Tutorial
Video-assisted thoracoscopic surgery and open decortication for pleural empyema
Video-assisted thoracoscopic therapy is an elegant method of treatment for ATS stage II fibrinopurulent empyema. It has been shown to be superior to repeated instillation of fibrinolytic agents into the chest cavity. However, a more chronic empyema (organizing empyema, ATS stage III empyema) requires open decortication in order to prevent ongoing infection and late restriction. Conversion thoracotomy should be liberally used if a chronic stage III empyema is found at VATS exploration since open decortication is still the best treatment modality for chronic empyema.
The mainstay of treatment of pleural empyema is the treatment of ongoing infection and the prevention of recurrent infection and late restriction . The choice of the appropriate intervention depends on the nature of the underlying disease, the chronicity of the empyema, and the patient’s overall condition .
The American Thoracic Society has suggested classifying empyema in 3 different stages according to its chronicity in order to facilitate the establishment of treatment guidelines . A CT scan is of utmost importance in estimating the chronicity of empyema and detecting its underlying cause .
ATS stage I parapneumonic effusions are usually treated with antibiotics and thoracocentesis or chest tube drainage. However, recent studies have challenged the usefulness of chest tube drainage alone in complicated parapneumonic effusions and a high failure rate has been reported, especially in multicolulated effusions .
Treatment of stage II empyema consists of fibrinolysis via chest tube or thoracoscopic (VATS) debridement . VATS is preferred in low-risk patients while fibrinolysis is an excellent option in patients who cannot tolerate surgery.
Fibrinolysis and VATS are valid options in the treatment of fibrinopurulent empyema but they are not effective during its organizing stage.
Stage III empyema requires formal decortication by thoracotomy in order to prevent recurrence and restriction. Alterations of lung perfusion and respiration mechanics induced by chronic empyema may be restored if decortication is promptly performed once empyema has been diagnosed.
Open window thoracostomy, thoracoplasty and intrathoracic muscle transfer are still valid surgical options in the treatment of special kinds of empyema. These procedures have in fact experienced a renaissance in recent years due to an increase of complex intrathoracic diseases observed in a growing number of immunocompromised patients.
VATS debridement and open decortication for early and chronic empyema, respectively, have been assessed in a number of series with surgically treated patients for ATS stage II and III pleural empyema .
Surgical technique for VATS debridement
1 - Patient positioning & incision (0:00)
The patient is placed in a lateral position after double lumen intubation. A posterolateral thoracotomy line is drawn on the skin. A 2–3 cm long incision is made in the anterior aspect of the line and the chest cavity is entered by blunt dissection.
2 - Assessment & thoracoport placement (0:55)
The surgeon’s index finger is inserted and the chest cavity is palpated. This gives an excellent impression of the chronicity of the empyema (by assessing rigidity and narrowing of the intercostal spaces, pleural peel on the lung, and difficulties in mobilizing the lung from the chest wall). The lung is freed from the chest wall first with finger dissection followed by a Senning suction device (Ulrich AG, St Gallen, Switzerland). A 7-mm flexible thoracoport is introduced beside the suction device through the same incision in order to prevent aspiration of the lung to the chest wall by suction. A 7-mm thoracoport is then introduced one intercostal space above the initial incision under digital control.
3 - Endoscopic inspection of the cavity (1:27)
The thoracoscope, branched to the camera and a TV screen, is introduced through this port and endoscopic inspection of the cavity is performed.
4 - Removal of loculations & fibrin (1:36)
Loculations and fibrin deposits within the chest cavity are removed by use of the Senning suction device.
5 - Removal of fibrin & costophrenic sulcus (2:09)
Fibrin deposits on the chest wall and costophrenic sulcus are removed using Kaiser forceps. Special attention is given to clear the costophrenic sulcus in order to prevent adhesion-related impairment of diaphragmatic mobility.
6 - Freeing the lung (2:21)
The lung is then entirely freed by blunt dissection from the chest wall, the diaphragm, and the mediastinum while taking care to avoid injury of the phrenic nerve.
7 - Visceral debridement & decortication (3:39)
Visceral debridement and decortication is then performed using an endoscopic lung dissector (Ulrich, St Gallen, Switzerland).
8 - Decorticating the lung: Step 1 (4:56)
A third thoracoport is introduced at the posterior aspect of the 6th intercostal space and an endoscopic lung forceps is inserted through this additional port and the dissected peel overlying the lung is grasped.
9 - Decorticating the lung: Step 2 (6:20)
The entire lung is then gradually decorticated, including the fissures. If the peel is organized and sticks to the surface of the lung conversion thoracotomy and open decortication has to be performed in order to prevent recurrent infection and late restriction which might occur after an inadequate VATS procedure.
