Thoracoscopy for Empyema and Hemothorax

doi:10.1378/chest.109.1.18

Chest

Volume 109, Issue 1, January 1996, Pages 18-24

https://doi.org/10.1378/chest.109.1.18 Get rights and content

Video-assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural disease. Since 1990, we have performed VATS procedures to manage a variety of pathologic pleural processes in 306 patients. The 99 patients with complex empyemas or hemothoraces are the focus of this report. Seventy-six patients with complex empyemas (including 26 chronic) were approached with VATS after inadequate chest tube drainage. The causes associated with the thoracic empyemas were parapneumonic collections in 47, after hemothorax in 8, infected sympathetic effusions associated with intra-abdominal sepsis in 6, postresectional in 5, prolonged bronchopleural fistula following spontaneous pneumothorax in 4, chronic drainage of malignant pleural effusions in 4, and chronic drainage of pleural effusion in 2 patients undergoing chemotherapy. Ages ranged from 14 to 78 years. Sixty-three patients (83%) were treated with thoracoscopic drainage±decortication alone. Thirteen patients (17%) required subsequent thoracotomy for decortication, including 12 of the 26 (46%) chronic empyemas known to be greater than 3 weeks old. Chest tubes were removed 3.3±2.9 days postoperatively in 67 patients; 9 patients (12%) were sent home with empyema tubes. Postoperative hospital stay for these patients with empyema averaged 7.4±7.2 days. There were five deaths, all related to progressive sepsis from associated pneumonia (6.6%). Twenty-three patients underwent thoracoscopic evacuation of hemothoraces that resulted following open heart surgery in 6, thoracic trauma in 7, were iatrogenic in 7, and bleeding into malignant effusions in 3. All were successfully treated by thoracoscopic drainage and pleural debridement alone. Chest tubes were removed 2.8±0.5 days postoperatively and hospital stay averaged 4.3±1.9 days. There were no complications; one patient with a hemothrax (after heart transplant) died of unrelated causes. In our experience, VATS has been highly successful in the early management of empyemas and hemothoraces. Conversion to open thoracotomy must always be anticipated, especially when approaching chronic empyemas.

Section snippets

Patient Profile

From December 1990 to November 1994, we have used video-assisted thoracic surgical approaches to manage pleural pathologic processes in 306 patients (Table 1). Sixty-seven percent of these patients (n=207) underwent VATS for the diagnosis of idiopathic pleural processes or for the management of known malignant pleural effusions that had failed to respond to tube thoracostomy drainage alone. The remaining 99 patients underwent VATS to approach complex empyemas and hemothoraces recalcitrant to

RESULTS

Of the 76 patients with complex empyemas in this series, 63 (83%) were treated solely with thoracoscopic drainage, adhesolysis, and decortication of fibrinous visceral pleural peel. Thirteen patients (17%) required conversion to open procedures after the VATS procedure. This included 12 of the 26 (46%) patients with chronic empyemas known to be present for greater than 3 weeks. Immediate conversion to thoracotomy for decortication was performed in seven patients with obvious trapped lung and

DISCUSSION

With the advent of effective antibiotic therapies, empyema has become a much less common clinical problem; however, this complication remains an important cause of morbidity and mortality following pneumonia or lung resection.6, 27 Delays in appropriate referral for surgical drainage of the empyema continue to cause significant prolongation in recovery from these infectious problems and frequently result in the need for more aggressive surgical interventions to correct the pleural process.1, 2,