Does videothoracoscopy improve clinical outcomes when implemented as part of a pleural empyema treatment algorithm?

Abstract

OBJECTIVE:We aimed to evaluate whether the inclusion of videothoracoscopy in a pleural empyema treatment algorithm would change the clinical outcome of such patients.METHODS:This study performed quality-improvement research. We conducted a retrospective review of patients who underwent pleural decortication for pleural empyema at our institution from 2002 to 2008. With the old algorithm (January 2002 to September 2005), open decortication was the procedure of choice, and videothoracoscopy was only performed in certain sporadic mid-stage cases. With the new algorithm (October 2005 to December 2008), videothoracoscopy became the first-line treatment option, whereas open decortication was only performed in patients with a thick pleural peel (>2 cm) observed by chest scan. The patients were divided into an old algorithm (n = 93) and new algorithm (n = 113) group and compared. The main outcome variables assessed included treatment failure (pleural space reintervention or death up to 60 days after medical discharge) and the occurrence of complications.RESULTS:Videothoracoscopy and open decortication were performed in 13 and 80 patients from the old algorithm group and in 81 and 32 patients from the new algorithm group, respectively (p<0.01). The patients in the new algorithm group were older (41±1 vs. 46.3±16.7 years, p = 0.014) and had higher Charlson Comorbidity Index scores [0(0-3) vs. 2(0-4), p = 0.032]. The occurrence of treatment failure was similar in both groups (19.35% vs. 24.77%, p = 0.35), although the complication rate was lower in the new algorithm group (48.3% vs. 33.6%, p = 0.04).CONCLUSIONS:The wider use of videothoracoscopy in pleural empyema treatment was associated with fewer complications and unaltered rates of mortality and reoperation even though more severely ill patients were subjected to videothoracoscopic surgery.

Video-assisted thoracic surgery in pleural empyema: predictors of complications and treatment failures

“…The complication rate after VATS empyemectomy varies from 9% to 40.2% (5,6,8,9,11,17,18,20,24,25,32). Prolonged air leak, bleeding, recurrence or persistence of the disease, surgical wound infection and residual pleural space are the most common complications.…”

“…Clinically it may provide better clues for the decision to perform the early surgical approach. The positive culture from the pleural space is assessed by different authors in 10-60% of patients (5,6,8,15,24,25,(28)(29)(30)(31)(32). Such a low percentage of positive cultures may represent an effective antibiotic treatment prior to sample collection.…”

“…Some recent studies suggest that VATS and open thoracotomy are showing similar treatment success rates and are equally effective. Successfully done VATS, being less invasive, provides the additional advantages of decreased postoperative discomfort, pain, better cosmetics, higher patient satisfaction and shorter hospitalization time, especially if performed relatively early (5,8,9,11). However, in up to 59% of patients VATS is inadequate and conversion to open thoracotomy is necessary during the same operation (12,13).…”

“…However, in up to 59% of patients VATS is inadequate and conversion to open thoracotomy is necessary during the same operation (12,13). Re-do surgery after VATS (when disease remains or complication occurs) reaches up to 11.5% and is higher compared to direct open thoracotomy (5,9). So, failed VATS empyemectomy results in longer operating time, prolonged hospital stay, higher need of additional surgery, of a treatment at the Intensive Care Unit (ICU) and therefore increases treatment costs.…”

“…Hence, surgical management of pleural empyema plays an important role in the treatment of this disease, described already by Hippocrates (2-4). Traditionally, open thoracotomy represented the main stay of treatment for this condition, but recently numerous attempts have been performed to replace it by a minimally invasive approach (2,(5)(6)(7). The precise role of video-assisted thoracic surgery (VATS) in the management of pleural empyema remains controversial and no consensus is currently in place on which surgical option and for what the patient is the first line (8)(9)(10).…”