Minimally invasive surgery in the treatment of empyema: intraoperative decision making

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.

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 chi(2) test.

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.

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.