Thoracoscopy for empyema, bronchopleural fistula, and chylothorax

The management of complications affecting the pleural space is sometimes technically demanding, but has been enhanced by the recent introduction of thoracoscopic techniques. An empyema in the fibrinopurulent phase is best managed by disruption of the loculations and complete drainage of the infected space. This is easily accomplished with the use of thoracoscopy, which also permits inspection of the pleural space to determine whether additional surgical intervention is required. In contrast, thoracoscopy is not indicated in the management of a free-flowing empyema or a chronic empyema associated with a fibrous capsule. Bronchopleural fistulas are occasionally treated by thoracostomy tube drainage alone, but, in most situations, surgical intervention is necessary to permit reclosure of the bronchus, coverage of the stump with vascularized tissue, and decortication or tissue flap rotation to fill the pleural space. These maneuvers are beyond the capabilities of current thoracoscopic techniques. Chylothorax is best treated initially by intercostal tube drainage and supportive measures. When surgical intervention is necessary to directly close a lymph vessel leak, thoracoscopic techniques have been successful in effecting closure, according to anecdotal reports.