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Ann Thorac Surg 2010;89:220-225. doi:10.1016/j.athoracsur.2009.09.021
© 2010 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Outcomes of Video-Assisted Thoracoscopic Decortication

Betty C. Tong, MDa,*, Jennifer Hanna, MDa, Eric M. Toloza, MDb, Mark W. Onaitis, MDa, Thomas A. D'Amico, MDa, David H. Harpole, MDa, William R. Burfeind, MDc

a Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
b Thoracic Surgery, Duke Health Raleigh Hospital, Raleigh, North Carolina
c Thoracic Surgery, St. Luke's Health Network, Bethlehem, Pennsylvania

Accepted for publication September 8, 2009.

* Address correspondence to Dr Tong, Duke University Medical Center, DUMC Box 3531, Durham, NC 27710 (Email: betty.tong{at}duke.edu).

Presented at the Twenty-first Annual Meeting of the General Thoracic Surgery Club, San Diego, CA, Mar 15, 2008.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Video-assisted thoracoscopic surgical decortication (VATSD) is widely used for treatment of early empyema and hemothorax, but conversion to open thoracotomy for decortication (OD) is more frequent in the setting of complex, chronic empyema. This study compared indications for and outcomes associated with VATSD and OD.

Methods: The outcomes of 420 consecutive patients undergoing VATSD or OD for benign conditions from 1996 to 2006 were reviewed and compared with respect to baseline characteristics, preoperative management, and operative and postoperative course. Patients were analyzed on an intention-to-treat basis.

Results: The cohort consisted of 326 VATSD and 94 OD patients. The conversion rate from VATSD to OD was 11.4%. The operative time and median in-hospital length of stay were shorter for the VATSD group: 97 vs 155 minutes (p < 0.001), and 15 vs 21 days (p = 0.03), respectively. The median postoperative length of stay was 7 days for the VATSD group vs 10 days for the OD group (p < 0.001). Significantly fewer postoperative complications occurred in the VATSD group in the following categories: atelectasis, prolonged air leak, reintubation, ventilator dependence, need for tracheostomy, blood transfusion, sepsis, and 30-day mortality.

Conclusions: Thoracoscopic decortication for empyema, complex pleural effusion, and hemothorax yields results that are at least equivalent to open decortication. Patients undergoing VATSD have fewer postoperative complications. The conversion and reoperation rates are low, suggesting that a thoracoscopic approach is an effective and reasonable first option for most patients with complex pleural effusions and empyema.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Approximately 40% of the 1.2 million new cases of pneumonia every year in the United States are accompanied by pleural effusion. Of these, 35% will resolve with antibiotic treatment, and in the other 5% (nearly 60,000 patients), contamination by bacterial infection will result in a complicated effusion, or empyema, often causing considerable morbidity and death [1]. As described by Andrews and colleagues [2] in 1962, the three phases of empyema, exudative (stage I), fibrinopurulent (stage II), and organizing (stage III), represent a continuously evolving process that can be arrested by therapeutic intervention.

The initial exudative stage can often be managed by closed-chest drainage and appropriate antibiotic coverage. This is not effective in the fibrinopurulent or organizing stages, because fibrin deposits produce a pleural peel and loculation of fluid that restricts expansion of the lung. Failure of primary treatment in stage I necessitates surgical intervention, traditionally involving thoracotomy and decortication. Early and aggressive management of empyema provides rapid relief from sepsis and may shorten the hospital stay [3, 4]. Depending on surgeon experience, surgical management can be accomplished by video-assisted thoracoscopic surgical (VATS) decortication (VATSD) or open decortication (OD).

VATS is now an established surgical approach for a variety of benign and malignant indications [5]. To date, smaller studies have addressed the feasibility of VATSD compared with OD [6–10]. This study was undertaken to compare indications for and outcomes associated with VATSD and OD in the context of an established surgical center and with a large prospective database.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
The Institutional Review Board of the Duke University Health System granted approval for this retrospective study with a waiver of individual consent. The prospectively collected Duke Thoracic Surgery database was queried to identify potential patients for inclusion in the study, and medical records were reviewed to identify patients who fulfilled the inclusion criteria.

