Original Article

Modern Management of Thoracic Empyema

Authors: Matthew T. Bender, BS, Victor A. Ferraris, MD, PhD, Sibu P. Saha, MD

Abstract

Objectives: Historically, surgical management of empyema was performed predominantly via open thoracotomy; however, during the past decade the use of video-assisted thoracoscopic surgery (VATS) as an alternative has increased. This study retrospectively compared the outcomes and management of patients with empyema at the University of Kentucky Medical Center who had undergone VATS versus those receiving open thoracotomy to determine whether VATS decortication provided comparable results.

Methods: Adult patients who had undergone open thoracotomy or VATS decortication for empyema between 2005 and 2009 at the University of Kentucky were identified by querying the hospital’s cardiothoracic surgery database. Patients were sorted by procedure on an intent-to-treat basis. Comorbid conditions, preoperative course, operative outcomes, and postoperative outcomes were compared. Quantitative data were analyzed with either an unpaired t test or the Mann–Whitney U test. Qualitative data were analyzed using the Fisher exact test.

Results: Fifty-three patients were identified, 18 of whom underwent VATS and 35 underwent open thoracotomy. Eight of the 18 VATS procedures (44.4%) were converted to open thoracotomy. Patients undergoing VATS had a significantly shorter median length of stay (11 vs 18 days, respectively; P = 0.044), chest tube duration (6 vs 12 days, respectively; P < 0.001), operative blood loss (55.6 vs 344 mL, respectively; P = 0.003), and fewer postoperative respiratory failures (0% vs 22.9%, respectively; P = 0.0451). The two groups did not differ significantly in overall morbidity, reoperation, mortality, or preoperative comorbidities.

Conclusions: In adults, VATS offers results comparable to those of open thoracotomy, and lengths of stay, chest tube durations, and postoperative outcomes are superior. Although the conversion rate of VATS to open thoracotomy at our institution was high (38.1%) compared with studies at other institutions, the data still indicate that VATS is both a safe and reliable alternative to open thoracotomy.

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References

1. Chen W, Lin YC, Liang SJ, et al. Hospital-acquired thoracic empyema in adults: a 5-year study. South Med J 2009;102:909-914.
 
2. Light RW, Girard WM, Jenkinson SG, et al. Parapneumonic effusions. Am J Med 1980;69:507-512.
 
3. Sahn SA. Management of complicated parapneumonic effusions. Am Rev Respir Dis 1993;148:813-817.
 
4. Ferguson AD, Prescott RJ, Selkon JB, et al. The clinical course and management of thoracic empyema. Q JM 1996;89:285-289.
 
5. Grijalva CG, Zhu Y, Nuorti JP, et al. Emergence of parapneumonic empyema in the USA. Thorax 2011;66:663-668.
 
6. Burgos J, Falcó V, Pahissa A. The increasing incidence of empyema. Curr Opin Pulm Med 2013;19:350-356.
 
7. Tong BC, Hanna J, Toloza EM, et al. Outcomes of video-assisted thoracoscopic decortication. Ann Thorac Surg 2010;89:220-225.
 
8. Molnar TF. Current surgical treatment of thoracic empyema in adults. Eur J Cardiothorac Surg 2007;32:422-430.
 
9. Angelillo Mackinlay TA, Lyons GA, Chimondeguy DJ, et al. VATS debridement versus thoracotomy in the treatment of loculated postpneumonia empyema. Ann Thorac Surg 1996;61:1626-1630.
 
10. Waller DA, Rengarajan A. Thoracoscopic decortication: a role for videoassisted surgery in chronic postpneumonic pleural empyema. Ann Thorac Surg 2001;71:1813-1816.
 
11. Luh SP, Chou MC, Wang LS, et al. Video-assisted thoracoscopic surgery in the treatment of complicated parapneumonic effusions or empyemas: outcome of 234 patients. Chest 2005;127:1427-1432.
 
12. Hippocrates, Adams F. The Genuine Works of Hippocrates: Translated from the Greek with a Preliminary Discourse and Annotations. Bethesda, MD: Classics of Medicine Library; 1985.
 
13. Molnar T, Hasse J, Jeyasingham K, et al. Changing dogmas: history of development in treatment modalities of traumatic pneumothorax, hemothorax, and posttraumatic empyema thoracis. Ann Thorac Surg 2004;77:372-378.
 
14. Yim AP. Paradigm shift in empyema management. Chest 1999;115:611-612.
 
15. Muskett A, Burton NA, Karwande SV, et al. Management of refractory empyema with early decortication. Am J Surg 1988;156:529-532.
 
16. Ashbaugh DG. Empyema thoracis. Factors influencing morbidity and mortality. Chest 1991;99:1162-1165.
 
17. Mayo P. Early thoracotomy and decortication for nontuberculous empyema in adults with and without underlying disease. A twenty-five year review. Am Surg 1985;51:230-236.
 
18. Shahin Y, Duffy J, Beggs D, et al. Surgical management of primary empyema of the pleural cavity: outcome of 81 patients. Interact Cardiovasc Thorac Surg 2010;10:565-567.
 
19. Cardillo 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.
 
20. Wurnig PN, Wittmer V, Pridun NS, et al. Video-assisted thoracic surgery for pleural empyema. Ann Thorac Surg 2006;81:309-313.
 
21. Marks DJ, Fisk MD, Koo CY, et al. Thoracic empyema: a 12-year study from a UK tertiary cardiothoracic referral centre. PLoS One 2012;7:e30074.
 
22. Solaini L, Prusciano F, Bagioni P. Video-assisted thoracic surgery in the treatment of pleural empyema. Surg Endosc 2007;21:280-284.
 
23. Gokce M, Okur E, Baysungur V, et al. Lung decortication for chronic empyaema: effects on pulmonary function and thoracic asymmetry in the late period. Eur J Cardiothorac Surg 2009;36:754-758.
 
24. Chan DT, Sihoe AD, Chan S, et al. Surgical treatment for empyema thoracis: is video-assisted thoracic surgery ‘‘better’’ than thoracotomy? Ann Thorac Surg 2007;84:225-231.