Video-assisted Thoracoscopic Decortication Research Articles

Evaluation of uniportal video-assisted thoracoscopic decortication in treatment of drug-resistant tuberculous empyema

Objective: To examine the safety and efficacy of the uniportal video-assisted thoracoscopic decortication in treatment of drug-resistant tuberculosis empyema. Methods: From January 2018 to December 2020, 122 cases of tuberculous empyema treated by decortication in Department of Surgery, Wuhan Pulmonary Hospital were retrospectively analyzed, including 100 males and 22 females, aged(M(IQR)) 29.5(28.0) years (range: 13 to 70 years). According to the surgical approach and drug resistance, patients with drug-resistant tuberculosis who underwent uniportal video-assisted thoracoscopic decortication were included in group A (n=22), and those who underwent thoracotomy decortication were included in group B (n=28). Drug-sensitive patients who underwent uniportal video-assisted thoracoscopic decortication were included in group C (n=72). There was no statistical difference in the baseline data of the three groups (P>0.05). The operation, early postoperative recovery, and prognosis-related indicators were compared among three groups by Kruskal-Wallis test and χ2 test by Mann-Whitney U test and Bonferroni method between groups A and B, groups A and C. Results: The intraoperative blood loss of group A, group B, and group C was 200(475) ml, 300(200) ml, and 225(300) ml, respectively. There was no significant difference in intraoperative hemorrhage (H=2.74, P=0.254) and treatment outcome (χ2=4.76, P=0.575) among the three groups. Compared with group B, the operation time of group A (302.5(187.5) minutes vs. 200.0(60.0) minutes, U=171.0, P=0.007) and postoperative pulmonary reexpansion duration (4.5(3.0) months vs. 3.0 (2.2) months, U=146.5, P=0.032) were longer, and the postoperative drainage duration (9.5(7.8) days vs. 13.0(10.0) days, U=410.0, P=0.044), and the postoperative hospitalization time (12.0(7.8) days vs. 14.5(4.8) days, U=462.2, P=0.020) were shorter. There was no significant difference in complications between group A and group B (63.6%(14/22) vs. 71.4%(20/28), χ2=0.34, P=0.558). Compared with group C, the postoperative drainage duration of group A (9.5(7.8) days vs. 7.0(4.0) days, U=543.5, P=0.031), the postoperative hospitalization time (12.0(7.8) days vs. 9.0(4.0) days, U=533.0, P=0.031) and postoperative pulmonary reexpansion duration (4.5(3.0) months vs. 3.0(2.0) months, U=961.5, P=0.001) were longer. The operation time (302.5(187.5) minutes vs. 242.5(188.8) minutes, U=670.5, P=0.278), and complications (63.6%(14/22) vs. 40.3%(29/72), χ2=3.70, P=0.054) were not different between group A and group C. Conclusions: For drug-resistant tuberculous empyema, the uniportal video-assisted thoracoscopic decortication can achieve the same good therapeutic effect as drug-sensitive tuberculous empyema, and it is as safe as thoracotomy. At the same time, it has the advantage of minimally invasive and can accelerate the early postoperative recovery of patients.

Case report on peri-operative surgical and anaesthetic management of ruptured humongous lung abscess.

IntroductionEarly thoracic empyema is usually treated through video-assisted thoracoscopic (VATS) decortication. Patient selection is important for decortication if an effective surgical outcome is required. Lung isolation techniques are required to provide anesthesia for these patients to facilitate the surgeon while operating on the affected lung. The ultimate target is to protect the non-diseased contra-lateral lung from contamination.Presentation of caseWe are presenting a unique case of 20-year-old female, resident of Karachi, who was brought to the emergency room (ER) with signs of sepsis, hypotension, and multi-organ failure. She was brought to the operating room to undergo video-assisted thoracoscopy (VATS) for lung abscess decortication when her medical therapy had failed. On table decision of right upper lobe resection was made and ventilation strategy had to be modified accordingly.DiscussionThe main anaesthetic aim was to protect the healthy parts of the lung from the abscess. Regular suctioning of secretions during surgery via the double lumen tube (DLT) lumen on the diseased side is recommended. While performing VATS, the lung abscess got ruptured and immediate measures to isolate the lung was taken to assist with surgical resection of the affected lobe. Lobectomy can only be done once the lung was completely isolated and maintaining perfusion and ventilation of the relatively healthy lung help in managing hypoxia.ConclusionPeri-operative management of ruptured lung abscesses required thorough pre-op evaluation, intraoperative lung isolation and ventilation, and postoperative analgesia with combined team effort both surgical and anaesthetic, are vital fundamentals to consider in guaranteeing the best outcome.

