Video-assisted Thoracoscopic Surgery Decortication Research Articles

Uniportal versus triportal video-assisted thoracic surgery in the treatment of tuberculous empyema

To examine the effectiveness of decortication to treat chronic tuberculous empyema (TE) using uniport video-assisted thoracoscopic surgery (VATS) versus conventional triport VATS. Data from consecutive patients with stage II or III TE who underwent decortication with either uniport VATS (uniportal group) between July and December 2017, or triport VATS between January and July 2018 (triportal group), were retrospectively analysed. VATS procedures were performed under general anaesthesia with double lumen endotracheal intubation and clinical outcomes were compared between the two groups. Clinical data were comparable between the groups (20 patients in each) regarding demographic and baseline characteristics, operative and postoperative characteristics, surgical procedure-related complications, and postoperative adverse events. No surgical procedure-related complications occurred during the perioperative period in either group. Threshold values for mechanical pain at 8 h postoperatively were significantly higher in the triportal group versus the uniportal group. Furthermore, the incidence of nausea and vomiting was significantly lower in the uniportal versus triportal group. In the triportal group, one patient required readmission and further intervention due to recurrence. Uniport VATS decortication for stages II and III TE may be a feasible and safe procedure in selected patients. Moreover, uniport VATS may be less painful than triport VATS.

The thoracoscopic approach in the management of parapneumonic pleural effusion in children

Background: Parapneumonic pleural effusion is a relatively common entity and continues to be a major cause of morbidity in children. However, managing this disease is still a matter of controversy between surgical and non-surgical options. With the advancement of mini-invasive surgery, video-assisted thoracoscopic surgery (VATS) has become a mainstay in the treatment of parapneumonic effusion in children. This study aimed to evaluate the clinical characteristics and pathological features of parapneumonic pleural effusion in children and to explore the feasibility and safety of the thoracoscopic approach in the pediatric population. Methods: The clinical data of all patients who underwent VATS for parapneumonic effusion between 2007 and 2021 were analyzed retrospectively. Factors that were documented included demographic criteria, clinical manifestations, preoperative examinations, therapeutic procedures, intraoperative findings, postoperative complications, and outcomes. Results: Totally, 35 patients with a mean age of 5.14 ± 3.9 years were operated on thoracoscopically. The mean duration of evolution before VATS was 9 days ± 4. All children were hospitalized in a Pediatric Continuing Care Unit. Antibiotic therapy was administrated in combination in all cases. Corticosteroid therapy was used in 2 patients. Thoracentesis was performed in 6 patients. Thoracostomy tube drainage was placed before surgery in 11 patients. The average duration of drainage before VATS was 6 days ± 4. VATS decortication and/or debridement was indicated as second-line in 23 patients. The average duration of the surgery was 51 minutes (20 min - 115 min). There is no conversion to open surgery and no intraoperative procedure-dependent complication. 4 children have early complications after the VATS and one patient had a late postoperative complication. There were no deaths during the hospital stay or follow-up. Conclusion: In skilled hands, VATS is safe, feasible, and effective in the management of parapneumonic pleural effusion in children with excellent outcomes.

Role of Video-Assisted Thoracoscopic Surgery in the Management of Pleural Empyema

Background: Video-assisted thoracoscopic surgery (VATS) has revolutionized surgical management of patients with empyema. Thoracoscopic management of empyema includes VATS debridement and decortication. VATS debridement has been employed by many centres as the primary treatment option for early-stage empyema. Objective: To evaluate the outcome of VATS over open thoracotomy. Methods: This cross-sectional study was conducted in the department of Thoracic Surgery of Combined Military Hospital Dhaka from 01 January 2017 to 30 May 2018 among 30 patients (20 patients underwent VATS and 10 patients underwent open decortication/OD). The results were viewed with respect to baseline characteristics, preoperative management, operative and postoperative course. Results: Operative time and median in-hospital length of stay were shorter for the VATS group: 128 vs 140 minutes (p < .001), and 14 vs 11 days (p .03), respectively. The median postoperative length of stay was 12 days for the VATS group vs15 days for the OD group (p < .001). Complications after Video Assisted Thoracic Surgery is less like prolonged air leakage, infection and atelectasis. Conclusions: VATS decortications for empyema thoracis, complex effusion, haemothorax yields better results than open decortications. Patients treated with VATS have less postoperative complications. VATS debridement and decortication is safe and effective treatment in the management of empyema thoracis. JAFMC Bangladesh. Vol 18, No 1 (June) 2022: 19-22

