Tag: decortication

Case Report: Dual port thoracoscopy for decortication, part II

case report on dual port thoracoscopy

This case study was prepared with assistance from Dr. Carlos Ochoa. Since we have been discussing the relevance of case reports and providing tips on case report writing for new academic writers – we have written the following case report in the style advocated by McCarthy & Reilley (2000) using their case report worksheet to demonstrate the ease of doing so in this style.

Since the previous presentation of dual-port thoracoscopy for decortication was missing essential materials, we are presenting a second case report.

Authors: K. Eckland, ACNP-BC, MSN, RN & Carlos Ochoa, MD

Case Report: Dual port thoracoscopy for decortication of a parapneumonic effusion

Abstract:  The use of increasingly minimally invasive techniques for the treatment of thoracic disease is becoming more widespread. Dual and even single port thoracoscopy is becoming more frequent in the treatment of parapneumonic effusions and empyema.

Clinical question/problem: the effectiveness and utility of dual port thoracoscopy for parapneumonic effusions.

Analysis of literature review: Despite the increasing frequency of dual and single port thoracoscopic techniques, there remains a dearth of literature or case reports on this topic.  Pubmed and related searches reveal only a scattering of reports.

Summary: As the case report suggests, dual port thoracoscopy is a feasible and reasonable option for the treatment of parapneumonic effusion.

Case history:  50-year-old patient with a three-week history of pneumonia, with complaints of right-sided chest pain, cough and increased phlegm production.  Additional past medical history is significant for poorly controlled diabetes, hypertension, and obesity with central adiposity.  Medications included glyburide and lisinopril.

After being seen and evaluated by an internal medicine physician, the patient was started on oral antibiotics.  After three weeks, when his symptoms failed to improve, he was referred by internal medicine to thoracic surgery for out-patient evaluation.

On exam: middle-aged obese diabetic gentleman in no immediate distress, resting comfortable in the exam room.  Face appeared moderately flushed, but skin cool and dry to the touch, no evidence of fever.

On auscultation, he had diminished breath sounds over the right lower lobe with egophony over the same area.  The remainder of the exam was essentially normal.

Lab studies showed a mildly elevated WBC of 11.6, decreased Hgb of 10.4 / HCT 32.5.   Hemoglobin A1c 10.6, Fasting glucose 228, HDL mildly low at 40.

EKG showed slight axis deviation, with slightly prolonged QRS complex (.16) with no evidence of loss of R, St elevation or other abnormalities.  He was cleared by internal medicine for surgery.

Radiographic data:

Chest x-ray showing right-sided loculated effusion
CT slices, tissue window

After risks, benefits and alternatives to VATS decortication were explained to the patient – the patient consented to proceed with surgical decortication.  After scheduling surgery, the patient was seen by anesthesia in preparation for the procedure.

Surgical procedure:  Dual-port thoracoscopy with decortication of parapneumonic effusion.

Dual port thoracoscopy

After being prepped and drapped in sterile fashion and confirmation of dual lumen endotracheal tube placement, a small 2 cm incision was made for insertion of a 10mm port.  Following entry into the chest with the thoracoscope, the right lung was deflated for optimal inspection and decortication of loculations.  After completing the majority of the procedure, a second access port was created for better visualization and to ensure that a thorough decortication was completed.  The lung and pleural were separated from the chest wall, and diaphragm, and demonstrated good re-expansion with lung re-inflation prior to completion of the procedure.

chest tubes at conclusion of case

At the conclusion of the procedure, two 28 french chest tubes were placed in the existing incisions.  These were sutured into place, and connected to a pleurovac drainage system before applying a sterile gauze dressing.  The patient remained hemodynamically stable throughout the case, with no episodes of hypoxia or desaturation.  Following surgery, the patient was transferred to the PACU in stable condition.

Post-operative course was uncomplicated.  Chest tubes were water-sealed on POD#3 and chest tubes were removed POD#4, with the patient being subsequently discharged after chest x-ray.

close up view of dual port thoracoscopy

Literature Review

A literature review was performed on PubMed using “dual port thoracoscopy”, “dual port VATS”, “2 port” as well as minimally invasive thoracoscopic surgery “

Results of search:  A limited number of case studies (3) described thoracoscopic surgery with a single port.  There was one case found describing cases conducted with two ports, and the majority of reports involved three or more access ports.

Discussion/ Conclusion

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). 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, and offers a minimally invasive option when single port surgery may not be feasible.

During the case above, visibility and access to the thoracic cavity was excellent.  However, in cases requiring additional access, reversion to the standard VATS configuration can be done easily enough with significant delays or additional risks to the patient.

References/ Resources

Foroulis CN, Anastasiadis K, Charokopos N, Antonitsis P, Halvatzoulis HV, Karapanagiotidis GT, Grosomanidis V, Papakonstantinou C. (2012). A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study.  Surg Endosc. 2012 Mar;26(3):607-14. [free full text not available.]

Gonzalez – Rivas, D., Fernandez, R., De la Torre, M., & Martin – Ucar, A. E. (2012).  Thoracoscopic lobectomy through a single incision.  Multimedia manual cardio-thoracic surgery, Volume 2012.  This is an excellent article which gives a detailed description, and overview of the techniques used in single incision surgery.  Contains illustrations, full color photos and videos of the procedure.

Gonzalez-Rivas D, Paradela M, Fieira E, Velasco C. (2012).  Single-incision video-assisted thoracoscopic lobectomy: initial results.  J Thorac Cardiovasc Surg. 2012 Mar;143(3):745-7.

Gonzalez-Rivas D, de la Torre M, Fernandez R, Mosquera VX. (2011).  Single-port video-assisted thoracoscopic left upper lobectomy.  Interact Cardiovasc Thorac Surg. 2011 Nov;13(5):539-41.

Case Report: Dual port VATS decortication of empyema

case report of dual port thoracoscopy for decortication of empyema in a thirty-eight year old woman.

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.