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Updated: Apr 11, 2026
Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion
Published on: November 10, 2023
Mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema
Zsolt Sziklavari1, Michael Ried2, Reiner Neu2
1Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany zsolt.sziklavari@barmherzige-regensburg.de.
Objectives:
This prospective study is an evaluation of the mini-open vacuum-assisted closure with instillation (Mini-VAC-Instill) therapy for the treatment of complicated pleural empyema.
Methods:
We investigated septic patients in poor general physical condition (Karnofsky index ≤50%) with multimorbidity and/or immunosuppression who were treated by minimally invasive intrathoracic VAC-Instill therapy without the insertion of an open-window thoracostomy (OWT) between December 2012 and November 2014. All patients underwent mini-thoracotomy with position of a tissue retractor, surgical debridement and local decortication. Surgery was followed by intrathoracic vacuum therapy including periodic instillation using antiseptics. The VAC dressings were changed under general anaesthesia and the chest wall was closed during the same hospital stay. All patients received systemic antibiotic therapy.
Results:
Fifteen patients (13 males, median age: 71 years) underwent intrathoracic Mini-VAC-Instill dressings for the management of pleural empyema without bronchopleural fistula. The median length of vacuum therapy was 9 days (5-25 days) and the median number of VAC changes per patient was 1 (1-5). In-hospital mortality was 6.7% (n = 1) and was not related to Mini-VAC-Instill therapy or intrathoracic infection. Control of intrathoracic infection and closure of the chest cavity was achieved in 85.7% of surviving patients (12 of 14). After the follow-up at an average of 13.2 months (range, 3-25 months), we observed recurrence once, 21 days after discharge. Two patients died in the late postoperative period (Day 43 and Day 100 after discharge) of fulminant urosepsis and carcinoma-related multiorgan failure, respectively. Analysis of the follow-up interviews in the outpatient clinic showed a good quality of life and a subjectively good long-term aesthetic result.
Conclusions:
Mini-VAC-Instill therapy is an upgrade of Mini-VAC, which guarantees the advantage of an open treatment, including flushing but without OWT. This procedure is minimally invasive, highly compatible especially with patients in poor general condition and may be an alternative to the OWT in selected patients. Consequently, a very short course of therapy results in good patient acceptance.
Insights
Mini-VAC-Instill therapy effectively treats complicated pleural empyema in frail patients, offering advantages of open treatment without open-window thoracostomy. This minimally invasive approach leads to good outcomes and patient acceptance.
Area of Science:
- Thoracic Surgery
- Infectious Diseases
- Critical Care Medicine
Background:
- Complicated pleural empyema presents a significant challenge, particularly in patients with poor general health.
- Traditional treatments like open-window thoracostomy (OWT) can be highly invasive and poorly tolerated by debilitated individuals.
Purpose of the Study:
- To evaluate the efficacy and safety of mini-open vacuum-assisted closure with instillation (Mini-VAC-Instill) therapy.
- To assess Mini-VAC-Instill as a minimally invasive alternative to OWT for complicated pleural empyema in high-risk patients.
Main Methods:
- A prospective study involving 15 septic patients with poor general condition (Karnofsky index ≤50%) and multimorbidity/immunosuppression.
- Patients underwent mini-thoracotomy with debridement and local decortication, followed by intrathoracic vacuum therapy with antiseptic instillation.
- VAC dressings were changed under general anesthesia, with chest wall closure during the same hospital stay; systemic antibiotics were administered.
Main Results:
- Successful infection control and chest cavity closure were achieved in 85.7% of surviving patients (12/14).
- The median duration of vacuum therapy was 9 days, with a median of 1 VAC change per patient.
- In-hospital mortality was 6.7% (1 patient), unrelated to the therapy; late mortality occurred in 2 patients due to unrelated causes. Good quality of life and aesthetic results were reported post-discharge.
Conclusions:
- Mini-VAC-Instill therapy is an effective upgrade to standard Mini-VAC, providing open treatment benefits without OWT.
- The procedure is minimally invasive, well-tolerated by patients in poor general condition, and serves as a viable alternative to OWT in selected cases.
- This therapy offers good patient acceptance with a short treatment course.
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