Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication

We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with chronic postpneumonic pleural empyema.

From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3 years, range: 17-82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment.

Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain (p<0.0001), postoperative air leak (p=0.004), operative time (p<0.0001), hospital stay (p=0.020) and time to return to work (p<0.0001). The analysis of postoperative pain at 6 months follow-up showed no significant differences among the different groups.

In the light of our experience, videothoracoscopic decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.