Original article: general thoracic
Minimally invasive surgery in the treatment of empyema: intraoperative decision making

Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.
https://doi.org/10.1016/S0003-4975(03)00025-0Get rights and content

Abstract

Background

Pneumonia, parapneumonic effusions, and empyema continue to be significant health problems, especially in elderly individuals. Minimally invasive thoracic surgery in the treatment of empyema has been demonstrated but has not been well defined. Furthermore, it has not been determined how to choose patients who can be treated with thoracoscopy versus thoracotomy. We report the results of a strategy in which all patients were initially approached with thoracoscopy and converted to open decortication only if the lung could not be inflated to fill the chest.

Methods

A total of 172 patients underwent decortication for empyema over a 5-year period. Thoracoscopic decortication was attempted in all patients; patients were converted to open decortication if access to the pleural space was not possible, or if the lung could not be mobilized sufficiently to reach both the chest wall and the diaphragm. Proportions were compared using the χ2 test.

Results

Of the 172 patients, 66 successfully underwent decortication with thoracoscopic techniques only. The remaining 106 patients required complete thoracotomy. No difference was found in the reoperation rate; 3 of 106 open thoracotomy patients underwent reexploration for recurrent empyema, whereas two of 66 thoracoscopy patients required reoperation for hemothorax (p = 0.347). There was a tendency for thoracoscopic patients to require reoperation for bleeding (p = 0.08); both patients taken back to the operation room for bleeding had undergone thoracoscopic pleurectomy. Eleven of 166 patients (all explored with open thoracotomy) died after decortication, for a mortality rate of 6.6%. All of these patients had gone to surgery from the intensive care unit.

Conclusions

Using the criteria of complete expansion of the lung surface to the chest wall and diaphragm allowed accurate selection of patients who could undergo complete thoracoscopic decortication without risk of recurrent empyema. Computed tomographic scans did not help to predict which patients would require open procedures. Thoracoscopic patients were more likely to require reoperation for bleeding if thoracoscopic pleurectomy was performed.

Section snippets

Material and methods

All patients undergoing surgical treatment for empyema under 1 surgeon’s care for the last 5 years were analyzed. Patients were considered to have empyema if they had fever, leukocytosis, pleural fluid with a pH less than 7.2, and a pulmonary infiltrate, with no other source of fever identified before or after the surgery. Positive cultures of neither fluid nor blood were required to make the diagnosis.

All patients were brought to the operating room, underwent general anesthesia, and then

Results

Demographic results are summarized in Table 2. A total of 172 patients underwent surgical treatment for empyema, 106 by open thoracotomy, and 66 by thoracoscopic drainage. Of the patients, 73% were men, of whom two thirds required open drainage. The remaining 27% of the patients were women, almost half of whom were treated thoracoscopically. Patients ranged in age from 3 to 92 years; there was no significant difference between the two groups. Most of the empyemas resulted from either primary or

Comment

Although the principles of drainage for empyema have not changed in the past 30 years, the acceptance by pulmonologists of the importance of early surgical drainage of empyema and of parapneumonic effusions has changed [4]. Drainage of parapneumonic fluid is recommended when patients have pus in the pleural space, pleural fluid with a positive Gram stain or culture, or pH less than 7.2 (Table 4) 5, 6. Typical management of a patient with parapneumonic effusions or empyema might include multiple

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