Uniportal video-assisted thoracoscopic decortication in the treatment of stage III tuberculous empyema: a case report

Background: Stage III tuberculous empyema is a chronic tuberculosis infection in the pleural cavity and usually requires surgical treatment. Pleurectomy is preferred. Due to dense pleural adhesion, pleural exfoliation is necessary and has in the past been performed through thoracotomy. In recent years, video-assisted thoracic surgery (VATS) has undergone rapid development and is applied to the stripping of stage III tuberculous empyema. Some surgeons believe that this method is feasible, safe, and effective, with good short-term and long-term results. However, uniportal (U)-VATS is rarely performed and reported.

Management of chronic empyema thoracis in children, a single center retrospective observational study

Abstract: Background: Chronic empyema thoracis (CET) is common in developing and developed countries despite advancement in diagnostic and therapeutic technologies. Some of the cases of CET can be managed with antibiotics and tube drainage alone, some of them managed with less extensive surgical procedure like video-assisted thoracoscopic surgery (VATS) or open decortication alone, while some of the complicated cases need extensive decortication and debridement of necrotic lung tissue or lobectomy. Our aim is to present our experience of management of cases of chronic empyema thoracis in children. Methods and Material: This is a retrospective observational study of cases, managed at tertiary care center with chronic empyema thoracis. Records of cases of CET admitted, referred or transferred to department of pediatric surgery at our center over last three years were studied. Demographic data, clinical, radiological profile, surgical/ non-surgical intervention, hospital stay, aetiology, outcome was analysed. Follow up was up to the last recorded outpatient visit. This study is a retrospective observational study with small number of cases statistical tool are not used to draw any statistical interference. Results: Twenty-nine cases with median age 3 years, male to female ratio was 25:4 were admitted over three years. Pre-operative bronchopleural fistula was seen in four. Five cases were managed conservatively, twenty underwent decortication alone while four cases required decortication along with lobectomy. Tuberculosis was detected in three cases. A pyogenic organism was identified in ten cases only. Post-operative ventilation was required in three patients. There was no mortality. All thrived well at 12-18 months follow up. Conclusions: Management of chronic empyema should be case based. Cases of CET in children can managed with conservative (with appropriate drainage of cavity, proper antibiotics, and nutritional build-up of child), thoracotomy and decortications alone or some time removal of disease lung also required depending on clinical and radiological finding of cases.

A nomogram to predict residual cavity formation after thoracoscopic decortication in chronic tuberculous empyema

OBJECTIVESThe goal of this study was to develop and validate a nomogram for predicting residual cavity formation after video-assisted thoracoscopic decortication in patients with chronic tuberculous empyema (CTE).METHODSWe retrospectively analysed patients who were diagnosed and treated for CTE at our hospital from January 2017 to December 2020. We used univariable and binary logistic regression analyses to identify independent risk factors. A predictive nomogram was developed and validated for predicting the risk of residual cavity formation after video-assisted thoracoscopic decortication in patients with CTE. The receiver operating characteristic (ROC) was used to evaluate the nomogram.RESULTSData from 103 patients were analysed. The contact area between the lung and empyema (P = 0.001, odds ratio [OR] 1.017, 95% confidence interval [CI] 1.007–1.028), calcification (P = 0.004, OR 0.12, 95% CI 0.029–0.501) and thickness of the pleura (P = 0.02, OR 1.315, 95% CI 1.045–1.654) were risk factors for residual cavity formation after video-assisted thoracoscopic decortication. A 50% residual cavity formation rate was used as the cut-off to validate the nomogram model. The area under the ROC curve for the nomogram was 0.891 (95% CI, 0.82–0.963). The sensitivity and specificity of the nomogram were 86.67% and 82.19%, respectively. The calibration curve indicated good consistency between the predicted and actual risks.CONCLUSIONSThe preliminary nomogram could contribute to preventing postoperative residual cavity formation and making appropriate surgical decisions.

