99 patients, streptococcus was found in 10, pneumococcus in 11, mycobacterium tuberculosis in 4, and a mixed infection in 6. The underlying cause was pneumonia in 71 patients, tuberculosis in 5, HIV infection in 3, post thoracotomy infection in 1, trauma in 13, and unknown in 37.

One hundred twenty-eight patients were extubated at the end of the procedure. Two required intensive care unit admission for ventilatory support and stayed 1 and 2 days. The mean operating time was 93 minutes [range, 55–180 minutes]. Conversion to an open procedure was necessary in 4 patients (3.1%); twice due to bleeding, once due to adhesions, and once due to inexperience of the surgeon. Airleaks were seen in 14 (10.7%) patients at the end of the operation. The duration of tube drainage ranged from 5 to 32 days (mean, 10 days). The duration of hospital stay ranged from 3 to 56 days (mean, 16 days). Ninety-seven (72.3%) patients were treated postoperatively by antiseptic irrigation (Varidase).

Fifteen patients had complications. Three of them were treated conservatively (we declared these as mild complications), 12 patients (9%) required reoperation, four because the empyema recurred, four for collapsed lung, one of which needed lobectomy, one for postoperative bleeding, and one for persistent airleak longer than 10 days. For the patient with postoperative internal bleeding video-assisted thoracic surgery (VATS) was successfully performed. The others required open surgery.

Two patients were readmitted to the hospital. One had a recurrence of empyema and was treated by open operation and the other had a lung destroyed by tuberculosis and required a pnemonectomy.

Final chest x-ray before discharge from hospital showed a well-expanded lung and a partially obliterated costodiaphragmatic sulcus in all patients (Fig 3). Blood loss ranged from negligible to 1,150 cc, with a median of 224 cc. Blood transfusions [2 to 6 units] were given to 14 (10.7%) patients.



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  		Fig 3. Chest X-ray on discharge.

 
The follow-up period ranged from 4 to 26 months (mean, 12 months). Postoperative spirometry was obtained six months postoperatively in 114 (87.6%) patients. Two patients were lost to follow-up. The mean postoperative vital capacity was 84.4% (range, 59.9% to 97.9%) of the predicted. No patient had recurrence of empyema. Based on the pulmonary spirometry, 71 patients (54.6%) had an excellent outcome and 56 (43.07%) a good outcome [7].


   Comment
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The goals of therapy for pleural empyema are control of infection, prevention of persistent and recurrent disease of the pleural space, and restoration of pulmonary function by obviating restrictive lung disease [8]. There is a division in three forms of empyema [1]. In the exudative stage I and fibropurulent stage II the lung retains its compliance and has the capacity to expand fully if the fibrin layer is removed and the pleural space is evacuated. After four to six weeks of the development of the empyema the fibrin layer becomes organized and forms a thick peel, the organized and chronic phase (III). The therapy is different and depends on the stage of the disease. In stage I (exudative) the main therapy is drainage, irrigation, and systemic antibiotics. Drainage with a chest tube of adequate size (28 French [Fr] or larger), sometimes aided by irrigation and antibiotics, is successful in most cases. A chest x-ray is the basic diagnostic tool. Ultrasound and CT scan help to identify loculated empyema, which is an indication for surgical intervention because the septa prevent a complete drainage of the empyema and effective irrigation. Computed tomographic scan helps with the detection of underlying lung disease such as abscess or tumor, and indicates the thickness of the intrapleural fluid which helps to determine the stage of the empyema. When a diagnosis of stage III empyema is made, an open procedure is indicated. Chest x-ray, CT scan, sonography, and chemical parameters should be performed in all cases to detect and diagnose the empyema as accurately as possible in order to prescribe the proper therapy. As with the other authors [9], we believe the procedure should begin with VATS and if the diagnosis of stage III empyema is confirmed, open operation will be necessary. Although Striffeler and colleagues [10] detected an underlying malignancy in 8% of their patients, we found no tumors in our patients. Video-assisted thoracic surgery is now recognized to be as effective as an open surgery for a variety of diagnostic and therapeutic conditions, but with significantly less morbidity [11–14]. When minimally invasive surgery was introduced in 1990 for thoracic cases, we realized that the same goal as for open decortication can often be obtained by the use of VATS: VATS provides good visualization and magnification, direct visualization of all surgical maneuvers and surgical regions, and often avoidance of thoracotomy. In our opinion, video-assisted thoracoscopic debridement offers an ideal surgical technique for the treatment of early empyema. The VATS procedure facilitates the evacuation of multilocular effusions and the division of fibrin septum.

In contrast to other authors we place the first port superior to the empyema, usually in the third intercostal space in the midclavicular or the midaxillary line, and work toward the empyema from the "healthy" part of the lung with blunt dissection by fingertips and instruments. This way it is relatively simple to find the pleural space and get oriented. Although adhesions may be present throughout the pleural space, the empyema collection is usually located in the dorsobasal areas of the pleural space. We find that it is relatively easy to separate the adhesions in the upper part of the pleural cavity and begin to separate the lung from the empyema.

We believe that this approach minimizes fistulas, airleaks, and bleeding in most cases. With the finger palpation it is quite simple to assess the narrowing and the rigidity of the pleural space as well as the thickness of the pleural peel and the degree of the adherence of the lung to the chest wall. The disadvantage for this port placing is that it is not possible to use the first port for utility thoracotomy or for conversion-thoracotomy. However, the incision itself is so small that another incision can be made without risk of complication. We found that it was not necessary to peel the lung to such a degree as with open surgery. We peel the lung surface as much as possible without injuring it and causing airleaks and bleeding. The main goal in our method is for a fully expanded lung and the peeling and evacuation of all empyema membranes and fluids. When the anatomic structures of the lung are visible and the lung has fully expanded the operation can be concluded.

