Asian Cardiovasc Thorac Ann 2007;15:238-239
© 2007 Asia Publishing EXchange Ltd
Definitive Management of Advanced Empyema by Two-Window Video-Assisted Surgery
Andrew J Drain, MRCS,
Jonathon I Ferguson, FRCS,
Rana Sayeed, FRCS,
Sharon Wilkinson, BSc1,
Andy Ritchie, FRCS
Department of Surgery
1 Clinical Audit and Effectiveness Unit, Papworth Hospital, Cambridge, United Kingdom
For reprint information contact: Andrew J Drain, MRCS Tel: 44 1480 830 541 Fax: 44 1480 364 335 Email: andrewdrain{at}doctors.org.uk, Department of Surgery, Papworth Hospital, Papworth Everard, Cambridge, CB3 8RE, United Kingdom.
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ABSTRACT
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We describe how 2-window video-assisted thoracoscopic decortication and lung mobilization can provide definitive management of stage III empyema. This technique was used in 52 patients with stage III empyema. None required additional ports or a thoracotomy. Three patients (6%) needed computed tomography-guided drainage of persistent large loculi, but none required further surgery. Chest radiographs at 6 weeks after surgery confirmed full lung expansion and resolution of pleural collection in the other 49 patients (94%).
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INTRODUCTION
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Pleural empyema complicated by pleural thickening and loculation is associated with significant morbidity and mortality. Video-assisted thoracoscopic surgery (VATS) has been successfully employed in stage II empyema; however, VATS in stage III empyema is associated with a high rate of conversion to thoracotomy.1,2 We investigated whether a 2-window VATS technique could effectively control pleural sepsis in advanced empyema.
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PATIENTS AND METHODS
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Fifty-two consecutive patients with stage III empyema (according to standard staging) were referred to our regional center between 1998 and 2004 after failure of alternative therapy, including tube thoracostomy and intrapleural streptokinase. Forty-nine (94%) had stage III empyema based on preoperative computed tomography and intraoperative assessment.
With the patient in the lateral position, the optimal siting of the first window was based on chest radiography and computed tomography findings, the size of the intercostal space, and lung mobility at the point of entry. A 5-mm zero-degree video thoracoscope was introduced through the window to assess pleural pathology and to identify the best site for a 2nd window. Efforts were taken to ensure the 2nd incision lay in the same intercostal space to reduce postoperative pain. Instruments used included standard Roberts forceps, peanut swabs, a range of lung retractors, tissue holding forceps, and scissors of a suitable size to fit through the port. Specialized VATS equipment was not generally used.
The instruments were introduced through the 2nd incision (never more than 2 cm long) without the use of a port to allow for 2 instruments in the same incision, and to aid a greater range of movement. With a combination of blunt and sharp dissection similar to an open technique, the plane was developed and tissues manipulated to allow adequate decortication of visceral and parietal cortices, and lung mobilization. By alternating the camera and instruments between the two windows, good access could be achieved. As the main aim of surgery was to achieve lung expansion, small areas where the fibrous cortex was densely adherent were left intact to minimize parenchymal damage, without significant impact on lung expansion. Decortication was considered complete when the lung expanded sufficiently, as seen with the thoracoscope. This usually took 1–1.5 hr from the time of the first incision. Two chest tubes were left in situ. All drains were put on 7 kPa continuous suction at the end of the procedure, and removed when any air leak had stopped and daily drainage totaled less than 100 mL. Patients were discharged home when fully ambulant. Follow-up was by postal questionnaire of the patient’s family doctor and referring specialist, and by outpatient review. Follow-up was complete in all patients.
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RESULTS
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All patients underwent VATS decortication and lung mobilization with the two-window technique; none required conversion to thoracotomy. Five patients (14%) had active pleural infection confirmed by culture of intraoperative pleural fluid samples. The mean duration of postoperative thoracostomy drainage was 3.9 days (range, 2–10 days; median, 4 days), and the median time to hospital discharge was 10 days. There were no deaths within 30 days postoperatively. Three patients (6%) required computed tomography-guided drainage of persistent large loculi, but none required further surgery. Chest radiography at 6 weeks after surgery confirmed full lung expansion and resolution of pleural collection in the other 49 patients (94%).
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DISCUSSION
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Empyema is a common thoracic surgical problem but there is little consensus on management, with differing opinions between surgeons and physicians.2 Current surgical techniques include VATS decortication, rib resection, and thoracotomy. Video-asisted thoracoscopic surgery decortication has traditionally been considered to provide the lowest cure rate for all stages of empyema. Although overall mortality from empyema is high, VATS for the early stages of empyema was recently found to be successful in 75% of selected patients.2,3 We found 2-window VATS to be a safe and effective approach in stage III empyema, even after prolonged and ineffective medical management.1
Traditionally, VATS is performed using 3 or more ports. A 2-port technique for pulmonary resection has been described; however, there are no previous reports of 2- or single-port VATS for decortication of stage II and III empyema.4 Although there may be no intraoperative benefit (time, blood loss), the expected benefits of 2-window VATS decortication in this setting include a shorter duration of chest drainage, less pain, better cosmesis, earlier mobilization, and a potentially shorter hospital stay. Our institution acts in a tertiary referral capacity, and is a stand-alone cardiothoracic center. Some of the difference between mean thoracostomy drainage time and late discharge was due to a necessary delay in discharging patients with no suitable follow-up facility. With the appropriate infrastructure in place, we feel this difference could be reduced.
Two-window VATS decortication and lung mobilization may add a further refinement to a growing area of thoracic surgery. Our experience highlights the need for a standardized measurement of patient benefit of the standard versus the described 2-window treatment of stage III empyema. Furthermore, despite a recent trial looking at the use of streptokinase in the management of early stage empyema, there are currently no published randomized trials on the surgical management of empyema.3 Video-asisted thoracoscopic surgery should be compared to the best medical management for the early stages of empyema and to other surgical approaches for stage III empyema in a prospective randomized controlled trial.
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REFERENCES
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- Waller DA, Rengarajan A. Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic empyema. Ann Thorac Surg 2001;71:1813–6.[Abstract/Free Full Text]
- Anyanwu AC. Surgical treatment of thoracic empyema: In: Treasure T, Keogh B, Hunt I, Pagano D, editors. The evidence for cardiothoracic surgery. 1st ed. Shrewsbury, UK: Tfm Publishing Ltd., 2004:131–9.
- Maskell NA, Davies CW, Nunn AJ, Hedley EL, Gleeson FV, Miller R, et al. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005;352:865–74.[Abstract/Free Full Text]
- Kaga K, Park J, Nishiumi N, Iwasaki M, Inoue H. Usefulness of video-assisted thoracic surgery (Two Windows Method) in the treatment of lung cancer for elderly patients. J Cardiovasc Surg (Torino) 1999;40:721–3.[Medline]
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ABSTRACT
INTRODUCTION
