[Is a minimally-invasive treatment concept in the late stage of pleural empyema successful?]

Thoracoscopic treatment of pleural empyema is still a controversial method, especially in the chronic stage of the disease. The issue is raised whether the thoracoscopic approach to the empyema-possibly combined with a small additional thoracotomy in advanced stages-is successful and of low risk.

Between January 1993 and May 1995 we treated 13 patients in advanced stages of pleural empyema. The patients were all seriously ill and had severe underlying disease. The procedures were performed under general anesthesia involving intubation with a double-lumen endotracheal tube. The steps of our standard operative procedure are outlined.

In 5 patients with a pleural empyema in stage III thoracoscopy was facilitated by a small additional thoracotomy. A complete resolution of the disease was obtained in 12 cases and a secondary intervention was necessary in 1 patient. There was no peri- or postoperative mortality, and apart from a prolonged drainage of the pleural cavity in 3 patients no morbidity was registered. In the long-term follow up, 3 patients had died. There was no correlation between the deaths and the intervention or the empyema disease.

We discuss the advantages of a limited additional thoracotomy in case of intraoperative difficulties encountered with late stages of empyema. This treatment can still be considered minimally invasive. All patients tolerated the procedure well, and the overall results were favourable in 92% of our collective. However, thoracoscopic treatment should preferably take place at an earlier stage.

We recommend the thoracoscopic approach-possibly combined with a limited thoracotomy-as primary treatment in late stages of pleural empyema.