Video-Assisted Thoracoscopic Surgery for the Stage II Pleural Empyema: A Prospective Observational Study

Background and objectives Empyema thoracis is a condition in which purulent fluid collects in the pleural cavity. Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that involves insertion of a thoracoscope through small incisions, or ports, in the chest wall. Despite modern diagnostic methods, pleural empyema remains a serious problem. The common causes are complications of pneumonia (fungal and mycobacterial), abdominal infections, or those following trauma and surgical procedures. The aim and objectives of this study are to evaluate the role and efficacy of VATS in stage II empyema in terms of duration of hospital stay, post-operative intercostal drain (ICD) removal, clinical and radiological recovery, and to evaluate the complications associated with the procedure. Methods This prospective observational study was carried out on a sample size of 31 patients fulfilling the inclusion and exclusion criteria, admitted to the General Surgery Department at Sahyadri Super Speciality Hospital, Pune, India, over a period of two years (January 2017 to December 2018). The patients were diagnosed with Stage II empyema as per a high-resolution computed tomography (HRCT) scan of the thorax. All patients underwent thoracoscopic decortication after the required pre-operative investigations. Pleural tissue and fluid were sent for biochemical, microbiological, and histopathological examination (HPE). All data were critically analysed to support the results and conclusions. Results The mean age of the cases was 52.5 years, with a male-to-female ratio of 1.58:1. Shortness of breath was the most common symptom (24 cases, 77.4%), followed by cough (20 cases, 64.5%). In the study group, diabetes was the most common comorbidity (11 cases, 35.5%), followed by hypertension (8 cases, 25.8%). Pre-operatively, the most common radiological finding was loculated pleural effusion (28 cases, 90.3%), followed by pleural thickening (20 cases, 64.5%) and split pleura sign (14 cases, 45.2%). Acute-on-chronic inflammation was the most common histopathological report of pleural tissue biopsy (16 cases, 51.6%). The majority of patients had an uneventful recovery (29 cases, 93.5%); however, there was a complication of pulmonary embolism (1 case, 3.2%) and elective intra-operative conversion to thoracotomy in 3.2% of cases. Stable patients were discharged with a posterior chest drain (16 cases, 51.6%), resulting in a reduced duration of hospital stay. The majority of patients were discharged within a week of surgery (19 cases, 61.3%) after confirming adequate lung expansion on chest radiograph. Conclusions Empyema thoracis should be suspected in patients with long-standing pneumonia or pneumonia unresponsive to antibiotic therapy. Ultrasound and HRCT scan are useful in diagnosis, whereas chest radiography is useful for monitoring postoperative lung re-expansion. Pre-emptive referral of patients for VATS will avoid multiple attempts at pigtail or chest drain insertion and prevent progression of the disease, thus reducing the hospital stay, morbidity, and mortality associated with the disease.