The Role of VATS in the Treatment of Thoracic Empyema

Česká verzia

Authors: F. Vyhnánek; D. Jirava; M. Očadlík
Authors place of work: Chirurgická klinika FNKV a 3. LF UK, Praha, přednosta: prof. MUDr. R. Gürlich, CSc.
Published in the journal: Rozhl. Chir., 2011, roč. 90, č. 3, s. 143-147.
Category: Monothematic special - Original

Summary

Introduction:
Videothoracoscopy (VTS) and video-assisted thoracoscopic (VATS) decortication is commonly used in the treatment of early thoracic empyema. However, its conversion to thoracotomy is more frequent in chronic empyema cases. The authors evaluate the role of VTS/VATS in the pleural empyema therapy in the group of patients treated for thoracic empyema using VATS or thoracotomic decortication.

Patients, Method and Results:
The retrospective study included 165 patients who underwent surgery for thoracic empyema. Pneumonia was the the commonest cause of pleural empyema (77%), while elective lung and esophageal surgery resulted in pleural empyema in 11% of the subjects, trauma in 9% and intraabdominal infection in 3% of the subjects. The subjects were diagnosed with thoracic empyema stage II or III either prior to the procedure on CT examination, or during the procedure. VTS/VATS was indicated in 52 subjects, and conversion to open decortication was required in 23 of them. Open thoracotomic decortication was performed in 113 subjects. VTS/VATS was successful in stage II disorders, in particular in the removal of pus and fibrin, with targeted chest drain insertion. VATS decortication was performed in 15 subjects with stage II or early stage III disorders. In open decortications, the procedure was extended to lung resection (8x lobectomy and 10x wedge non-anatomical resection) for residual abscess pneumonia or lung abscess. Conservatively managed postoperative complications included protracted chest drain air leak (11 patients) and fluidothorax relapses which were treated with redrainage (8 patients). Early postoperative rethoracotomy was indicated in 6 patients for hemothorax, resulting from hemocoagulation disorder in septic conditions. 4 patients were indicated for rethoracotomy for empyema relapses. During the postoperative period, 6 patients exited in the open decortication group.

Conclusion:
VTS is the method of choice in the treatment of stage II thoracic empyema, with a potential for the infectious focus removal, targeted drainage and lung reexpansion. VATS is an alternative thoracotomy method for decortication in the early stage III empyema. Decortication via thoracotomy is a standard treatment method for the management of chonic empyema.

Key words:
thoracic empyema – VTS/VATS – decortication

Zdroje

1. Cardilo, G., Carleo, F., Carbone, L., et al. Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication. Eur. J. Cardiothorac. Surg., 2009; 36: 914–918.

2. Chan, D. T. L., Sihoe, A. D. L., Chan, S., et al. Surgical treatment for empyema thoracis: Is video-assisted thoracic surgery „better“ than thoracotomy? Ann. Thorac. Surg., 2007; 84: 225–231.

3. Wozniak, C. J., Paull, D. E., Moezzi, J. E., et al. Choice of first intervention is related to outcomes in the management of empyema. Ann. Thorac. Surg., 2009; 87: 1525–1531.

4. Casali, Ch., Storelli, E. S., Di Prima, E., Morandi, U. Long-term functional results after surgical treatment of parapneumonic thoracic empyema. Interact. Cardio Vasc. Thorac. Surg., 2009; 9: 74–78.

5. Chambers, A., Routledge, T., Dunning, J., Scari, M. Is video-assisted thoracoscopic surgical decortication superior to open surgery in the management of adults with primary empyema? Interact. Cardio Vasc. Thorac. Surg., 2010; 11: 171–177.

6. Tong, B. C., Hanna, J., Toloza, E. M., et al. Outcomes of video-assisted thoracoscopic decortication. Ann. Thorac. Surg., 2010; 89: 220–225.

7. Roberts, J. R. Minimally invasive surgery in the treatment of empyema: intraoperative decision making. Ann. Thorac. Surg., 2003; 76: 225–230.

8. Tacconi, F., Pompeo, E., Fabbi, E., Mineo, T. C. Awake video-assisted pleural decortication for empyema thoracis. Eur. J. Cardiothorac. Surg., 2010; 37: 594–601.

9. Solaini, L., Prusciano, F., Bagioni, P. Video-assisted thoracic surgery in the treatment of pleural empyema. Surg. Endosc., 2007; 21: 280–284.

10. Tong, B. C., Hanna J., Toloza, E. M., et al. Outcomes of video-assisted thoracoscopic decortication. Ann. Thorac. Surg., 2010; 89: 220–225.

11. Cassina, P. C., Hauser, M., Hillejan, L., et al. Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome. J. Thorac. Cardiovasc. Surg., 1999; 117: 234–238.

12. Lardinois, D., Rock, M., Pezzetta, E., et al. Delayed referral and gram-negative organisms increase the conversion thoracotomy rate in patients undergoing video-assisted thoracoscopic surgery for empyema. Ann. Thorac. Surg., 2005; 79: 1851–1856.