Uniportal thoracoscopic decortication for stage Ⅲ tuberculous empyema of 158 cases

Objective: To examine the safety and feasibility of uniportal video-assisted thoracoscopic (VATS) decortication in patients presenting with stage Ⅲ tuberculous empyema. Methods: From August 2017 to July 2020, 158 patients of stage Ⅲ tuberculous empyema underwent uniportal VATS decortication with partial rib resection and customized periosteal stripper in Department of Thoracic Surgery, Shanghai Pulmonary Hospital. There were 127 males and 31 females, aged (M(IQR)) 32(28) years (range:14 to 78 years). Follow-up was performed in the outpatient clinic or via social communication applications, at monthly thereafter. If there was no air leak and chest tube drainage was less than 50 ml/day, a chest CT was performed. If the lung was fully re-expanded, chest tubes were removed. All patients received a follow-up chest CT 3 to 6 months following their initial operations which was compared to their preoperative imaging. Results: There was one conversion to open thoracotomy. The operative time was 2.75 (2.50) hours (range: 1.5 to 7.0 hours), and median blood loss was 100 (500) ml (range: 50 to 2 000 ml). There were no perioperative mortalities. There were no major complications except 1 case of redo-VATS for hemostasis due to excessive drainage and 1 case of incision infection, The incidence of prolonged air leaks (>5 days) was 80.3%(126/157). The postoperative hospital stay was 5.00 (2.25) days (range: 2 to 15 days). All patients were discharged with 2 chest tubes, and the median duration drainage was 21.00 (22.50) days (range: 3 to 77 days). Follow-up was completed in all patients over a duration of 20 (14) months (range: 12 to 44 months). At follow-up, 149 patients(94.9%) recovered to grade Ⅰ level, 7 patients to grade Ⅱ level, and 1 patient to grade Ⅲ level. Conclusion: Uniportal VATS decortication involving partial rib resection and a customized periosteal stripper is safe and effective for patients with stage Ⅲ tuberculous empyema.

OUTCOMES OF VIDEO ASSISTED THORACOSCOPIC DECORTICATION VERSUS CONVENTIONAL OPEN DECORTICATION IN PATIENTS WITH STAGE II OR STAGE III EMPYEMA

Objective: To compare outcomes of video assisted Thoracoscopic Decortication (VATD) with conventional open decortication (COD) in patients with stage–II or stage–III empyema thoracic.
 Study Design: Prospective comparative study.
 Place and Duration of Study: Department of Thoracic Surgery, Combined Military Hospital, Rawalpindi, Pakistan, from Jun 2018 to May 2019.
 Methodology: A total 60 patients underwent in this study. Patients of both gender who reported for decortication of empyema thoracic were evaluated. All patients diagnosed to have Stage II or III empyema with age 25-50 years were studied for outcomes. All patients were evaluated for operative time, blood loss, post-operative pain, pneumonitis, duration of airleak and post-operative drainage, duration of chest drains and length of hospital stay.
 Results: Mean operative time in group-1 was 133.63 ± 8.55 min and in group-2 was 147.83 ± 10.36 min (p-value 0.037). Mean blood loss in group-1 was 296.66 ± 46.11 while in group-2 was 207.30 ± 53.81. Post-operative pain score on VAS for pain was 5.8 ± 1.7 for group-1 and 4.06 ± 1.4 for group-2 (p-value 0.032). Chest tubes were retained for an average of 5.58 ± 0.8 days in group-1 while 3.86 ± 0.8 days in group-2 (p-value <0.001).
 Conclusion: Video-Assisted Thoracoscopic Surgery Decortication is superior to open decortication in operative management of Stage II and Stage III Empyema thoracic in terms of post op pain, duration of chest intubation, air leak and hospital stay of the patient.

Uniportal VATS Lobectomy and Decortication: Not an Everyday Occurrence.

Management of trapped lung with an underlying lung lesion and hydropneumothorax remains controversial. Furthermore, Aspergillus empyema and aspergilloma are rare pathologies for which uniportal video-assisted thoracoscopic (VATS) surgical management remains controversial. We present a young patient referred to our service after recent hospitalization for pneumonia. The patient was found to have a chronic effusion with a right lower lobe cystic parenchymal lesion and was taken to the operating room. The patient underwent right uniportal VATS surgery with evacuation of empyema, total pulmonary decortication, and right lower lobectomy. His postoperative course was unremarkable, and he was discharged home. Postoperative workup demonstrated lymphocyte variant hypereosinophilia. He continues to follow with thoracic surgery at the time of this report and remains asymptomatic. We conclude that uniportal VATS is a most minimally invasive, safe, and efficient approach for management of complex intrathoracic pathology including total pulmonary decortication and lobectomy.

