empyema – Thoracic Surgery

Post operative pain after thoracic surgery

What kind of pain should patients expect after thoracic surgery, and how long will it last? Also, is this normal? When should I call my doctor?

Like all posts here at Cirugia de Torax, this should serve as a guide for talking to your healthcare provider, and is not a substitute for medical advice.

Quite a few people have written in with questions about post-operative pain after thoracic surgery procedures so we will try to address those questions here.

1. What is a normal amount of pain after these procedures?

While no two people will experience pain the same, there are some general guidelines to consider. But to talk about this issue – we will need to refer to a basic pain scale which rates pain from 0 (no pain) to 10 – (excruciating, writhing pain, worst possible imaginable).

Unfortunately, for the majority of people who have thoracic surgery, there will be some pain and discomfort.

Pain depends on the procedure

In general, the intensity and duration of pain after thoracic procedures is related to the surgical approach – or the type of surgical incision used.

open thoracotomy,empyema, advanced with extensive purulence — This open incision (with rib spreading) will hurt more..
Photo: advanced empyema requiring open thoracotomy for decortication

Pain will be much less with a single incision VATS surgery (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)

Patients with larger incisions like a sternotomy, thoracotomy or clamshell incision will have more pain, for a longer period of time than patients that have minimally invasive procedures like VATS because there is more trauma to the surrounding tissues. People with larger incisions (from ‘open surgeries’) are also more likely to develop neuralgia symptoms as they recover.

. (I will post pictures of the various incisions once I return home to my collection of surgical images).

Many patients will require narcotics or strong analgesics for the first few days but most surgeons will try to transition patients to anti-inflammatories after surgery.

Post-operative surgical pain is often related to inflammation and surgical manipulation of the chest wall, particularly in procedures such as pleurodesis, decortication or pleurectomy. For many patients this pain will diminish gradually over time – but lasts about 4 to 6 weeks.

Anti-inflammatories

This pain is often better managed with over the counter medications such as ibuprofen than with stronger narcotics. That’s because the medication helps to relieve the inflammation in addition to relieving pain. Anti-inflammatory medications also avoid the risks of oversedation, drowsiness and severe constipation that often comes with narcotics.

Use with caution

However, even though these medications are available without a prescription be sure to talk to your local pharmacist about dosing because these medications can damage the kidneys. Also, be sure to keep hydrated while taking this medications.

People with high blood pressure should be particularly cautious when taking over the counter anti-inflammatories because many of these medications have drug interactions with blood pressure medications.

2. “I had surgery three weeks ago, and I recently developed a burning sensation near the incision”

Neuralgias after surgery

For many patients, the development of a neuralgia is a temporary effect and is part of the healing process. However, it can be quite disturbing if patients are unprepared. Neuralgic pain is often described as a burning or stinging sensation that extends across the chest wall from the initial incision area. Patients also describe it as a ‘pins and needles’ sensation or “like when your foot falls asleep”. This usually develops a few weeks after surgery as the nerves heal from the surgery itself.

It the discomfort is unmanageable, or persists beyond a few weeks, a return visit to your surgeon is warranted. He/She can prescribe medications like gabapentin which will soothe the irritated nerves and lessen the sensations. However, these medications may take some time to reach full effect.

Range of motion and exercise after surgery

Exercise limitations are related to the type of incision.

Sternotomy incisions/ sternotomy precautions

If you have a sternotomy incision – (an incision through the breast bone at the center of your chest), this incision requires strict precautions to prevent re-injury to the area. Since the sternal bone was cut, patients are usually restricted from lifting anything greater than 10 pounds for 6 to 12 weeks, and to avoid pushing, pulling or placing stress on the incision. Patients are also restricted from driving until bone healing is well underway. (Be sure to attend a rehab program or physical therapy program to learn the proper way to exercise during this time period).

Patients will also need to take care to prevent a surgical skin infection or something more serious like mediastinitis. The includes prohibitions against tub bathing/ soaking, swimming or over- aggressive cleaning of the incision with harsh abrasives like hydrogen peroxide or anti-bacterial soaps. These chemicals actually do more harm than good in most cases by destroying the newly healing tissue. A good rule of thumb to remember (unless your doctor says otherwise): No creams or lotions to your incisions until the scabs fall off.