The study population included adult patients who underwent VATSD or OD in the 10-year period between July 1, 1996 and June 30, 2006. The study included patients aged older than 16 years who had preoperative diagnoses of empyema, loculated or complex pleural effusion, recurrent pleural effusion, or retained posttraumatic hemothorax. The analysis excluded patients who underwent decortication for malignant effusion or visceral pleural malignancy, diagnosed either preoperatively or perioperatively.

Data regarding patient demographics, preoperative and postoperative diagnoses, comorbidities, intraoperative details, and postoperative events were available in the database for all patients included in the study. The medical records and operative notes were reviewed to obtain information about prior interventions or attempts at treatment, preoperative and postoperative culture data, and postoperative course.

Patients who had undergone two or more procedures to facilitate pleural drainage, including thoracentesis, chest tube placement, or a prior operation, were defined as having had multiple prior procedures. Complex pleural effusion was defined as that which did not resolve with simple chest tube drainage or demonstrated loculation on computed tomography or ultrasound imaging. Patients were classified as having an empyema if testing of their pleural fluid demonstrated a pH less than 7.2, lactate dehydrogenase greater than 1000 IU/L, protein level greater than 2.5 g/dL, or growth of microbiologic organisms in culture.

The following postoperative complications were recorded within 30 days after operation: reoperation, prolonged air leak, atelectasis, pneumonia, pulmonary embolism, ventilator dependence, reintubation, need for tracheostomy, other pulmonary complications, atrial or ventricular arrhythmia, myocardial infarction, deep venous thrombosis, need for blood transfusion, urinary tract infection, wound infection, sepsis, acute renal failure, other medical or surgical complications, readmission for any reason, and 30-day mortality.

Surgical Technique
All procedures were performed with general anesthesia using lung isolation by way of a double-lumen endotracheal tube or bronchial blocker. Open decortication was accomplished by using a standard posterolateral or muscle-sparing thoracotomy with rib spreading and placement of a retractor.

Thoracoscopic decortication adhered to the same principles of open decortication with the goal of complete débridement of the peel and full lung reexpansion. Two incisions were used: a 1-cm incision located in the eighth intercostal space in the midaxillary line served as a camera port, and a 3- to 4-cm incision located anteriorly in the fifth intercostal space was used as an access port. These two incisions, as described for thoracoscopic lobectomy, allowed for complete visualization and access to the pleural space by the surgical instruments [11]. Under thoracoscopic guidance, instruments were introduced through the access incision and the lung was decorticated. Importantly, no retractors were used and no rib spreading was involved.

Standard thoracic surgical instruments and techniques were used in the procedures. The inflammatory peel was separated from the visceral pleura using both sharp and blunt dissection, avoiding significant parenchymal injury. Chest wall bleeding was managed using electrocautery and, in some instances, packing. The operating surgeon assessed the adequacy of lung expansion by temporary inflation of the affected lung.

Postoperative Care and Follow-Up
When possible, patients were extubated in the operating room and were transferred to a thoracic surgery recovery area where postoperative laboratory samples and chest roentgenogram were obtained. After being monitored for 1 to 2 hours, patients not previously in the intensive care unit were transferred to the step-down unit for the duration of their stay. Principles of early mobilization and aggressive chest physiotherapy were the same for all patients regardless of surgical approach. Chest tubes were maintained on –20 cm H2O of wall suction for 48 hours postoperatively; criteria for removal included the absence of air leak and less than 250 mL of drainage during a 24-hour period.

Patients were seen in the outpatient clinic within 2 weeks of discharge, where a follow-up chest roentgenogram was obtained. After the visit, patients were monitored for up to 12 months. For patients discharged home with empyema tubes and Heimlich valves, follow-up was conducted every 2 weeks until the air leak resolved and the chest tube was removed.