10 - Decorticating the lung: Step 3 (6:40)
Dissection of the peel overlying the visceral peel is performed at the dorsal and diaphragmatic aspects of the lung using the lung dissector and lung forceps until the entire lung has been decorticated and debrided.
11 - Rinsing the cavity & reinflation of the lung (10:01)
At the end of the procedure, two large-bore chest tubes are inserted through the two thoracoports of the 6th interspace and are placed by use of endoscopic vision at the pleural dome and the costophrenic sulcus, respectively. The cavity is then rinsed with 3 l of warmed NaCl solution through the chest tubes, with instillation of the solution through the caudal and aspiration through the apical chest tube. The lung is inflated at the end of the procedure. Bronchoscopy is liberally performed at the end of the procedure in order to clean the bronchial tree from secretion and to facilitate lung expansion.
Surgical technique of open decortication
Open decortication as initially described by Delorme and Fowler at the end of the 19th century remains the treatment of choice for chronic stage III pleural empyema.12 - Extrapleural dissection: Initial steps (10:08)
A standard posterolateral thoracotomy is performed with resection of the 6th or 7th rib to avoid undue traction and fractures of the adjacent ribs in case of restriction when using the rib spreader. The latissimus dorsi muscle is spared, dissected, and detached at its insertion if an intrathoracic muscle transposition is planned. Extrapleural dissection is performed to circumferentially free the peel together with the lung in order to prevent parenchymal lesions of the lung tissue during intrapleural mobilization. Initially, this is best performed by use of a dissector or scissors.
13 - Extrapleural dissection: Finger dissection (10:43)
Once the extrapleural plane has been identified, further extrapleural dissection may be performed by digitoclastic dissection in order to prevent parenchymal lesions of the lung tissue interfering with mobilization of the lung.
14 - Extrapleural dissection: Swab mounted on forceps (11:03)
Dissection may be performed using a swab or tampon mounted on a forceps or curved clamp, depending on the location of dissection and the degree of chronicity of the infection.
15 - Freeing the lung (11:21)
The lung is gradually freed in an extrapleural plane from the chest wall, the apex, the diaphragm and the anterior and posterior mediastinum. Dissection with a swab may be especially helpful at the level of the vena cava superior and the anterior mediastinum in order to prevent venous lacerations or injury to the phrenic nerve.
16 - Dissection of visceral pleura using scissors (11:36)
After circumferential extrapleural dissection, the peel is incised and decortication of the visceral pleura is performed. This may be achieved by use of a vascular dissector, finger dissection, a tampon mounted on a curved clamp, or with scissors, depending on the properties of the peel and the chronicity of the empyema. This sequence shows dissection using scissors.
17 - Dissection of visceral pleura using a dissector (11:51)
Depending on the situation encountered, dissection of the visceral pleura may require the use of a vascular dissector.
18 - Dissection of visceral pleura using a dissector (continued) (12:13)
Ongoing dissection of the visceral pleura using a vascular dissector, which is particularly useful in dealing with dense adhesions between the peel and the visceral pleura.
19 - Dissection of visceral pleura using a dissector & scissors (12:28)
This sequence shows the combined application of scissors and dissector in order to achieve dissection as close as possible to the visceral pleura without perforating the lung.
20 - Finger dissection of visceral pleura (12:52)
Depending on the degree of adhesions between the lung and the peel, finger dissection may be considered.
21 - Blunt dissection using a swab (13:04)
Blunt dissection may also be achieved by use of a swab mounted on a Kelly forceps.
22 - Freeing lung from visceral peel (13:27)
The dissected peel is gradually incised by scissors in order to facilitate further dissection until the entire lung has been freed from its visceral peel.
It is important to be aware of the proper dissection plane between the lung surface and the peel. This is achieved by gentle ventilation of the lung with low tidal volumes which facilitates the identification of the proper dissection plane between the peel and the lung. An inadequate dissection plane will prevent the lung from proper expansion during ventilation and carries the risk of late restriction and recurrent infection.
Wound closure
The closure of thoracotomy must be water- and air-tight, and this is achieved by adapting the ribs using pericostal figure-of-eight 2-Vicryl sutures. Careful preservation of the soft tissues during rib resection (including the periosteum) is mandatory in order to achieve a tight wound closure. Intraoperative intercostal injection of Carbostesin will help to diminish postoperative pain if the insertion of a peridural catheter is contraindicated.
The mainstay of treatment of pleural empyema is the control of ongoing infection and the prevention of recurrent infection and late restriction. Incomplete drainage of the pleural space with persistent signs of infection should prompt surgical intervention. Delaying surgical treatment results in functional impairment and substantial morbidity and mortality. However, the decision-making process for appropriate treatment (surgical and non-surgical) is a vexing clinical problem due to the absence of specific clinical, radiological and laboratory characteristics for appropriate preoperative staging of empyema .
