Note: This case report was written with the assistance of Dr. Carlos Cesar Ochoa Gaxiola.
Case Report: Dual port thoracoscopic decortication of empyema
Presentation: A 38-year-old woman presented to the local hospital with fever, pneumonia, chest pain and an elevated leukocyte count of 25,000. Initial chest x-ray showed a large left-sided effusion.
Risk factors: Patient had several traditional risk factors for the development of empyema including heavy ETOH, and malnutrition, poor access to healthcare. Patient HIV, and Hep C negative.
Initial Hospital Course: She was admitted, and started on dual therapy antibiotics (ceftriaxone & levofloxacin). A chest tube was placed with return of frank purulent material. After several days of draining minimal amounts of pus, patient remained febrile.
Subsequent CT scan showed a left-sided empyema with large loculated areas. At that time, thoracic surgery was consulted for additional evaluation and treatment. Surgery was scheduled.
At the time of surgery, patient remained on dual antibiotics with WBC of 19,000. Albumin 1.5 , Hgb 10.2, Hct 33, other labs within normal limits.
Surgical procedure: dual-port VATS with decortication
The initial chest tube was removed, patient was prepped and draped in the traditional sterile fashion. The previous chest tube site was carefully cleaned with a betadine solution, and debrided of purulent material to prevent abscess tract formation, with instrumentation traded out after debridement.
A single additional ten mm thoracoscopy port was created, with visual interior inspection performed. Initial inspection confirmed the presence of a stage IV empyema with large loculations, moderate pleural thickening and the presence of frankly purulent material adhering to the pleural/ chest wall and lung tissue. The pleura was noted to be thickened but malleable, loosely adherent to the pleural and lung surfaces.
A formal decortication was undertaken with separation of the lung from the diaphragm and adhesions to obliterate the empyema cavity. Decortication of visceral pleura was performed until the lung was completely free and able to re-expand. Lavage was performed with evacuation and drainage of copious amounts of purulent materials.
After decortication was complete, two chest tubes were placed*; anteriorly and posteriorly, under thoracoscopic guidance, and the lung was re-inflated.
*Due to the location, and presence of infection/ purulent material in the initial chest tube site, an additional chest tube site (5mm) was created at the time of chest tube insertion to prevent additional infectious complications.
At the conclusion of the case, patient was awakened and extubated prior to being transferred to the PACU as per post-operative protocols.
EBL during the case was minimal.
Post-operative course: Patient’s post-operative course was uncomplicated. On post-operative day #5, anterior chest tube was removed. On post-operative day #7, the posterior chest tube was removed. Patient was discharged post-operative day #8.
Discussion: While convention medical wisdom dictates a trial and error treatment approach with initial trial of antibiotic therapy followed by chest tube placement (Light, 1995), surgeons have long argued that this delay in definitive treatment places the patient at increased risk of significant morbidity and mortality (Richardson, 1891). Indeed, as discussed by Dr. Dov Weissburg (on a previous discussion of empyema and lung abscess) multiple recent reviews of the literature and research comparisons continue to demonstrate optimal outcomes with surgery based approaches versus antibiotics alone, TPA and tube thoracostomy. The ability to perform these procedures in the least invasive fashion (VATS versus thoracotomy approaches) defies the arguments against surgical intervention as advanced by interventionalists (radiologists and pulmonologists.) Successful decortication with the use of dual port thoracoscopy is another example of how technology is advancing to better serve the patient and provide optimal outcomes.
Earlier, not late surgical referral would have been of greater benefit to this patient.
I apologize but I was unable to take films / photographs of this procedure during this case.
References (with historical perspectives)
Andrade – Alegre, R., Garisto, J. D. & Zebede, S. (2008). Open thoracotomy and decortication for chronic empyema. Clinics, 2008; 63 (6), 789 – 93. Color photographs. Panamanian paper discussing the effectiveness of traditional open thoracotomy and decortication for stage III / chronic empyemas in an era of increased reliance on VATS. Observations and recommendations for open thoracotomy approach for chronic empyema based on 33 cases spanning from March 1992 – June 2006, showing safe and effective results with open surgery for more advanced/ chronic empyemas.
Light, R. W. (1995). A new classification of parapneumonic effusions and empyema. Chest (108) 299 – 301.
Marks, D. J., Fisk, M. D., Koo, C. Y., et. al. (2012). Thoracic empyema: a 12-year study from a UK tertiary cardiothoracic referral centre. PLoS One. 2012;7(1):e30074. Epub 2012 Jan 20. Treatment with VATS was shown to reduce the length of stay versus open surgery with a 15% conversion rate.
Nwiloh, J., Freeman, H. & McCord, C. Malnutrition: an important determinant of fatal outcome in surgically treated pulmonary suppurative disease. Journal of National Medical Association, 81(5) 525-529.
Richardson, M. H. (1891). Surgical treatment of acute and chronic empyemas. While surgical techniques have greatly changed in the 100+ years since this paper was initially published (and no one suffers from carbolic acid poisoning anymore), many of the observations of Drs. Richardson and Loomis remain clinically relevant and valid today. (As previously noted by Dr. Weissburg, this was a pre-antibiotic era.)
Balance, H. A. (1904). Seven cases of thoracoplasty performed for the relief of chronic empyema. British medical journal, 10 Dec 1904, 1561 – 1566. Dr. Balance discusses the development of Delnorme’s operation as an alternative to thoracoplasty while presenting several cases from his career. Photographs.
Tuffier, T. (1922). The treatment of chronic empyema. Discussion of 91 cases, with radiographs.
Thoracic Surgery 