Statistics
Statistical analysis was completed using the SAS 9.1 software (SAS Institute, Cary, NC). Patients were classified on an intention-to-treat basis; thus, 37 patients on whom thoracoscopic decortication was initially attempted but required conversion to an open operation were analyzed in the VATSD group. Unless noted otherwise, data are presented as mean ± standard deviation. Length of stay and duration of chest tube were not normally distributed and are reported as medians. The Fisher exact test was used for comparison of dichotomous data, and the t test or Wilcoxon signed rank test were used for continuous data, where appropriate.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Between July 1996 and June 2006, 420 patients underwent decortication for benign conditions at the Duke University Medical Center. Of these, 289 underwent VATSD. Although 37 were converted to an OD procedure, they were included in the VATSD group for statistical analysis. A planned OD was done in 94 patients.

Table 1 reports the preoperative characteristics and management associated with each group in the study. The two groups were similar in terms of their mean age and comorbid medical conditions. A greater proportion of patients in the OD group (84.5%) had undergone prior general thoracic operations than in the VATSD group (42.8%; data not shown, p < 0.001). However, 53.4% of patients in the VATSD group had undergone prior cardiac operations vs 5.2% in OD group (p < 0.001). The number of patients who had undergone both prior cardiac and general thoracic surgical procedures did not differ between the two groups (p = 0.08). The proportion of patients with hypertension and preoperative renal failure was higher in the VATSD group than the OD group.


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  		Table 1 Preoperative Patient Characteristics
 
A higher proportion of VATSD patients had thoracentesis as attempted preoperative management. In the OD group, 19.2% had undergone prior surgical intervention aimed at treating the underlying problem vs 4.9% in the VATSD group (p = 0.001). No prior intervention before decortication was noted in 30.9% of the OD group and 21.5% of the VATSD group. In contrast, 30.9% of the OD group and 31.3% of the VATSD group had multiple interventions, including an operation, before the decortication procedure.

The most common indication for surgery in OD was empyema (Table 1). For the VATSD group, complex effusion was the most common indication, followed by empyema, recurrent effusion, hemothorax, and "others." The "other" primary indications for surgery included lung resection (with decortication done to facilitate the resection) and bronchopleural fistula (BPF). The proportion of patients who had other indications for surgery was higher in the OD group (14.9%) than in the VATSD group (4.6%).

With the exception of the first year of the study, the proportion of VATSD cases was 65% or higher for all study years (Fig 1). Analyzing the cases by surgeon, we found that 403 of 420 (95.9%) of decortications were performed by dedicated general thoracic surgeons at our institution, and cardiothoracic surgeons with mixed or transplant-focused practices performed the others (data not shown). Of the 4 general thoracic surgeons, the proportion of decortications done by VATS were 62%, 78%, 90%, and 92%. In contrast, the surgeons with mixed cardiothoracic practices in our division used VATS less than 44% of the time.


Figure 1
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  		Fig 1. Use of video assisted thoracoscopic surgical (VAT) decortication (VATSD) and open decortication (OD) by year of the study. Each bar represents the relative percentage of cases done by VATS approach (white bar) and open approach (black bar).

 
Operative time was available for 151 VATSD cases and 34 OD cases (Table 2) and was 97 minutes for VATSD compared with 154 minutes for OD (p < 0.001). At the time of operation, 37 of the 326 VATSD patients (11.4%) were converted to OD for various reasons. Concomitant procedures were recorded, and included lung resection, pleural biopsy, pleurectomy, pleurodesis, and "other" procedures. At the time of the operation, 7.1% of VATSD patients had concomitant pleurodesis vs 1.1% in the OD group (p = 0.0001). The most common "other" procedures performed with decortication were bronchoscopy, esophagogastroduodenoscopy, and placement of a muscle flap. At the time of operation, 58.3% of the VATSD patients had only decortication done compared with 34% of the OD group (p = 0.0001). Cultures were sent from the operating room for 286 patients (88%) in the VATSD group, and 42.7% of these ultimately grew organisms. In contrast, intraoperative cultures were sent for 62 patients in the OD group and 66.1% of these were positive (p = 0.001). The two most common organisms in the study patients were coagulase-negative Staphylococcus and methicillin-resistant S aureus.