Post-thoracotomy incisions

With a large thoracotomy incision, most patients will be restricted from lifting any items greater than 10 pounds on the surgery side for around two weeks. However, unlike sternotomy patients – we want you to use and exercise that arm daily – otherwise patients have a risk of developing a ‘disuse’ syndrome. One of the common exercises after a thoracotomy is called the spider crawl. This exercise helps the muscles to heal and prevent long-term disability or problems. The physiotherapist at your local hospital should have a list of several others that they can teach you to practice at home.

The spider crawl

In this example, the patient had a left thoracotomy:

1. Stand with your surgical side within arm’s length of the wall.

Now, use your hand to “walk” up the wall, similar to a spider crawling.

'walking' the hand up the wall — ‘walking’ the hand up the wall

Continue to walk your hand up the wall until your arm is fully extended.

Perform this exercise (or similar ones) for several minutes 5-6 times a day. As you can see – it is fast and easy to do.

VATS

For patients with minimally invasive procedures – there are very few exercise restrictions, except no heavy lifting for 2 to 3 weeks (this is not the time to help your neighbor move his television.)

General incision care guidelines are similar to that for sternotomy patients – no soaking or bathing (showering is usually okay), no creams or lotions and no anti-bacterial soaps/ hydrogen peroxide/ harsh cleaners.

Whats NOT normal – when it’s time to call your surgeon

– dramatic increase in pain not associated with activity (i.e. lifting or reaching). If your pain has been a “4” for several days and suddenly increases to an “8”

– If the quality of the pain changes – ie. if it was a dull ache and becomes a stabbing pain.

– any breathlessness, shortness of breath or difficulty breathing

– Any increase in redness, or swelling around your incisions. Incisions may be pink and swollen for the first 2-3 days, but any increase after that warrants a ‘wound check’ by your surgeon

– Any fresh bleeding – bright red blood. A small amount of drainage (from chest tube sites) that is light pink, clear or yellow in nature may be normal for the first few days.

– Drainage from the other sites (not chest tube sites) such as your primary incision is not normal and may be a sign of a developing infection.

– Fever, particularly fever greater than 101.5 – may be a sign of an infection.

– If you are diabetic, and your blood sugars become elevated at home, this may also be a sign of infection. (Elevation in the first few days is normal, and is often treated with insulin – particularly if you are in the hospital.

– Pain that persists beyond 3 months may be a sign of nerve damage (and you will need additional medications / therapies).

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:

CXR — Chest x-ray showing right-sided loculated effusion

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.

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.

OLYMPUS DIGITAL CAMERA — 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.

VATS decortication: Empyema

an in-depth look at video-assisted thoracoscopy for decortication of advanced empyema.

In a previous series of posts discussing a recent paper presented by a group of Australian pulmonologists, we debated the use of VATS for decortication of advanced empyemas versus medical treatments. Today, I would like to talk more about the VATS decortication procedure itself. This procedure is performed to remove infected material (pus) from the thoracic cavity so the lung can re-expand.

In advanced empyema, a tough, fibrous layer (or peel) forms around the lung and prevents full re-expansion. (This peel has the appearance and texture of rubbery chicken skin.)

pleural peel — thick pleural removed during decortication

In these cases, decortication (or peel removal) is necessary for full recovery.

renteria 007 — VATS decortication of a loculated empyema

If the peel isn’t removed, the lung will remain compressed and infection can easily recur. In VATS surgery, several ports are used (small 2cm incisions) versus a larger thoracotomy incision. This isn’t always possible; if the infection is severe, or surgeons are unable to free the lung through the smaller incisions. Sometimes surgeons have to convert to open surgery intra-operatively. However, VATS is preferable for patients, (if possible). Smaller incisions mean less injury, less pain leading to fasting healing, and a shorter hospital stay.

empyema, advanced with extensive purulence — advanced empyema requiring open thoracotomy for decortication

Click here to see a video showing a standard thoracotomy incision (with retractors holding it open).

As we mentioned in a previous post – empyema is a serious, potentially fatal infection* – in fact – one out of three patients with this condition will die from it.

What’s the difference between empyema and a parapneumonic effusion? Answer: Pus.

