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.

In the operating room with Dr. Carlos Ochoa

Dr. Ochoa (left) & Dr. Vasquez (right)
Dr. Ochoa (left) & Dr. Vasquez (right)

After my first encounter with the young, energetic thoracic surgeon in Mexicali in November of 2011, I’ve been waiting for an opportunity to return to Mexico to learn more about Dr. Ochoa and his practice.  After spending an exhausting 48 hours with Dr. Ochoa, I must say that my first impressions regarding this surgeon were correct.  He is tireless in his dedication to his patients, and his efforts to treat the people of Mexicali with the most modern surgical treatments available are impressive.

He carries a small black backpack with him everywhere he goes.  After following him to the operating room for the first case; I know why.  He brings much of his own, privately purchased sterile equipment with him – especially when he is operating at the public hospital.  Out of the bag came sterile packages of double lumen endotracheal tubes*.  Sterile packages of surgical instruments.  His own freshly laundered surgical scrubs.  (The hospital does provide its own sterile surgical gowns, gloves and patient drapes.)

Dr. Ochoa’s black bag filled with sterile supplies

He knows he could ‘do better’ and make more money in a larger city at a more affluent hospital in Mexico, but as he explains – there are only three thoracic surgeons for all of Northern Mexico[1].  He says this without pretension, or expectations. The people of Mexicali need him – even if they don’t know it.  Prior to his arrival, affluent patients went to Tijuana or the United States for treatment.  Poorer patients often went without.

Dr. Carlos Ochoa, at Hospital General de Mexicali

After two cases that morning, and another that evening, we round at several hospitals seeing patients – finishing well past midnight.  He remains unflagging, unhesitating – even swinging past the emergency department at the General hospital to make sure there were no chest trauma cases arriving before finally signing out for the night[2].

We meet again, the next morning and it starts all over again – rounds, clinic visits, surgery, and more rounds.  It is well past ten pm when we finish.  In my brief 48 hours in Mexico during this trip – I’ve spent most of it in the company of Dr. Ochoa while he strives to build his practice and his reputation as a new surgeon.  Watching him, I am frankly, fatigued but he’s ready to continue for as long as he’s needed.

It’s an impressive start to what I anticipate to be a long and rewarding career in thoracic surgery.

* This isn’t as strange as it sounds, especially since he is the only thoracic surgeon in the area (thus the only surgeon using double lumen ET tubes in the city.)

[1] Despite high rates of thoracic diseases such as empyema and XDR tuberculosis.

[2] ‘Signing out’ simply means he is no longer on/ or in the nearby vicinity.  He remains on-call 24/7.