Uniportal Thoracoscopic Decortication for Stage III Tuberculous Empyema With Severe Rib Crowding

This study explored the safety and feasibility of uniportal video-assisted thoracoscopic (VATS) decortication in patients presenting with stage III tuberculous empyema with severe rib crowding. From August 2017 to January /2019, 33 patients with stage III tuberculous empyema and severe rib crowding underwent uniportal VATS decortication with partial rib resection and the use of a customized periosteal stripper. Preoperative and postoperative chest computed tomography (CT) imaging and pulmonary function testing were analyzed to evaluate the clinical significance of certain imaging findings and surgical efficacy. There was 1 conversion to open thoracotomy. Median operative time was 3.5 hours (range, 2.1-4.5 hours) and the median blood loss was 500 mL (range, 250-1000 mL). There were no perioperative mortalities. The incidence of prolonged air leaks (>5 days) was 81.8%. Median postoperative hospital stay was 4 days (range, 4-5 days). All patients were discharged with 2 chest tubes, and median duration drainage was 39 days (range, 30-60 days). The presence of a low-density line between the parietal fibrous pleural rind and chest wall was demonstrated on chest CT in 13 patients. Intraoperative blood loss was considerably lower in these patients compared with those without this imaging finding. Follow-up was complete in all patients over a median of 8 months (range, 6-11.5 months). All patients recovered well and achieved notable improvement in pulmonary function. Uniportal VATS decortication is safe and effective. Patients presenting with a low-density line around the thickened fibrous pleural rind on preoperative chest CT scan may be good candidates.

Declining frequency of thoracoscopic decortication for empyema — redefining failure after fibrinolysis

BackgroundPrimary fibrinolysis for pediatric empyema has become standard of care at our institution. Early study of our protocol revealed a 16% thoracoscopic decortication rate after primary fibrinolysis. We now report the frequency with which children progress to operation with maturation of the protocol. MethodsA database of patients diagnosed with empyema between September 2014 and March 2019 was examined. Patients who underwent tissue plasminogen activator (tPA) therapy with or without subsequent video-assisted thoracoscopic (VATS) decortication were included. Patients with additional indications for tube thoracostomy or VATS were excluded. ResultsForty-eight patients were included. Median age was 4.5 years [IQR 2–9.3]. Median length of stay (LOS) was 8 days [IQR 6–11]. No patients underwent primary VATS. Median days with a chest tube was 5 [IQR 5–6] and median number of doses of tPA was 3 [IQR 3–3]. Seven patients (14.6%) had a chest tube replaced without undergoing VATS. The VATS rate was 4.2% in the first half of this study but 0% in the last 33 months. ConclusionThoracoscopic decortication is rarely necessary in children with empyema. Raising the threshold for surgical intervention and utilizing further nonoperative measures can avoid an operation in most children without increasing in-hospital length of stay. Level of evidenceIV

COMPLICATED PNEUMONIA WITH EMPYEMA CAUSED BY STREPTOCOCCUS ANGINOSUS IN A CHILD

ABSTRACTObjective: To highlight the pathogenicity of Streptococcus anginosus, which is rare in pediatric patients, but can cause severe infections that are known to have a better outcome when treated early with interventional procedures and prolonged antibiotic therapy.Case description: The patient is a 6-year-old boy with global developmental delay, examined in the emergency room due to fever and respiratory distress. The physical examination and diagnostic workout revealed complicated pneumonia with empyema of the left hemithorax; he started antibiotic therapy and underwent thoracic drainage. Pleural fluid cultures grew Streptococcus anginosus. On day 11, the child had a clinical deterioration with recurrence of fever, hypoxia, and respiratory distress. At this point, considering the causative agent, he was submitted to video-assisted thoracoscopic decortication, with good progress thereafter.Comments: Streptococcus anginosus is a commensal bacterium of the human oral cavity capable of causing severe systemic infections. Although reports of complicated thoracic infections with this agent are rare in the pediatric population, they have been increasing in adults. Streptococcus anginosus has a high capacity to form abscess and empyema, requiring different therapeutic approaches when compared to complicated pneumonia caused by other agents.