*while this case report features a patient from Uganda, similar cases have been encountered in my practice here in the USA.

References:

Prilozi. 2010 Dec;31(2):61-70. Indications for VATS or open decortication in the surgical treatment of fibrino-purulent stage of parapneumonic pleural empyema. Colanceski R, Spirovski Z, Kondov G, Jovev S, Antevski B, Cvetanovski M V. Article linked in text above, recommending early surgical treatment for better patient outcomes. However, this study did not compare surgical treatments to medical therapies.

Asian Cardiovasc Thorac Ann 2010;18:337–43. Thoracic empyema in high-risk patients: conservative management or surgery? Bar I, Stav D, Fink G, Peer A, Lazarovitch T, Papiashvilli M. Limited study of 119 patients showing benefit in both groups of patients with surgery used as primary management strategy in clinically unstable patients. (Increased mortality in this limited study of surgical interventions versus medical management can be attributed to the fact that surgery was used as a last resort in the sicker, more debilitated patients by the authors descriptions).

Metin M, Yeginsu A, Sayar A, Alzafer S, Solak O, Ozgul A, Erkorkmaz U, Gürses A. Treatment of multiloculated empyema thoracis. Singapore Med J. 2010, Mar 51(3): 242-6. Comparison of VATS, open surgery and conventional treatment for empyema. Authors recommend VATS for first line treatment.

older references on VATS decortication:

J Thorac Cardiovasc Surg 1999;117:234-8. Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome. Cassina PC et al. Authors discuss the results of VATS decortication in 45 patients after failed medical treatment and attempted thoracostomy drainage. Several patients required open thoracotomy due to late organized infectious process.

Ann Thorac Surg 2006;81:309-313. Video-Assisted Thoracic Surgery for Pleural Empyema. Wurnig, S. S.,Wittmer, V., Pridun, N., & Hollaus, P. H. (2006). Linked in text above. Austrian study of 130 patients

Ann Thorac Surg 2003;76:225-30. Minimally invasive surgery in the treatment of empyema: intraoperative decision-making. Roberts, J. R

Surgery for pleural infection: Empyema

second in a series of articles questioning whether thoracic surgery remains a relevant treatment for pleural diseases – as discussed in an article by Davies et. al.

In a previous post, we presented an article by Australian pulmonologists that challenged several of the current surgical treatments utilized in thoracic surgery for different pleural conditions. In today’s post we will discuss Davies, Rosenstengel & Lee’s contention that fibrinolytics and thoracostomy drainage are superior versus surgical decortication and evacuation for treatment of empyema. (An empyema is a collection of purulent material or pus from a lung infection that collects in the pleural space. Additional references and information on this condition are listed below.)

Unfortunately, Davies et.al are operating on a faulty premise – that all empyemas are currently managed with surgery or that current treatment theories support the use of surgery for uncomplicated empyemas. For the most part, in early, and uncomplicated empyemas (stage I) – thoracostomy (chest tube placement) and antibiotics are the most common first line treatment. In fact, Na, Dikensoy & Light at Vanderbilt (2008) attributed the high mortality rates in this condition to the failure to pursue more aggressive( surgical) treatment after early evidence of treatment failure (with antibiotics, and thoracentesis.) They, along with most of the thoracic surgery community, advocate surgery as treatment once initial conservative measures fail (as discussed in this article by Barbetakis et. al(2011).

Davies also contends that thoracentesis is an effective measure noting that thoracostomy catheter size is not an issue, stating “Empyema fails to drain most commonly because of multiple septations, a hurdle which large drains will not overcome; increasing numbers of studies now show that larger drain size does not increase efficacy, even in empyema” as an argument against surgery – however – it is this very condition (septations) that is best served by surgery, where surgeons can physically break up and remove these pocketed areas of infectious material.

Photo courtesy of CTSnet – CT scan showing loculatations

While the Austrailian authors argue that the use of antibiotics has changed the treatment regimen of empyema in recent times, a look back at a previous article by our guest commentator shows this too, to be a dated approach.

Surgery is usually reserved for advanced empyemas, with patients presenting in septic conditions, or failure of conservative measures (antibiotics & chest tube treatment) or residual trapped lung following attempted drainage. (However, multiple authors content that the problem with the treatment of empyema is that surgery is not utilized early enough).