Our conversion rate was 3.1%. In literature the conversion rate is from 10 and 40 percent all over [13–22]; Lawrence's conversion rate [18] was 4.7 %, Waller and Rengarajan's [19] was a 41.6% conversion rate.

During the study period, 424 patients with empyema were treated surgically. Nonsurgical treatment was exclusively done by the Pulmonology Department in our institution. One hundred and thirty patients were treated with VATS and 294 were treated by open surgery. The number of patients treated endoscopically rose with our growing experience. While in 1993 only very few patients underwent video thoracoscopy for empyema, in 2002 more than 50% of those treated surgically had VATS (Fig 4). However, "older" surgeons in our group still prefer the classical open way. The "endoscopic" surgeons start every procedure with VATS, while the others still prefer open surgery. As the good results that we were achieving with VATS became more widely known, referrals of patients in earlier stages of their disease markedly increased. Now, most of our patients present in an early empyema phase (stage I or II). Our current strategy is to start every empyema by endoscopy but with the option to convert to open procedure.



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  		Fig 4. Number of patients sorted by endoscopy or thoracotomy. ( · · · = endoscopic; — = thoracotomy.)

 
Computed tomographic scan and other radiologic methods often do not establish the stage of empyema so that a preoperative determination of operability by VATS is often not possible. Additionally, the preoperative determination of the stage of the empyema remains unsolved and therefore is of questionable use. Huertgen and colleagues [23] and Sunder-Plassmann [24] advocate the use of VATS for empyema staging. Sunder-Plassmann mentioned that the choice of drainage therapy, VATS or an open procedure, cannot be determined from the classic empyema classification. When VATS is used as the first maneuver, a conversion rate to an open procedure of up to 30% may be anticipated [8, 10]. A conversion to open procedure should be done if there is any doubt concerning the expansibility of the lung [23]. In stage three empyema, open surgery remains the procedure of choice. Antibiotic therapy prescribed by family doctors is in part responsible for the delayed admittance of these patients to the hospital, which ultimately delays referral to thoracic surgeons. Antibiotic therapy may also account for the inability to culture organisms from the empyema fluid.

It is important to focus on the failures of VATS. Our reoperation rate decreased from 14% to 9% and is higher in comparison with other authors [23].

In a prospective study comparing VATS and posterolateral thoracotomy for lung resection there was no significant difference in regard to pulmonary function, post thoracotomy pain, or patient acceptance between the two methods three months after surgery [25]. These results do not support the universal use of VATS in the treatment of pleural empyema, especially in its more chronic organizing phase, which we believe is not well-suited to this technique.

There are no randomized data available to compare thoracotomy and minimally invasive surgery; all groups report a retrospective evaluation of their patients [26]. Although the open approach to empyema thoracis has excellent results in regard to infection control and restoration of lung function, morbidity and mortality remain higher compared with the VATS procedure. Additionally, open thoracotomy has a low acceptance rate among both patients and physicians because of pain-related morbidity in the early postoperative period. Reluctance to use an early surgical approach in patients with empyema eventually leads to late referral of the patients in a more advanced stage of empyema and a lower chance of restoring pulmonary function. Since establishing video-assisted decortication, a rising frequency for decortication for empyema was significant in different centers for thoracic surgery [23, 26].

In our opinion, and in agreement with other authors, we conclude that complete surgical debridement has proved to be the most successful treatment for thoracic empyema. Computed tomographic scan is the best method to detect loculated empyema so that operative treatment may be instituted early enough to avoid advanced empyema. Video-assisted thoracic surgery is a safe and effective treatment option for fibropurulent empyema, with lower morbidity and mortality than an open procedure. Conversion to thoracotomy should be used if necessary to achieve complete removal of the purulent material and peel and complete expansion of the lung for a good outcome.


   The Thoracic Surgery Foundation for Research and Education
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The Thoracic Surgery Foundation for Research and Education (TSFRE) extends its best wishes to all its colleagues and friends for the upcoming year. We thank you for your support. Your commitment to TSFRE has furthered many invaluable research and education initiatives that are making substantial differences in the practice of cardiothoracic surgery.

The time period between the end of the old year and the start of the new is often one of reflection. The TSFRE urges you to take a moment to consider the legacy you would like to leave behind within your specialty of cardiothoracic surgery. To acknowledge what your specialty has done for you, please consider ways in which you might leave your own mark and legacy in cardiothoracic surgery. Our great progress within the last decade is in large measure the result of extraordinary research and strong education programs. You can help assure that these programs will continue to transform the specialty for decades to come.

To do so, consider making a planned gift to the TSFRE. Planned gifts come in many varieties that will fit many different life circumstances. Certainly the most common is a bequest through your will to the TSFRE after you have assured that your family and other loved ones will be secure. In some circumstances a bequest of $10,000 may represent only $2,500 that would go to the family should estate, income and capital gains taxes be required. Real estate as a planned gift is often a very practical and financially sound mechanism. Real estate donations can be structured to provide income for periods of time or allow use of the property even after the gift has been made.

Your generosity has made a very important difference for TSFRE and the specialty. Please continue to donate to the utmost of your capability.


   References
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 Abstract
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 Patients and Methods
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 The Thoracic Surgery Foundation...
 References
 

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