Pleural infections have high morbidity and mortality, and their incidence in all age groups is growing worldwide. Pleural effusion develops in 40% of pneumonia patients, but only 15% of patients develop thoracic empyema after antibiotic treatment. Pleural empyema can be differentiated into three phases, exudative (Stage I), fibrinopurulent (Stage II) and organizing (Stage III). It is important to emphases that it is representing as a continuously evolving process that can be stop by therapeutic intervention. The initial exudative stage can be often managed by antibiotics and placement of chest tube. However, it is not effective in the fibrinopurulent or organizing stages, due to fibrin deposits over the parietal pleura and loculation of fluid, that restricts the expansion of the lung. The variety of strategies in the treatment of parapneumonic pleural empyema demonstrates the ambiguity for the method of choice. Many publications demonstrated that an early and aggressive minimally invasive approach for empyema in stage II provides rapid relief from infection and guarantees lower morbidity rate, shorter hospital stay, lower costs and clinical resolution. Though, the role of video assisted thoracic surgery in organizing stage III of pleural empyema is still controversial. The objective of surgical treatment of pleural empyema is to drain infected collections from pleural cavity and to achieve a complete lung re-expansion which is usually trapped due to adhesion’s or thickening of the visceral pleura. Fibrinolysis has been shown to be superior to chest tube drainage alone. There are some trials who documented lower charges with fibrinolysis comparing to VATS procedures. However, a fibrinolitic therapy may make the subsequent operation more difficult. VATS provides higher diagnostic value as good visualization and magnification, direct visualization of all surgical regions, facilitates the evacuation of multilocular effusions, the division of a fibrin septa’s, debridement and decortication, as well as fluid sampling and pleural biopsy.
Keywords: Video-assisted surgery, pleural empyema, fibrinolysis, decortication.
This study included 468 patients with complicated parapaneumonic effusion and pleural empyema who were treated at the Clinic for Thoracic Surgery, Institute for the pulmonary diseases of Vojvodina, Sremska Kamenica, Serbia, between 2013. and 2017. From the 2004. it has been implemented the chest tube placement and fibrinolysis with streptocinasae, for all the patients upon the diagnosis of pleural empyema. Among those patients, in 45 patients the initial treatment was VATS debridement/decortication. The indication for the primary VATS procedure were radiological confirmation of multilocular effusion and positive Light’s criteria. In all patients, beside the debridement or decortication, the fluid sampling and pleural biopsy has been performed.
The VATS procedure has been performed successfully in all operated patients. There were no mortality and serious postoperative complications which demand artificial ventilation. The conversion to the thoracotomy has been performed in 3 patients (6.67%) due to intraoperative finding of thick and denser cortex over the pleura. In the majority of the patients, after the VATS procedure the fibrinolysis therapy has been instilated for two to three times. The re operation with thoracotomy and open decortication has been performed in 4 patients (8.89%) due to the radiological finding of incomplete lung re expansion. Group of patients with VATS procedure had less postoperative complications such as atelectasis, prolong air leak, blood transfusion of ventilator dependence.
The usage of videothoracoscopic surgery in treatment of pleural infections can be very effective in selected patients, especially in stage II, as well as it can be significant part of the therapeutic algorithm and protocol in its treatment.
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