Video-Assisted Thoracoscopic Surgery versus Open Decortication in Chronic Pleural Empyema

Background: The role of video-assisted thoracoscopic surgery (VATS) for managing organized empyema is still limited. This study compared VATS versus open decortication in patients with chronic pleural empyema.
 Methods: This randomized controlled trial included 58 patients with stage III empyema. Patients were divided into two groups. Group A (n= 30) included patients who had decortication through an open thoracotomy, and Group B (n= 28) included VATS decortication patients. Two patients in the VATS group were converted to the open approach and were excluded from the analysis.
 Results: The mean age in Group A was 48.23 ± 8.44 years and 49.79 ± 7.85 years Group B (p= 0.47). There were 16 males (53.3%) in Group A and 15 (63.6%) in Group B (p= 0.99). The operative time was 336.0 ± 67.60 min in Group A and 291.07 ± 56.66 min in Group B (p= 0.01). There was no difference in intraoperative complications between groups. Postoperative hospital stay (p= 0.23) and ICU admission (p= 0.24) did not differ between groups. In Group A, the pain scale was 8 (6- 8), and it was 4 (2- 4) in Group B (p˂ 0.001). No difference was recorded in the postoperative complications between groups.
 Conclusion: The outcomes of VATS in managing stage III empyema are comparable to the open approach. VATS has the advantage of lower postoperative pain. VATS could be an alternative to open decortication in patients with stage III pleural empyema.

Multidisciplinary, minimally invasive approach for oesophageal perforations with delayed presentation.

Background:The present study aims to report the outcomes of a multidisciplinary, minimally invasive approach to treating patients with delayed presentation of oesophageal perforation.Patients and Methods:The present study is a retrospective analysis of prospectively maintained data at a tertiary care centre. All patients with oesophageal perforation presenting over 48 h after the onset of symptoms and without oesophageal obstruction were included in the study. Self-expanding Metallic Stent (SEMS) or endoscopic clip placement was performed in all the patients, followed by video-assisted thoracoscopic surgery (VATS) debridement and decortication of pleural cavity collection. 'Success’ was defined as, discharge without the need of oesophageal diversion and complete healing of leak site at 8 weeks with successful removal of the stent.Results:Between March 2012 and December 2019, 12 patients (10 males, median age of 55 years– range of 39–71 years) with oesophageal perforation and delayed presentation underwent treatment with this approach. Ten patients had spontaneous perforation (83.3%) and one patient each had upper gastrointestinal endoscopy-induced and post-traumatic perforation. The median duration of symptoms was 8 days (range 3–31 days). SEMS was placed in ten patients and, in two patients, an over-the-scope clip was used. VATS decortication was done in ten patients (83.3%) and the remaining two (16.7%) underwent VATS debridement. One patient required oesophageal diversion and another patient expired due to sepsis. The overall success with this approach was 83.3%.Conclusion:This multidisciplinary, minimally invasive approach is feasible in patients with thoracic oesophageal perforation and delayed presentation, with a high success rate.

Uniportal thoracoscopic decortication: start away from empyema approach

Aim: Video-assisted thoracoscopic surgery (VATS) is now a gold standard in treating early-stage empyema, while much debate still exists considering the effectiveness of this approach for late-stage empyema. Most concerns arise from the crowded rib cage, narrow working space, and ability to free trapped lungs quickly, mainly if uniportal VATS is used. However, unlike uniportal VATS lobectomy, there is no consensus about standard steps for uniportal VATS decortication to ensure smooth and effective surgery. We try to offer standard, easy-to-replicate steps for this approach to evaluate the efficacy and safety of the “start away from empyema” approach for uniportal VATS decortication in the management of stage II and III empyema. Methods: A prospective case series study has been conducted on 25 patients. All patients with stage II and III empyema were admitted to the Cardiothoracic Surgery Department between October 2017 and March 2020. VATS procedure was done under general anesthesia by a double-lumen tube for selective ventilation. Demographic data, preoperative diagnosis, intraoperative findings, hospital stay, and complications were recorded. Results: Twenty-five patients were enrolled in this study with a median age of 35 years. The duration of illness ranged between 14 and 60 days, with a median (IQR) of 25 (17) days. In (88%) of the patients, there was a successful outcome defined as a near-complete resolution on Chest X-ray (scoring of 3 or 4) and chest US (scoring of 2 or 3). Only three (12%) patients had a partially successful outcome. All patients with partial success suffered from infection associated with malignant effusion. Conclusion: “Start away from empyema” approach for uniportal VATS decortication in stage II and III empyema could be safe and effective in treating loculated nonmalignant pleural effusion.

