Henrietta Wilson*, Prashant Mohite, Anne Hall, Vladimir Anikin
Harefield Hospital, Hill End Road, Uxbridge, Middlesex, UB9 6JH, UK
Received: 29 April, 2016;Accepted: 29 June, 2016;Published: 30 June, 2016
Henrietta Wilson, Harefield Hospital, Hill End Road, Uxbridge, Middlesex, UB9 6JH, UK, Tel: 01895 823737; Fax: 01895 825948; E-mail:
Wilson H, Mohite P, Hall A, Anikin V (2016) Timing and Efficacy of VATS Debridement in the Treatment of Parapneumonic Empyema. Arch Pulmonol Respir Care 2(1): 016-019.
© 2015Wilson H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Objectives: Empyema thoracis is a common thoracic disease seen in both developing and developed countries. Despite modern management techniques, this condition is still associated with significant morbidity and mortality. Video assisted thoracoscopic surgery (VATS) has become an established mode of treatment for this condition; however the first-line approach and timing of surgical intervention remains controversial. The present study was undertaken to assess our experience of VATS debridement in the management of empyema, focusing on the timing of surgical intervention, and the affect this has on outcomes.
Method: Between May 2007 and May 2011, 75 patients underwent VATS debridement of empyema in our institution. Retrospective analysis of clinical notes was performed to collect data regarding length of pre-operative conservative management, operative strategy and post-operative course. The primary outcomes were the need for open thoracotomy, post-operative complications, length of hospital stay and survival.
Results: The mean pre-operative duration of conservative management in this cohort was 15.7 days (range 4-35). A total of 9 patients (12%) required open thoracotomy. Patients who had been managed conservatively for two weeks or more were significantly more likely to require open thoracotomy (p > 0.05). Both approaches were well tolerated with minimal post-operative complications. Average length of stay was 8.2 days (range 2-38) with no correlation found between this and pre-operative length of management. There were no in hospital deaths following this procedure.
Conclusions: VATS is now fully established as a safe and effective approach in the management of patients with empyema. The timing of any surgical intervention, however, remains controversial. There appears to be an ongoing trend for delayed referral, with the majority of our patients managed conservatively for over two weeks. The current study supports early surgical involvement, as later referral has been shown to lead to a significant increase in the need for open thoracotomy.
Empyema thoracis is defined as an accumulation of purulent material and fluid within the pleural cavity. The most common cause is as a complication of pneumonia . The natural history of the disease is one of transition and a number of stages have been classified. The early or exudative phase (stage I) is a simple fluid or pus collection. Without treatment this will soon evolve into a loculated, fibrinopurulent effusion (stage II) followed finally by a complex, organised collection with trapping of the underlying lung (stage III).
As the name would suggest, empyema thoracis was first described in Greece by Hippocrates and his followers in 500BC, at which time surgical drainage was proposed as the treatment of choice . Open thoracic drainage remained the only management option until the early 1900s at which time unacceptable mortality rates during the influenza pandemics of 1917 and 1918 forced further investigation into the disease. The novel approach of drainage using a closed chest tube was introduced at this time leading to a dramatic reduction in mortality rates .
This approach remains the basis for the current rationale in the management of empyema. It is generally agreed that success is dependent upon appropriate antibiotic therapy combined with drainage of the pleural space, re-expansion of the underlying lung and treatment of co-morbidities such as diabetes and malnutrition. The method of drainage and the timing of any surgical intervention, however, remain controversial. Despite modern management techniques the condition is still associated with significant morbidity, and a mortality rate of 20% in adults . The present study was therefore undertaken to assess our experience of VATS debridement for empyema, focusing on the timing of surgical referral and intervention, and the affect this has on outcomes.
A review of the thoracic surgical database identified 75 patients who had undergone VATS drainage in the management of post-pneumonic empyema between May 2007 and May 2011. Patients requiring open drainage with rib resection, thoracoplasty or flap reconstruction were excluded from this study. Patients with an underlying thoracic malignancy were also excluded. The most common presenting symptoms were shortness of breath, fever and cough and were reported in 35-40% of cases. Others seen less frequently included chest pain, loss of appetite, loss of weight and haemoptysis. All patients had been resistant to medical treatment which varied from antibiotic therapy only, to pleural aspiration or drain insertion. The cohort was divided into those patients managed conservatively for less than two weeks prior to surgery (Group I n=34) and those managed for 2 weeks or more (Group II n=41). Diagnosis in both groups was confirmed using CT scan of the chest (Figure 1), with or without analysis of pleural fluid.
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