Gastropleural Fistula: A Rare Complication of a Common Procedure

Weight loss surgeries are evident to be highly beneficial in patients with morbid obesity (body mass index (BMI) ≥40.0 kg/m2) and severe obesity (BMI between 35.0 and 39.9 kg/m2 with co-morbidities). While this results in significant mortality benefit, there is always the possible risk of postsurgical complications. Gastrobronchial and gastropleural fistulas are two rare, post-operative pulmonary complications associated with these surgeries. Our patient is a 54-year-old female who underwent a biliopancreatic diversion with a duodenal switch. A few weeks later, she started developing a cough, fever, and shortness of breath. Computed tomography (CT) chest showed the presence of a loculated right sided hydropneumothorax. A gastrointestinal fluoroscopic contrast study performed showed a large fistula originating from the distal end of the stomach and ending towards the right pleural cavity. The fistula was successfully closed with the endoscopic fulguration of fistulous opening with argon beam coagulation and orthoscopic clipping, resulting in complete obliteration of the fistula tract. The right-sided hydropneumothorax was initially treated conservatively with antibiotics and chest tube drains followed by video-assisted thoracoscopic decortication with chest tube placement. Gastropleural fistula formation is rare but is nonetheless a serious postoperative complication of bariatric procedures and mimics pneumonia clinically. It is, therefore, essential to obtain detailed imaging work-up to rule out fistula formation, which, in turn, can be timely treated without causing further devastating results to the patient.

A meta-analysis of video-assisted thoracoscopic decortication versus open thoracotomy decortication for patients with empyema.

Thoracic pleural empyema is a collection of pus within a thoracic cavity. In stage 2 (fibrinopurulent) and stage 3 (organizational), decortication is the only choice. But there is no consensus on whether to choose video-assisted thoracoscopic decortication (VATD) or open thoracotomy decortication (OTD). We sought to answer this question by performing a meta-analysis. Six electronic databases were searched. Primary outcomes were operative time, postoperative hospital stay, prolonged air leak, chest tube duration, relapse rate, morbidity and mortality. Review Manager (RevMan) [Computer program]. Version 5.2, 2014 was used to pool the data. Subgroup analysis and publication bias analysis were also conducted. The operative time [mean difference -36.89; 95% confidence interval (CI), -60.96 to -12.82; P=0.003], postoperative hospital stay (mean difference -2.41; 95% CI, -3.74 to -1.09; P=0.0004), prolonged air leak (9.7% vs. 17.1%; RR 0.56; 95% CI, 0.33 to 0.94; P=0.03), chest tube duration (mean difference -1.52; 95% CI, -2.55 to -0.48; P=0.004), morbidity (16.4% vs. 24.5%; RR 0.62; 95% CI, 0.44 to 0.88; P=0.007) and mortality (4.1% vs. 6.2%; RR 0.47; 95% CI, 0.26 to 0.86; P=0.01) of VATD were statistically less than the OTD. In terms of relapse rate, there was no statistical significance between two surgical approaches (7.2% vs. 4.2%; RRN1.28; 95% CI, 0.39 to 4.15; P=0.68). The present study summarized and compared the clinical outcomes of VATD versus OTD for the empyema patients. The current data showed that VATD might be comparable or even better than OTD in terms of operative time, postoperative hospital stay, chest tube duration, prolonged air leak rate, morbidity and mortality. But referring to the relapse rate, there was no statistical significance. The results from analysis was subject bias because of prospective randomized studies were not selected. However, VATD could be implemented safely as first-line management for most of empyema.

Trachway Intubating Stylet Facilitates the Double-Lumen Endobronchial Tube Placement in Patients with Limited Mouth Opening

Intubation for one lung ventilation in patients with difficult airways can be a challenge. Severely limited mouth opening restricts the use of direct laryngoscopy or video-assisted laryngoscopy. We present two patients with limited mouth opening undergoing video-assisted thoracoscopic decortication, who were successfully intubated with left-sided double-lumen endobronchial tube (DLT) using the Trachway® intubating stylet. This technique provides a safe and reliable method for DLT intubation in patients with limited mouth opening.