The advent of video-assisted thoracic surgery (VATS) for the management of fibrinopurulent stage II empyema has shown rewarding results in several reports . VATS has the advantage of being less invasive than open decortication and is better accepted by the referring physician and the patient. However, it has become apparent that VATS has its limitations for the treatment of stage III disease, according to several reports, and our own results endorse the findings of others that VATS is an inappropriate approach for formal decortication in true stage III empyema .
To overcome the limitations of VATS in the treatment of empyema, and the difficulties of preoperative prediction of the stage of empyema, several investigators have adopted a simple and pragmatic approach in patients with empyema referred for surgery. Patients with a long-lasting history, a thickening of the pleura, and signs of restriction on CT scan, and those with an additional pathological finding on CT scan such as an abscess or a tumor, usually undergo decortication by primary thoracotomy. In all other situations, patients are informed that a VATS approach will be attempted and informed consent is obtained to proceed to thoracotomy if chronic empyema is found at exploration by VATS.
A 3-cm long incision is made in the ventral aspect of a presumed thoracotomy line followed by finger palpation and endoscopic exploration. In case of a stage III empyema, the incision is enlarged to a standard thoracotomy. This pragmatic approach allows for a rapid differentiation between patients who may be treated by VATS debridement and those who require formal decortication.
A recent study analyzed the role of VATS and the predictors of conversion thoracotomy in a consecutive series of 328 patients referred for surgery of stage II and III empyema . This study demonstrated that VATS debridement was applicable in only a limited number of patients referred for surgery for empyema. Of the 328 patients, 150 underwent primary open decortication due to chronic stage III empyema or due to the underlying cause of empyema requiring thoracotomy and lung resection for abceeding lung tumors, bronchopleural fistula, or abceeding lung infarctions after pulmonary embolism. CT scan may not only help to estimate the chronicity of an empyema but also to determine its underlying cause, which is important when defining treatment strategy and surgical approach . One hundred and seventy-eight patients underwent a VATS attempt for presumed stage II disease but conversion thoracotomy was judged necessary in 79 patients because of chronicity of the disease.VATS debridement was achieved in only 30% of all patients referred for surgery in our series. These findings are similar to those from other recently published reports .
Several reports have shown the importance of the time interval between onset of symptoms and surgery on the chronicity of empyema and the likelihood of a successful treatment by VATS . Patients with presumed stage III disease usually have an interval between onset of symptoms and surgery of more than 3 weeks and present with a thickened enhanced pleura and signs of restriction on CT scan. The time-frame between onset of symptoms and surgery where VATS debridement can be performed with success has been shown to be between 1 and 2 weeks (Graph 1).
Graph 1. Probability of conversion thoracotomy in 178 patients
undergoing VATS for presumed stage II empyema according to the time interval between onset of symptoms and surgery.
The time interval between onset of symptoms and surgery has been shown to be the most important predictor for conversion thoracotomy in a multivariate analysis performed for this purpose; the probability of conversion thoracotomy rose from 22 to 86% for a time interval of 12 and 16 days, respectively . The importance of early referral of patients with suspected empyema to surgery cannot be overemphasized if a minimally invasive approach is to be considered.
The second predictor for conversion thoracotomy in this study was the presence of gram-negative microorganisms in the collected pleural fluid. The presence of Escherichia coli and Enterobacter cloacae was always associated with conversion thoracotomy in this series. It has been suggested that the rapidity of progression and stage transition of empyema are affected by the type and virulence of the involved organisms.
There is a trend that the conversion thoracotomy rate is also higher in patients with post-pneumonic empyema as compared to those with post-traumatic and postoperative empyema, which might be due to a longer period of unsuccessful medical treatment before referral to surgery in patients with parapneumonic empyema. The conversion thoracotomy rate in patients undergoing a VATS approach for parapneumonic empyema has been analyzed in several reports and ranged from 18 to 59% .
The 30-day postoperative mortality after VATS debridement and open decortication has been reported to range between 1.3 and 6.6% . Postoperative complications are expected in about 10% of the patients, including recurrence of empyema in 2% after VATS and 2.6% after open decortication, respectively .
In conclusion, VATS debridement offers an elegant minimally invasive approach in some patients with presumed stage II empyema. However, conversion thoracotomy should be liberally used if chronic disease is found.
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This tutorial was originally published by EACTS with Oxford University Press and has been adapted to fit our new MMCTS templates.
Authors
Hans-Beat Ris and Thorsten Krueger
Author Affiliations
Department of Thoracic Surgery, CHUV, 1011 Lausanne, Switzerland
Corresponding Author
Hans-Beat Ris
Department of Thoracic Surgery, CHUV, 1011 Lausanne, Switzerland
Phone: +41 21 3142 408
Email: hans-beat.ris@chuv.hospvd.ch
Keywords
© The Author 2005. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