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.

Study protocol for DICE trial: Video-assisted thoracoscopic surgery decortication versus interventional radiology guided chest tube insertion for the management of empyema

BackgroundEmpyema is a common thoracic surgery presentation, defined as pus in the pleural space. Despite the commonality of empyema, consensus on initial management remains ambiguous. Two standard of care treatment options include inserting a chest tube (thoracostomy) and the administration of intrapleural fibrinolytics, or an initial surgical approach, surgical decortication. Due to the complexity of this pleural space infection, often repeat interventions are required after initial management in order to achieve source control and resolution of clinical symptoms. This study aims to identify the most effective initial management option for empyema. Study designWe present a study protocol for a randomized control trial (RCT) comparing adult individuals with empyema to one of two standard of care initial management options. Participants will be randomized into either interventional radiology guided chest tube insertion with intrapleural fibrinolytics (Dornase 5 mg and Alteplase 10 mg intrapleural twice daily for three days) or video-assisted thoracoscopic surgery (VATS) decortication. MethodsAll adults with empyema meeting inclusion criteria will be invited to participate. They will be randomized into one of two intervention groups; interventional radiology guided chest tube insertion with fibrinolytics or initial VATS decortication. Each intervention will take place within 48 hours of randomization. The primary outcome will be the rate of re-intervention within 30 days. Re-intervention is defined as repeat chest tube insertion, VATS decortication, or decortication via thoracotomy. Secondary outcomes include a change in the size of empyema, length of stay, morbidity, as well as 30-day and 90-day mortality, as well as quality of life measurements. Anticipated impactThis study is aimed at identifying the most effective initial management option for individuals with empyema.

Cost-Effectiveness Analysis of Fibrinolysis vs Thoracoscopic Decortication for Early Empyema

Surgical decortication is recommended by national guidelines for management of early empyema, but intrapleural fibrinolysis is frequently used as a first-line therapy in clinical practice. This study compared the cost-effectiveness of video-assisted thoracoscopic surgery (VATS) decortication with intrapleural fibrinolysis for early empyema. A decision analysis model was developed. The base clinical case was a 65-year-old man with early empyema treated either by VATS decortication or intrapleural tissue plasminogen activator and deoxyribonuclease. The likelihood of key outcomes occurring was derived from the literature. Medicare diagnosis-related groups and manufacturers' drug prices were used for cost estimates. Successful treatment was defined as complete or nearly complete resolution of empyema on imaging. Effectiveness was defined as health utility 1 year after empyema. Intrapleural tissue plasminogen activator and deoxyribonuclease were more cost-effective than VATS decortication for treating early empyema for the base clinical case. Surgical decortication had a slightly lower cost than fibrinolysis ($13,345 vs $13,965), but fibrinolysis had marginally higher effectiveness at 1 year (health utility of 0.80 vs 0.71). Therefore, fibrinolysis was the more cost-effective option. Sensitivity analyses found that fibrinolysis as the initial therapy was more cost-effective when the probability of success was greater than 60% or the initial cost was less than $13,000. Surgical decortication and intrapleural fibrinolysis have nearly equivalent cost-effectiveness for early empyema in patients who can tolerate both procedures. Surgeons should consider patient-specific factors, as well as the cost and effectiveness of both modalities, when deciding on an initial treatment for early empyema.

Efficacy of Video-Assisted Thoracoscopic Surgery (VATS) in the Treatment of Primary Pleural Empyema.