Video-assisted thoracoscopic decortication for the management of late stage pleural empyema, is it feasible?

BACKGROUND:Video-assisted thoracoscopic surgical decortication (VATSD) is widely applicable in fibrinopurulent Stage II empyema. While, more chronic thick walled Stage III empyema (organizing stage) needs conversion to open thoracotomy, and existing reports reveal a lacuna in the realm of late stage empyema patient's management through VATS utilization, particularly Stage III empyema. We prospectively evaluated the application of VATSD regardless of the stage of pleural empyema for the effective management of late stage empyema in comparison to open decortications (ODs) to minimize the adverse effects of the disease.METHODS:All patients with pyogenic pleural empyema (Stage II and Stage III) in King Khalid University Hospital (KKUH) (admitted from January 2009 to December 2013) who did not respond to chest tube/pigtail drainage and/or antibiotic therapy were treated with VATSD and/or open thoracotomy. Prospective evaluation was carried out, and the effect of this technique on perioperative outcomes was appraised to evaluate our technical learning with the passage of time and experience with VATS for late stage empyema management.RESULTS:Out of total 63 patients, 26 had Stage II empyema and 37 had Stage III empyema. VATSD was employed on all empyema patients admitted in the KKUH. VATSD was successful in all patients with Stage II empyema. Twenty-five patients (67.6%) with Stage III empyema completed VATSD successfully. However, only 12 cases (32.4%) required conversions to open (thoracotomy) drainage (OD). The median hospital stay for Stage III VATSD required 9.65 ± 4.1 days. Whereas, patients who underwent open thoracotomy took longer time (21.82 ± 16.35 days). Similarly, Stage III VATSD and Stage III open surgery cases showed significance difference among chest tube duration (7.84 ± 3.33 days for VATS and 15.92 ± 8.2 days for open thoracotomy). Significantly, lower postoperative complications were detected in patients treated with VATSD in terms of atelectasis, prolonged air leak, wound infection, etc.CONCLUSION:VATSD facilitates the management of fibrinopurulent, organized pyogenic pleural empyema with less postoperative discomfort, reduced hospitalization, and have fewer postoperative complications. VATSD can be an effective, safe first option for patients with Stage II pleural empyema, and feasible in most patients with Stage III pleural empyema.

Experience with an evidence-based protocol using fibrinolysis as first line treatment for empyema in children

IntroductionWe previously reported a prospective, randomized trial comparing video-assisted thoracoscopic decortication (VATS) to fibrinolysis for the treatment of empyema. In that study no advantages to VATS were identified, although VATS resulted in significantly higher hospital charges. We subsequently implemented the algorithm from the trial utilizing primary fibrinolytic therapy in all children diagnosed with empyema. In this study, we reviewed our experience to examine the clinical efficacy of this protocol. MethodsAfter IRB approval, we conducted a retrospective review of all children diagnosed with empyema as all were treated with the fibrinolysis protocol utilized in the prospective trial since the completion of the trial. ResultsIn 102 consecutive patients treated with fibrinolysis, 16 patients (15.7%) required subsequent VATS. No patients were treated with initial VATS. No major side effects were seen from fibrinolytic therapy. Mean operative time for VATS after fibrinolysis was 62minutes. The length of stay after VATS was 5.9days. ConclusionsThe results of an evidence-based protocol using fibrinolysis to treat empyema have replicated the results of the trial that led to the implementation of the protocol. The pediatric empyema population can be successfully treated without an operation in the majority of cases.

Comparison of the Methods of Fibrinolysis by Tube Thoracostomy and Thoracoscopic Decortication in Children with Stage II and III EmpyemA: A Prospective Randomized Study