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  		Table 2 Operative Time, Length of Stay, and Chest Tube Duration
 
The median overall hospital length of stay was 21 days for OD group vs 15 days for VATSD group (p = 0.003). Postoperatively, the median length of stay was 10 days for the OD group and 7 days for the VATSD group (p < 0.001). In addition, the median number of days that patients had indwelling chest tubes was also different between the groups, 6 days for the OD group and 4 days for the VATSD group (p = 0.008). Finally, for patients discharged from the hospital with an indwelling empyema tube or chest tube for air leak, tubes in the VATSD group were removed at 30 days vs 41 days in the OD group (p = 0.015).

Table 3 lists the frequency of recorded postoperative complications. The need for reoperation was similar between the two groups, as was the incidence of postoperative pneumonia, cardiac arrhythmia, myocardial infarction, deep venous thrombosis, urinary tract infection, wound infection, acute renal failure, and need for readmission. Compared with the OD group, however, the VATSD group had a lower incidence of prolonged air leak, 6.5% v. 18.9% (p < 0.01). The VATSD group also had fewer postoperative respiratory complications such as ventilator dependence (13.0% vs. 25.8%, p = 0.006), reintubation (2.5% vs 11.0%, p = 0.002), and need for tracheostomy (8.9% vs 17.0%, p = 0.04).


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  		Table 3 Postoperative Complications
 
Perioperative blood transfusions were required in 33.8% of the VATSD group compared with 47.3% the OD group (p = 0.02). Also, the incidence of post-operative sepsis was lower in the VATSD group than the OD group, 1.2% vs 5.5% (p = 0.03). Finally, 30-day mortality was 7.5% in the VATSD group compared with 16.1% in the OD group (p = 0.02).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Empyema and complex pleural effusions are conditions commonly managed by the contemporary thoracic surgeon. Although the underlying principles of early drainage and complete decortication to facilitate lung expansion have not changed over the past 30 years, technologic advances have allowed for surgeons to treat these conditions with lower perioperative morbidity and mortality. Other groups have demonstrated the feasibility of VATS for management of empyema, with favorable results for those undergoing VATSD [12–14]. Potential advantages of the thoracoscopic approach include improved visualization, less surgical trauma, and improved postoperative quality of life outcomes. To date, there is not a consensus on the efficacy of the minimally invasive approach in terms of operative results and need for repeat interventions.

This large series of thoracic decortications compared results for 420 patients, 326 who underwent VATSD and 94 who had OD. The groups were well matched with respect to their baseline characteristics, with the exception of a significantly higher number of patients in the OD group who had undergone prior cardiothoracic operations. In the VATSD group, the proportion of patients with hypertension and baseline renal insufficiency was higher; however, this did not affect the incidence of postoperative complications such as perioperative myocardial infarction or acute renal failure.

The preoperative management of patients in both groups was slightly different. A higher proportion of patients in the VATSD group had thoracentesis as preoperative management; in contrast, patients who had OD were more likely to have had a prior operation. Interestingly, nearly one-third of patients overall had undergone multiple procedures before the decortication. "Other" indications for the operation were documented in both groups. Decortication was not the primary indication for the operation in most of these patients but was done either to facilitate repair of a known BPF or to facilitate a planned lung resection. The proportion of these patients with "other" procedures was higher in the OD group (14.9% vs 4.6%). This was expected, because most of the procedures performed concomitantly with the decortications were placement of muscle flaps for repair of BPF, which generally require thoracotomy.

The two groups were somewhat different with regard to their underlying disease pathology and preoperative management, and these factors could have influenced the surgeons' decisions about the operative approach. Specifically, the OD group had a higher number of documented empyemas and prior surgical management. Also, a higher proportion of patients in the OD group had undergone prior general thoracic surgical procedures. This may have led to the decision by the operating surgeon to proceed directly to OD rather than a trial of VATSD. Despite these differences, however, 2 of the surgeons used VATSD for more than 90% of cases, regardless of preoperative diagnosis or management. In addition, when the 37 patients whose VATSD were converted to OD were compared with the remaining VATSD patients, the proportions of patients who had prior cardiac and general thoracic surgical were not statistically different. The overall low conversion rate, shorter operative times, and lower rate of perioperative complications support the use of VATSD as an initial approach for any empyema or complicated effusion. However, if an adequate decortication cannot be accomplished in a timely fashion using VATS, then conversion to an OD may be necessary.