Background:Video-Assisted Thoracoscopic Surgery (VATS) has recently occupied a significant place in the surgical treatment of primary pleural empyema (PPE). Patients with anamnesis shorter than 4 weeks have a good chance of being cured only by VATS. As it is not easy to define precisely the beginning of the disease, it is difficult to say strictly to which period VATS method will be successful in PPE treatment.Objective:The aim of this study was to determine the efficacy of the VATS method in the surgical treatment of primary pleural empyema.Methods:The study included 50 patients with findings appropriate for PPE over a period of three years, in whom the VATS method was applied in the surgical treatment of pleural empyema.Results:The established total length of treatment was 13.56 ± 7.98 days and the length of hospital treatment after surgery was 9.90 ± 3.315. The duration of thoracic drainage was 8.06 ± 3.005. Treatment was completed by the primary procedure without additional interventions in 94% of patients. Based on the final outcome, all patients from the clinic were discharged as curedConclusion:The best time to indicate surgical treatment by using VATS method is history of disease in duration of four weeks Debridement or VATS decortication method is safe and efficient surgical procedure, especially in the first two stages. It is recommended to use this method as the first surgical option for patients in early stages of the disease.

Albumin and leukocyte: pre-operative factors for advanced management in pleural empyema?

Background: Surgical intervention such as video-assisted thoracoscopic surgery (VATS) has shown the benefit of reducing morbidity and mortality in the management of pleural empyema. The objective of the study was to investigate preoperative factors that could predict the need for VATS rather than chest tube thoracostomy.Methods: This is retrospective observational study of consecutive patients diagnosed with pleural empyema admitted to the Dr. Zainoel Abidin Hospital, Banda Aceh in period of 2015 to 2017. The demographic, clinical dan laboratory data of the patients were evaluated from hospital medical records.Results: A total of 48 consecutive patients were identified. The mean age of the patients was 34.3 ± 20.4 years; and 31 (64.6%) were male. Twenty-six patients underwent VATS decortication and twenty-two patients underwent chest tube thoracostomy. Patient demographics were similar between VATS decortication and chest tube thoracostomy group. The significant preoperative factors associated with the VATS were serum albumin level and leukocytes (p <0.05). The mean serum albumin level was 2.81 ± 0.44 g/dL for the VATS decortication group vs 3.06 ± 0.41 g/dL for the chest tube thoracostomy group (p = 0.047). In addition, serum leukocyte level was higher in VATS decortication group compared to chest tube thoracostomy group (21,600 mm-3 vs 12,900 mm-3; p = 0.024).Conclusion: We demonstrate that a low serum albumin level or an elevated leukocyte level may represent as preoperative factors in which surgical treatment may be required in the management of pleural empyema.

“Video Assisted Thoracoscopic Surgery (VATS) for all Stages of Empyema Thoracis: a Single Centre Experience”

Video assisted thoracoscopic surgery (VATS) is a surgical treatment option for empyema thoracis (ET). However, very few studies have been reported from India. The present study aims to evaluate the role, implementation and outcomes of VATS for all stages of ET. A prospective evaluation of 33 patients with ET managed by VATS decortication from January 2016 to December 2017 was performed. All were followed up for 6 months to evaluate surgical outcomes, conversion rate, morbidities and relapse.Out of 33, 5 patients had stage I, 18 had stage II and 10 had stage III empyema. Most common symptoms were dyspnea [75.75%] and fever [63.63%]. Commonest etiology was bronchopulmonary infection (51.51%) and tuberculosis (33.33%). Conversion rate was 3.03%. Mean operating time was 102, 178.8 and 323 min for stage I, II, III respectively. Mean hospital stay for stage I, II,III was 4, 5.11 and 9.3 days respectively. Intraoperative bleeding was high in stage III (625 ml) compared to stage II (327.7 ml). Mean chest tube duration for stage I, II and III was 13.4, 10.2 and 14.8 days respectively. VATS decortication is safe, feasible and effective treatment for all ET stages, when preformed in properly selected patients at appropriate time by experienced surgeons. It improves outcomes in stage I ET by reducing recurrence in cases with failure of conservative management. When timed appropriately, it has acceptable morbidity and postoperative recovery rates without significant conversion rates, even in stage III ET.

