Is video-assisted thoracoscopic surgical decortication superior to open surgery in the management of adults with primary empyema?

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracoscopic surgical decortication (VATSD) might be superior to open decortication (OD) (or chest tube drainage) for the management of adults with primary empyema? Altogether 68 papers were found using the reported search, of which 14 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 VATSD has superior outcomes for the treatment of persistent pleural collections in terms of postoperative morbidity, complications and length of hospital stay, and gives equivalent resolution when compared with OD. One study comparing VATSD and chest tube drainage of fibrinopurulent empyema found video-assisted thoracoscopic surgery (VATS) had higher treatment success (91% vs. 44%; P<0.05), lower chest tube duration (5.8+/-1.1 vs. 9.8+/-1.3 days; P=0.03), and lower number of total hospital days (8.7+/-0.9 vs. 12.8+/-1.1 days; P=0.009). Eight studies comparing early and late empyema report conversion rates to OD of 0-3.5% in early, 7.1-46% in late stage and significant reductions in length of stay with VATSD compared with OD both postoperatively (5 vs. 8 days; P=0.001) and in total stay (15 vs. 21; P=0.03). Additionally VATS resulted in reduced postoperative pain (P<0.0001) and complications including atelectasis (P=0.006), prolonged air-leak (P=0.0003), sepsis (P=0.03) and 30-day mortality (P=0.02). Five studies considered only chronic persistent empyema of which two directly compared VATSD to tube thoracostomy (TT). VATS resolved 88% of cases and had mortality rates of 1.3% compared with 62% and 11%, respectively, for TT. Moreover, conversion to OD was 10.5-17.1% with VATS and 18-37% with TT (P<0.05). In agreement with mixed stage empyema, hospital stay was reduced both postoperatively (8.3 vs. 12.8 days; P<0.05) and in total (14+/-1 vs. 17+/-1 days; P<0.05), and when compared with OD (one study), pain (P<0.0001), postoperative air-leak (P=0.004), hospital stay (P=0.020) and time to return to work (P<0.0001) were all reduced with VATS. Additionally, re-operation (4.8% vs. 1%; P=0.09) and mortality (4/123% vs. 0%) were lower in VATS vs. OD.

Video-assisted thoracic surgery in pleural empyema: predictors of complications and treatment failures

“…The average length of hospitalization varies from 5.7 to 18.5 days, but is significantly longer if VATS fails or if complications occur (3,6,8,9,17,(32)(33)(34). Postoperative stay, as stated by Waller and colleagues, is significantly longer in the conversion group vs the successfully done VATS group (8.5 and 5.5 days) (19).…”

“…Traditionally, open thoracotomy represented the main stay of treatment for this condition, but recently numerous attempts have been performed to replace it by a minimally invasive approach (2,(5)(6)(7). The precise role of video-assisted thoracic surgery (VATS) in the management of pleural empyema remains controversial and no consensus is currently in place on which surgical option and for what the patient is the first line (8)(9)(10). Some recent studies suggest that VATS and open thoracotomy are showing similar treatment success rates and are equally effective.…”

“…Some recent studies suggest that VATS and open thoracotomy are showing similar treatment success rates and are equally effective. Successfully done VATS, being less invasive, provides the additional advantages of decreased postoperative discomfort, pain, better cosmetics, higher patient satisfaction and shorter hospitalization time, especially if performed relatively early (5,8,9,11). However, in up to 59% of patients VATS is inadequate and conversion to open thoracotomy is necessary during the same operation (12,13).…”

“…However, in up to 59% of patients VATS is inadequate and conversion to open thoracotomy is necessary during the same operation (12,13). Re-do surgery after VATS (when disease remains or complication occurs) reaches up to 11.5% and is higher compared to direct open thoracotomy (5,9). So, failed VATS empyemectomy results in longer operating time, prolonged hospital stay, higher need of additional surgery, of a treatment at the Intensive Care Unit (ICU) and therefore increases treatment costs.…”

Thoracoscopic decortication for the management of trapped lung caused by 14‐year pneumothorax: A case report

“…Because we found no evidence of other possible causes and there were no contraindications to surgery, we determined that the only effective therapy would be surgical decortication with the aim of removing the fibrous cortex lying on the pleura 7. With recent advancements in medical technology, a thoracoscopic procedure is now a feasible choice for decortications 8, 9, 10. According to current reports, it has produced rewarding results in many cases.…”