Our examination of a variety of variables reinforced many of the established benefits of VATS procedures compared with thoracotomy. For instance, the VATSD group had a lower incidence of pulmonary complications such as atelectasis, reintubation, and need for tracheostomy. This is likely due to relatively superior respiratory mechanics resulting from lower pain levels after minimally invasive surgery, and is consistent with data demonstrating that patients who underwent VATS reported significantly lower pain scores than those who had thoracotomy [12, 15, 16]. With lower pain scores and improved respiratory mechanics, it follows that patients in the VATSD group had a shorter postoperative length of stay.

However, it is possible that the longer length of stay in the OD group also reflects that the patients may have more comorbidity at baseline. This possibility is reinforced by the higher rate of blood transfusion, postoperative sepsis, need for other surgical procedures, and 30-day mortality in the OD group. Although several preoperative patient characteristics were examined, it would be beneficial to have a better record of preoperative functional status, which certainly affects each patient's postoperative course.

Overall, the current series compares favorably with other published studies. The rate of conversion from VATSD to OD was 11.4%. In a summary of recent series comparing VATSD and OD, conversion rates to OD ranged from 3.5% to 41%, with higher conversion rates corresponding to stage III empyema and delays in diagnosis or therapy [14]. In another large series, comparing VATSD and OD, Cardillo and colleagues [17] reported shorter operative times and hospital stay in the group of patients treated with VATSD. The mean number of days with chest tube, 7.0 for VATSD and 9.7 for OD, corresponds well with published means of 4.1 to 10 days [7, 10, 18]. The rate of reoperation, considered to be a surrogate for adequacy of decortication, was 7.7% for VATSD and 10.6% for OD. These results are similar to other published series [18, 19].

Other authors have reported that S aureus and Streptococcus pneumoniae were the most common organisms isolated [20, 21] and that the presence of gram-negative organisms was an independent predictor of conversion from VATSD to OD [20–22]. In this study, the most common isolates were coagulase-negative Staphylococcus and methicillin-resistant S aureus, and these were not predictive of conversion from VATSD to OD.

This study is limited by its retrospective nature. Although a randomized controlled trial might be able to further elucidate the benefits associated with VATSD, it would likely be difficult for surgeons to maintain equipoise and allow randomization to unnecessary thoracotomy for patients whose clinical presentations could be easily treatable by VATSD [22].

Figure 2 depicts the decision-making process used in the evaluation of patients with complex effusions at our institution. VATSD is used as an initial approach in most patients, with an acceptable conversion rate. Although surgeon discretion and experience may favor OD in certain cases, we advocate at least a trial of VATSD in most instances. Planned OD or conversion to OD is indicated at the surgeon's discretion when a safe and adequate thoracoscopic decortication cannot be accomplished in a timely fashion or when there is another indication for thoracotomy, such as placement of muscle flap in the chest or open complex repair such as bronchoplasty or arterioplasty.


Figure 2
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  		Fig 2. Algorithm for patient selection and decision-making in video-assisted thoracoscopic surgical (VATS) decortication. (BPF = bronchopulmonary fistula.)

 
In conclusion, this study validates thoracoscopy as a viable approach for empyema of all stages and complex or recurrent pleural effusions. Compared with open decortication, thoracoscopic decortication is a safe and effective method for treatment of empyema, complex pleural effusion, recurrent pleural effusion, and hemothorax. For these indications, VATSD yields functional results that are comparable to OD and provides benefit in terms of length of stay, fewer prolonged air leaks, blood transfusion requirements, postoperative respiratory complications, and 30-day mortality. We believe that VATSD is a reasonable approach for all decortications not otherwise requiring placement of muscle flaps or complex open repair. However, when adequate decortication cannot be achieved in a timely and efficient manner thoracoscopically, conversion to OD should be considered.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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