[Efficacy of video-assisted thoracoscopic surgical decortication for stage Ⅲ tuberculous empyema]

Objective: To investigate the clinical efficacy, safety and feasibility of "double-portal" video-assisted thoracoscopic surgical(VATS) decortication among patients with stage Ⅲ tuberculous empyema, and then to evaluate the recovery of chest deformity. Method: This study was a single center retrospective study. A total of 49 patients with stage Ⅲ tuberculous empyema who underwent VATS pleural decortication at the Department of Thoracic Surgery, Public Health Clinical Center of Chengdu between June 2017 and April 2021 were enrolled, including 38 males, and 11 females, aged 13-60 (27.5±10.4) years. The safety and feasibility of VATS were further evaluated. The inner circumference of the chest on sternal and xiphoid planes on chest CT scans before and 1, 3, 6, 12months after decortication were collected through the measuring software of the CT. The samples in-pair test was used to compare the changes in the chest to reflect the recovery of the chest deformity. Results: In the 49 patients, The surgical time was (186±61) min, and the volume of blood loss was (366±267) ml. There were 8 cases (16.33%) with postoperative complications during the perioperative period. Constant air leak and pneumonia were the main postoperative complications. No relapse of empyema or dissemination of tuberculosis occured during the period of follow-up. Before surgery, the inner thoracic circumference of the thorax at the level of the carina plane was (655±54) mm, and the inner thoracic circumference of the thorax at the level of the xiphoid plane was (720±69) mm. Patients were followed for 12-36 months. The inner thoracic circumference of the thoracic cavity at the level of carina was (666±51), (667±47) and (671±47) mm at the 3rd, 6th and 12th months after operation, which were significantly larger than that at the level of carina before operation (all P<0.05). The inner thoracic circumference diameter of the thoracic cavity measured at the xiphoid level at the 3rd, 6th and 12th months after the operation was (730±65), (733±63) and (735±63) mm respectively(all P<0.05).The inner thoracic circumference of the thoracic cavity increased significantly than that before surgery (P<0.05). At 6 months after operation, there was significant difference in the improvement of the inner thoracic circumference of the carina plane in patients with age less than 20 years and FEV₁% less than 80% (P=0.015, P=0.003). The improvement in the inner thoracic circumference of the carina plane in patients with pleural thickening≥8 mm compared with those with less than 8 mm was not statistically different(P=0.070). Conclusions: For some patients with stage Ⅲ tuberculous empyema, pleural decortication under thoracoscopy is safe and feasible, and can significantly restore the inner thoracic circumference of the patient's chest, improve the collapse of the patient's chest, and have significant clinical effect. The "double-portal VATS" surgical technology has the advantage of less trauma, wide operation field, large operation space and is easy to master, which is worth further exploring for clinical application.