Today, in spite of the developments in imaging methods and antibiotherapy, childhood pleural empyema is a prominent cause of morbidity and mortality. In recent years, it has been shown that there has been an increase in the frequency of pleural empyema in children, and antibiotic resistance in microorganisms causing pleural empyema has made treatment difficult. Despite the many studies investigating thoracoscopic debridement and fibrinolytic treatment separately in the management of this disease, there is are not enough studies comparing these two treatments. The aim of this study was to prospectively compare the efficacy of two different treatment methods in stage II and III empyema cases and to present a perspective for treatment options.We excluded from the study cases with: i) thoracoscopic intervention and fibrinolytic agent were contraindicated; ii) immunosuppression or additional infection focus; iii) concomitant diseases, those with bronchopleural fistula diagnosed radiologically, and Stage I cases. This gave a total of 54 cases: 23 (42.6%) in stage II, and 31 (57.4%) cases in stage III. These patients were randomized into two groups of 27 cases each for debridement or fibrinolytic agent application by video-assisted thoracoscopic decortication (VATS). The continuity of symptoms after the operation, duration of thoracic tube in situ, and the length of hospital stay in the VATS group were of significantly shorter duration than in the streptokinase applications (P=0.0001). In 19 of 27 cases (70.37%) in which fibrinolytic treatment was applied and in 21 cases of 27 (77.77%) in which VATS was applied, the lung was fully expanded and the procedure was considered successful. There was no significant difference with respect to success rates between the two groups (P=0.533). The complication rate in our cases was 12.96% and no mortality was observed. Similar success rates in thoracoscopic drainage and enzymatic debridement, and the low cost of enzymatic drainage both served to highlight intrapleural streptokinase treatment as a reliable method in reducing the need for surgery in complicated empyema.

Thoracoscopic Decortication for Advanced Pediatric Empyema

Although tube thoracostomy with fibrinolytic agents and video-assisted thoracoscopic (VATS) decortication are relatively equivalent in the treatment of empyema with regard to time to patient defervescence and hospital discharge, the potential for greater benefit with VATS decortication in the setting of advanced empyema has not been explored fully. This paper describes our transition from a policy of drainage and antibiotics to primary operative management with VATS. We wanted to assess the safety and efficacy of primary operative management as a first-line treatment for advanced disease. A retrospective review was conducted of 25 patients treated for stage 3 or 4 empyema. The primary endpoints were morbidity and death. The secondary endpoints were conversion to an open procedure, time to defervescence, and length of hospital stay. The morbidity rate was 16% with no deaths. No patient required conversion to open decortication. The mean time to defervescence was 3.2 days, and on average, patients were discharged on postoperative day 9. Patients were discharged home earlier when managed primarily with VATS. Video-assisted thoracoscopic decortication is a safe and effective treatment for pediatric stage 3 or 4 empyema.

Outcomes of Video-Assisted Thoracoscopic Decortication

Video-assisted thoracoscopic surgical decortication (VATSD) is widely used for treatment of early empyema and hemothorax, but conversion to open thoracotomy for decortication (OD) is more frequent in the setting of complex, chronic empyema. This study compared indications for and outcomes associated with VATSD and OD. The outcomes of 420 consecutive patients undergoing VATSD or OD for benign conditions from 1996 to 2006 were reviewed and compared with respect to baseline characteristics, preoperative management, and operative and postoperative course. Patients were analyzed on an intention-to-treat basis. The cohort consisted of 326 VATSD and 94 OD patients. The conversion rate from VATSD to OD was 11.4%. The operative time and median in-hospital length of stay were shorter for the VATSD group: 97 vs 155 minutes (p < 0.001), and 15 vs 21 days (p = 0.03), respectively. The median postoperative length of stay was 7 days for the VATSD group vs 10 days for the OD group (p < 0.001). Significantly fewer postoperative complications occurred in the VATSD group in the following categories: atelectasis, prolonged air leak, reintubation, ventilator dependence, need for tracheostomy, blood transfusion, sepsis, and 30-day mortality. Thoracoscopic decortication for empyema, complex pleural effusion, and hemothorax yields results that are at least equivalent to open decortication. Patients undergoing VATSD have fewer postoperative complications. The conversion and reoperation rates are low, suggesting that a thoracoscopic approach is an effective and reasonable first option for most patients with complex pleural effusions and empyema.

Does video-assisted thoracoscopic decortication in advanced malignant mesothelioma improve prognosis?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Does video-assisted thoracoscopic (VATS) decortication in advanced malignant mesothelioma improve prognosis? Altogether more than 25 papers were found using the reported search, of which five represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATS decortication is useful as a palliative measure in advanced malignant mesothelioma. VATS provides a diagnostic tool, yielding tissue for histological diagnosis. Secondly, drainage of effusion and pleurectomy/decortication improves the quality of life and may increase survival as well.