Video-assisted thoracic surgery in the treatment of pleural empyema

The use of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has been proposed since the early 1990s, but among surgeons, its use varies considerably, and the results are discordant. This report aims to provide a retrospective assessment of the authors' experience and the literature on VATS in an effort to ascertain rational criteria for the use of this technique.

Over a period of 12 years, a total of 120 cases of pleural empyema were recorded. The patients were assessed with chest x-ray, computed tomography, ultrasound, and thoracentesis. On the basis of clearly defined clinical and radiographic parameters, 38 patients underwent VATS immediately, whereas the remaining 82 were treated initially by means of tube thoracostomy. The latter was found to be sufficient for only 10 patients. Consequently, for the remaining 72 patients, it was decided to proceed also with VATS.

The procedure was performed completely by VATS in 101 patients (91.8%), whereas in 9 patients (8.2%) it was necessary to convert to thoracotomy. The postoperative course was uneventful for 98 of the 110 patients (89%), whereas the remaining 12 patients experienced complications, including one case of persistent empyema (0.9%) treated by thoracotomy. The mean chest tube duration was 6 days (range, 3-25 days). The mean postoperative hospital stay was 7.1 days (range, 5-17 days). Of the 80 patients completing a 6-month follow-up evaluation, the results were considered good for 72, moderately good for 8, and less than satisfactory for 2 patients.

In conclusion, the authors consider VATS to be the technique of first choice for the treatment of pleural empyema when the disease is advanced or tube thoracostomy fails. It provides excellent results with a low level of invasiveness and considerably reduces the need for thoracotomy. These results can be achieved with good videothoracoscopic experience and the use of a very precise technique.