Thoracoscopy in stage 3 empyema thoracis in children – A safe and feasible alternative to thoracotomy

BackgroundEven though the role of thoracoscopy is well defined in Stage 2 empyema thoracis and is very popular, its role in the management of advanced empyema is still unclear. The technical difficulties and the potential complications are the principal reasons for the hesitancy in attempting video assisted thoracoscopic surgery (VATS) in advanced stages. MethodsWe prospectively studied the safety, feasibility and effectiveness of VATS for decortication in Stage 3 empyema. ResultsIn the 61 cases that we attempted VATS over the last 7 years, we could complete the procedure in 45 patients (73.77%). Four children among them required re-do procedure later for persistent problems. Conversion to thoracotomy was needed in 16 patients (26.23%). The post-operative hospital stay of patients who underwent primary VATS decortication was significantly less when compared to patients requiring conversion (p < 0.0001). ConclusionThoracoscopy is a safe, feasible and effective option even in advanced empyema thoracis and should be offered in centers with adequate expertise and set up. Level of evidenceLevel II.

Surgical management for pleural empyema – Single-center experience

Background: Pleural empyema occurs due to primary lung parenchymal infection or due to other pathologies. In this study, we analyzed the surgical management of empyema at our center. Patients and Methods: This study is a retrospective analysis of the patients who were surgically managed for pleural empyema between September 2014 and September 2017. A total of 54 patients underwent surgical management in the form of video-assisted thoracoscopic surgery (VATS) decortication or open procedure or a combination of both. The study population was evaluated for comorbid conditions, association with tuberculosis, bacteriological culture, length of hospital stay, morbidity and mortality. Results: Primary empyema was present in 52 patients while two patients had secondary empyema. Mycobacterium tuberculosis was associated in 17 (32%) patients, while 25 patients had other bacterial organisms. VATS decortication was performed in 21 (39%) patients and 23 (43%) patients underwent the open procedure. The remaining 10 patients underwent the combined procedure. The operative time and mean duration of hospital stay were less in the VATS group compared to the open group. Conclusion: In our experience, early surgical management of Stage II and Stage III empyema is successful with VATS. The nature of the disease process and the learning curve for VATS plays an important role in the conversion to open procedure.

Video-assisted thoracoscopic surgery in bacterial empyema thoracic result from developing country based on Thailand experience

Background: Empyemathoracic is a common surgical disease which increasing every year in worldwideespecially in developing countries. Surgical technique is very challenging dueto technical demanding and time consuming. The aim of this study is to comparesurgical outcomes between open thoracotomy (OT) and video-assistedthoracoscopic surgery (VATS) in bacterial empyema thoracic based on Thailandexperience. Methods: The retrospectivecohort study from 6 tertiary-care hospitals in Thailand was conducted. Patientswere diagnosed with bacterial empyema thoracis (BET) and underwent VATS or OTapproach between January 2015 to December 2017 were included in this study.Patient characteristics, operative procedures, perioperative complications andpostoperative outcomes were retrospectively reviewed from medical recordingsystem. Patients were divided into two groups; VATS and OT group. The endpointswere postoperative outcomes. The analysis was performed using multilevel modelstratified by propensity score (PS). Results: There were 300 patients; 98 in VATS group and 202 inOT group, enrolled in this study. There were statistically significantdifferences in gender, comorbidity index, smoking status, stage of empyemathoracis, clinical presentation, duration of symptoms before diagnosis, andproportion of patients underwent decortication between two groups. Inpostoperative outcomes, the proportion of patients who had completedecortication and fully expanded lung was not different between VATS and OT(92.9% vs. 96%; P=0.236 and 89.9% vs. 88.1%; P=0.867). Afterusing multilevel model stratified by PS, VATS was associated with decreasedrisk of re-intubation [risk ratio (RR) =0.29, 95% CI, 0.09–0.98], woundinfection (RR =0.09, 95% CI, 0.01–0.71), duration of intensive care unit (ICU)stay [mean difference =−4.36; 95% CI, (−8.55 to −0.18)] and ventilatordependence (RR =0.61, 95% CI, 0.38–0.96) whereas hospital stay, compositepost-operative rate, mortality rate and discharge status were no differencebetween two groups. Conclusions: VATS decortication is safe andeffective procedure for bacterial empyema thoracic and may reduce risk ofre-intubation, wound infection, duration of ICU stays and ventilatordependence. The prospective randomized controlled trial with larger sample sizeis warranted.