As commonly reported in the literature, advanced empyema (stage II or III) or empyema with septic presentation is a serious condition with patient mortality approaching or exceeding THIRTY percent. In these cases, it can easily be argued that more aggressive (and rapid) treatment of these critically ill patients is warranted. Many of these patients have already failed multiple rounds of antibiotics. Evacuation of the infected fluid is key to survival in these patients – and VATS decortication is the most effective way to remove the fibrinous material (that causes loculations and trapped lung.) In these patients – treatment failures lead to rapid reaccumulation of purulent material (pus), and worsening of patient condition.

Another factor to be considered – is that many of these patients initially present to hospitals with later stage empyemas due to delayed diagnosis in outpatient settings. These patients have loculations and evidence of trapped lung on initial CT evaluation. Given the gravity of this condition, and the relative ease (and safety) of modern-day surgery by VATS – surgical intervention at this time is not unreasonable. If we take practical issues into consideration – the risk of hemorrhage and bleeding with fibrinolytics not withstanding – VATS allows for direct visualization and manipulation within the pleural space.

Surgeons can physically and manually remove purulent material and necrotic tissue, and free compressed lung. (in comparison – fibrinolytics such as t-Pa are injected blindly into the pleural space in an attempt to chemically dissolve fibrous tissue.) These medications (which are also known as ‘clot busters’) can cause severe bleeding – particularly in these patients which often have very friable (or delicate) pleural tissue due to the extensive infection.

Conclusion: A review of existing literature and available studies shows mixed results – making Davies et.al.’s conclusions premature at best – and potentially harmful to this fragile subset of patients. For patients with advanced empyema, or empyema complicated by sepsis – surgical intervention remains the best course of treatment to reduce morbidity and mortality.

Additional references: (limited selection of more recent literature)

Overview and explanation of pleural abscess and empyema on Medscape.

Guidelines for surgical treatment of Empyema and Related Pleural Diseases (note these are pediatric guidelines but the article is clear, concise and well-written.)

Tuberk Toraks. 2008;56(1):113-20. New trends in the diagnosis and treatment in parapneumonic effusion and empyema. Na MJ, Dikensoy O, Light RW

Rahman et. al (2011) reported modest results in their double-blind randominzed study using fibrolytics versus placebo in “Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection,” with use of a combination of agents showing modest decrease in hospital stays and surgical referrals. No benefit was seen with a single agent alone versus placebo. There was no difference in the incidence of adverse outcomes in the treatment group versus placebo.

Curr Opin Pulm Med. 2011 Jul;17(4):255-9. Comparison of video-assisted thoracoscopic surgery and open surgery in the management of primary empyema. Zahid I, Nagendran M, Routledge T, Scarci M. (no free full text available.) In comparison to Davies et. al, Zahid et. al, contend that current evidence supports the use of early VATS decortication rather than conservative measures in this article, published in the same issue of Current Opinions in Pulmonary Medicine.

Clin Med Insights Circ Respir Pulm Med. 2010 Jun 17;4:1-8. Empyema thoracis. Ahmed AE, Yacoub TE. While the authors cite fibrinolytics and thoracostomy for first line treatment in children (who rarely have underlying co-morbidities) – the authors readily concede that VATS decortication is the treatment of choice in adults.

Monaldi Arch Chest Dis. 2010 Sep;73(3):124-9. Practical management of pleural empyema. Tassi GF, Marchetti GP, Pinelli V, Chiari S. (No free full text available). The authors in this review of the literature acknowledge the effectiveness of VATS decortication for the treatment of empyema but recommend additional consideration of medical manangement particularly in more fragile patients.

Asian Cardiovasc Thorac Ann 2010;18:337–43. Thoracic empyema in high-risk patients: conservative management or surgery? Bar I, Stav D, Fink G, Peer A, Lazarovitch T, Papiashvilli M. Limited study of 119 patients showing benefit in both groups of patients with surgery used as primary management strategy in clinically unstable patients. (Increased mortality in this limited study of surgical interventions versus medical management can be easily attributed to the fact that surgery was used as a last resort in the sicker, more debilitated patients by the authors descriptions).

older references on VATS decortication: