The role of videothoracoscopy in chronic pleural empyema

Abstract

I would like to congratulate Dr Cardillo and Dr Rena [1,2] for the valuable debate on the indications for video-assisted thoracoscopic surgery (VATS) in pleural space infection. In accordance with the authors, preoperative pulmonary function and blood gas analysis do not permit a clear evaluation of patient capacity to sustain monolateral ventilation because of the general septic condition. Thus, the possibility of carrying out a thoracoscopy is often decided in progress. We think that VATS is the main treatment in class 5 (complex complicated stage) of empyema, according to Light [3], by the debridement of the multiloculated pleural cavity. The process at class 6—7 (a simple and a complex empyema stage) required an open surgery approach as the mini-invasive procedure does not permit reaching the pleural symphysis and the cavity obliteration. Stressing VATS in the same conditions determines wide pulmonary lesions, prolonged operative time, and a high incidence of openthoracotomy wedge resections. Conversion rates of 16.4% by Cardillo et al. [1] and of 11.4% by Tong et al. [4] are not referable to an advanced state of empyema. In such cases, the use of a device may decrease the need for open thoracotomy. In selected patients with no complete fibrosis in the pleural cavity, we used carbon dioxide (CO2) insufflation during thoracoscopy [5]. This is a technique derived from laparoscopic pneumoperitoneum to facilitate the detection of a cleavage plan, which ensures pleurectomy and decortication. The eventual conversion of lateral thoracotomy was characterized by better pleural and parenchymal exposition and the easy dissection. The contraindications for such an approach are the hemodynamic instability of the patient and the wide parenchymal laceration, which increases the risk of a gas embolism. We opine that the ideal indication of videothoracoscopy is in class 1—5 for empyema. In class 6—7, VAT CO2 insufflation is effective in reducing the entity of thoracotomy conversion, postoperative air leaks, and time of hospitalization.