Current State of Empyema Management

Empyema affects up to 65,000 patients annually in the United States. Recent consensus guidelines demonstrate ambiguity about optimal treatment. We examined current treatment practices and outcomes for inpatient treatment of empyema using a comprehensive, longitudinal data set that encompasses an entire state cohort of hospitalized patients. We queried the Healthcare Cost and Utilization Project New York State Inpatient Database (2009 to 2014) for patients with primary empyema and subsequent readmissions. Patients were categorized into three groups by definitive treatment during their initial hospitalization: chest tube drainage, video-assisted thoracoscopic surgery (VATS) decortication and drainage, or open decortication and drainage. Treatment outcomes, including success rates, readmission, reintervention, and mortality, were compared between groups. The cohort included 4,095 patients undergoing intervention for primary empyema discharged during this period with chest tube, VATS, or open drainage and decortication. Most patients received definitive operative management (chest tube: 38.2%, VATS: 32.1%, open: 29.8%; p < 0.001). Patients had a high mortality rate during their initial hospitalization (chest tube: 15.4%, VATS: 4.7%, open: 6.0%; p < 0.001) and a substantial 30-day readmission rate for empyema (chest tube: 7.3%, VATS: 3.8%, open: 4.1%; p < 0.001), with reintervention at readmission significantly higher for chest tube (6.1%) vs surgical patients (VATS: 1.9%, open 2.1%; p < 0.001). This study characterizes recent treatment practices of patients with empyema. Higher readmission and reintervention rates were observed in patients managed with chest tubes, suggesting some of these patients may benefit from earlier definitive surgical intervention.

Comparison of analgesic efficacy and safety of continuous epidural infusion versus local infiltration and systemic opioids in video-assisted thoracoscopic surgery decortication in pediatric empyema patients.

Introduction:The stripping of the densely innervated and inflamed parietal pleura in empyema during video-assisted thoracoscopic surgery (VATS) decortication can lead to significant pain and major postoperative respiratory compromise. Hence, we compared the analgesic efficacy of continuous epidural infusion versus local infiltration and systemic opioids in children undergoing VATS decortications.Methodology:Following ethics approval and informed consent, forty patients from 1 to 12 years of age were randomized into two groups, Group E (epidural) and Group L (local infiltration) after induction of anesthesia. In Group E, a thoracic epidural catheter was inserted between T4 and T8. A bolus dose of 0.5 ml/kg of 0.25% injection bupivacaine was given epidurally before incision. Postoperatively, the patients received epidural infusion with bupivacaine and fentanyl up to 48 h using an elastomeric balloon pump. In Group L, patients received local infiltration of bupivacaine (2 mg/kg) and lignocaine (5 mg/kg) at the port sites before incision and at the end of surgery. They also received injection tramadol 1 mg/kg intravenously TDS with thrice daily postoperatively. The pain scores (Face, Legs, Activity, Cry, Consolability/ Wong-Baker FACES scale) were assessed every 4 h on the 1st day and 6 h on the 2nd day. Injection diclofenac 1 mg/kg intravenous was used as a rescue analgesic for pain scores more than 4. Side effects such as nausea, vomiting, constipation, and motor blockade were noted. Quantitative and categorical data were assessed using t-test and Chi-square test, respectively.Results:The pain scores were lower in the epidural group than in the local infiltration group at 0, 4, and 20 h postoperatively (P = 0.001, 0.01, and 0.038, respectively). Seventeen out of nineteen patients required rescue analgesia in the local infiltration group in the postoperative period as compared to five patients in the epidural group with a P value of 0.000081.Conclusion:Epidural analgesia can be considered as an effective modality of reducing pain in patients undergoing VATS decortication for empyema in pediatric patients.

The experience of using thoracoscopic surgery for treatment of patients with acute nonspecific parapneumonic pleural empyema

