Minimally invasive thoracic surgery for empyema

Abstract

The widely accepted and still increasing use of video-assisted thoracic surgery (VATS) in pleuro-pulmonary pathology imposes the need to deal with two major pitfalls: the first is to avoid its unselective use, while the second relates to inappropriate rejection of VATS on the basis of “insufficient radicality”. Unlike a quite established role of VATS in lung cancer patients, in patients with pleural empyema, the role of VATS is less clearly defined. The current evidence about VATS in patients with pleural empyema could be summarised as follows: VATS is accepted as a useful treatment option for fibrinopurulent empyema, but the treatment failure rate increases with the increasing proportion of stage III empyema, necessitating further surgical options like thoracotomy and decortication. As both pulmonologists and surgeons deal with diagnosis and treatment of pleural empyema, this article is an attempt to highlight the existing evidence in a more user-friendly way in order to help practising physicians to optimise the use of VATS in these patients. In other words, in the absence of randomised studies comparing VATS and thoracotomy, the key question to be answered is: are there any pre-operative findings that can be used to select patients for initial VATS versus proceeding directly to a thoracotomy?

The Physiologic and Radiologic Outcomes of Decortication for Chronic Empyema in the Long Term Follow Up: A Retrospective Analysis

“…In contrast to these studies favoring the use of VATS decortication in the treatment of empyema Subotic et al 1 was cautious for the use of VATS. He stressed that there were clear guidelines for the use of VATS decortications in the treatment of stage 3 empyema especially empyema with a long (>5 weeks) symptomatic clinical history.…”

“…Although the advances in the era of antibiotics and the availability of better medical care of the infected patient thoracic empyema is still a challenge for both chest physicians and thoracic surgeons. Even in developed countries, empyema affected 65000 people in each year 1 . As a developing country, the empyema issue is more profound in this country due to national and international immigration.…”

Pleural infection: moving from treatment to prevention

“…These are usually the more advanced cases where VATS debridement is more likely to fail and necessitate further surgical options such as thoracotomy and decortication, with significant conversion rates up to 61% [74]. The limitations of VATS at this stage are largely due to difficulty accessing the pleural space through thick parieto-visceral adhesions using a thoracoscope, or inadequate pleural decortication to achieve lung re-expansion [75]. The reported complication rate after VATS decortication varies from 9% to 40% [76], the most frequent complications being prolonged air leak, bleeding, recurrence or persistence of the disease, surgical wound infection and a residual pleural space [75].…”

“…The limitations of VATS at this stage are largely due to difficulty accessing the pleural space through thick parieto-visceral adhesions using a thoracoscope, or inadequate pleural decortication to achieve lung re-expansion [75]. The reported complication rate after VATS decortication varies from 9% to 40% [76], the most frequent complications being prolonged air leak, bleeding, recurrence or persistence of the disease, surgical wound infection and a residual pleural space [75]. The 30-day postoperative mortality ranges from 2-6% [77].…”

Breathe: surgical interventions in pulmonary diseases

“…Thoracic surgery including transplantation plays an important role in many lung diseases, and knowledge about surgical options is essential for respiratory clinicians who have to make decisions about when to refer patients to a thoracic surgeon and who follow-up patients after lung surgery. We have excellent reviews on: controversies and emerging topics in lung transplantation [ 7 ], a must-read for all respiratory professionals who would like to gain a better understanding of lung transplantation; minimally invasive thoracic surgery for empyema [ 8 ], providing a comprehensive overview of a topic of longstanding debate; and surgery in nontuberculous mycobacteria pulmonary disease [ 9 ], a summary of the available evidence on the topic, which is likely to become an important reference in this area.…”