Objective. To evaluate the effectiveness of thoracoscopic operations and to study the clinical and epidemiological characteristic of patients with pleural empyema (PE). Materials and Methods. A retrospective analysis of 51 patients with PE treatment results has been done. All participants were examined by standard clinical and laboratory tests, X-rays and CT scans of the chest, ultrasound of pleural cavities. All patients (n = 51, 100%) were subject to thoracoscopic interventions. Results. The average age of patients was 44.4 ± 14.7 years. Men prevailed among them - 36 (71%). The first stage of PE was diagnosed in 18 (35%) patients, and the second - in 33 (65%). Almost all patients (50 patients – 98%) had been treated in other hospitals before hospitalization to a specialized department. Diagnostics of PE and patients admission to the thoracic surgery department took place on the 2 - 3 week of disease in 70% of cases. The main types of surgery on the first stage of PE were: 1) thoracoscopy with targeted drainage of pleural cavity and pleural biopsy (n = 4, 22%), 2) video-assisted thoracoscopic surgery (VATS) with destruction of fibrinous adhesions (n = 14; 78%). It has been done at the second stage of PE: 1) VATS pneumolysis (n = 22; 67%) and 2) VATS decortication of lung (n = 11; 33%). The positive results of pleural exudates bacteriological analysis have been obtained from 9 patients (18%). The median of pleural exudation duration at the first stage of PE was 5 days (4, 6), at the second stage - 6 (5, 9) days (p = 0.058). Good results were obtained in 33 patients (65%), satisfactory - in 15 (29%), unsatisfactory - in 3 (6%). The median of hospital stay duration was 18 (16; 21). There have not been lethal outcomes. Conclusions. Diagnosis of pleural empyema is a complex task and requires a broad introduction of modern techniques (CT and ultrasound). Standard microbiological testing is not effective in the diagnosis of PE pathogens, due to imperfection of anaerobic bacteria methods of detection and previous antibiotic therapy. The use of VATS in patients with PE on the first and the second stage is effective and reasonable, leads to good and satisfactory results in 95 % and 94 % of cases respectively.

Video-Assisted thoracoscopic surgery for pediatric empyema by two-port technique: A single-center experience with 167 consecutive cases

Background/Purpose:The aim of our study is to determine efficacy, safety, and feasibility of video-assisted thoracoscopic surgery (VATS) in childhood empyema with a technique of only two ports and open instruments at a tertiary care center in India.Methods:This is a retrospective study of patients below 18 years, with empyema presenting to the Department of Pediatric Surgery of a Tertiary Care Referral Hospital in India, over a period of 9 years who underwent VATS decortication. Only two ports with open surgical instruments were used. The patients were assessed on the basis of mean duration of preoperative symptoms, duration of surgery, average blood loss, postoperative pain relief, complications, and need for redo surgery.Results:A total of 97 patients underwent primary VATS decortications without inserting an intercostal drainage (ICD) tube and 70 patients as a secondary procedure after ICD tube was inserted. Mean duration of symptoms was 11 days. The average blood loss during surgery was estimated to be 170 cc. The mean duration of surgery was 90 min. The most common postoperative complication was air leak seen in 19.16% of patients. Minor leaks usually settled by 24 h. In eight patients, a negative suction had to be applied to the ICD tube for persistent air leak. The average length of postoperative stay was 4 days. Two patients required a repeat open decortication procedure due to nonresolution of symptoms and poor lung expansion after VATS. Patients had minimal pain and excellent cosmetic outcome after VATS.Conclusion:Two-port VATS decortication procedure is as feasible and effective as three-port procedure for decortication with better cosmetic result and pain relief.

Surgical vs Non-Surgical Management of Pleural Empyema: A Meta-Analysis

Purpose: There is currently no consensus on the optimal treatment regimen for pleural empyema, with surgical decortication attracting interest due to recent advances in video-assisted thoracoscopic surgery (VATS). Some centres advocate early decortication, whilst others continue to prefer a trial of chest tube drainage (CTD) prior to surgical intervention. This meta-analysis sought to assess the evidence regarding non-surgical vs early surgical options. Methodology: Electronic searches were performed using six databases from their inception to July 2015, identifying all relevant randomised controlled trials (RCT) that compared a surgical versus a non-surgical method of pleural empyema management. Results: Eight RCTs with 391 participants were included. Six of these focussed on paediatric population and two on adults, with seven comparing CTD to VATS decortication, whilst one paediatric trial compared CTD to open decortication. The study (n = 30) comparing open decortication to CTD reported no deaths in either arm, but showed a reduction in length of hospital stay (9.5 vs 15.4 p < 0.05), and less procedural complications (p = < 0.05). In the seven studies (n = 361) comparing VATS decortication versus CTD, there were one mortality in each group, and a reduction in length of hospital stay (mean difference -2.52 p < 0.05). There was no statistically significant difference in procedural complications rate. Conclusions: Our findings suggest early surgical management of pleural empyema may reduce length of hospital stay when compared to CTD, without an increased risk of procedural complications. However, these were based on a limited number of studies and sample size. Future RCTs with larger sample sizes are required to validate our findings.