Accepted Manuscript. Current State of the Art for the Surgical Management of empyema thoracis. K. Robert Shen, M.D.

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1 Accepted Manuscript Current State of the Art for the Surgical Management of empyema thoracis K. Robert Shen, M.D. PII: S (18) DOI: Reference: YMTC To appear in: The Journal of Thoracic and Cardiovascular Surgery Received Date: 31 October 2018 Accepted Date: 1 November 2018 Please cite this article as: Shen KR, Current State of the Art for the Surgical Management of empyema thoracis, The Journal of Thoracic and Cardiovascular Surgery (2018), doi: j.jtcvs This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 Current State of the Art for the Surgical Management of empyema thoracis An Editorial Editorial Commentary on manuscript JTCVS R1 Morbidity and 30-day Mortality after Decortication for Parapneumonic Empyema and Pleural Effusion among patients in the Society of Thoracic Surgeons General Thoracic Surgery Database K. Robert Shen, M.D. Professor of Surgery Mayo Clinic Department of Surgery, Division of General Thoracic Surgery 200 First St. SW Rochester, MN Phone Fax I have no conflicts of interest relevant to this manuscript.

3 Although empyema is a disease that has plagued humanity since ancient times, it remains an important source of morbidity and mortality worldwide. Empyema is the most common complication of pneumonia. There are approximately 1 million patients hospitalized in the United States each year with pneumonia. Of those hospitalized for pneumonia, 20% to 40% will develop a parapneumonic effusion. 5%-10% of these parapneumonic effusions will progress on to an empyema (approximately 32, 000 patients per year in the United States). 1 Approximately 15% of these patients with empyema die and 30% require an operation in their chest to clear the infection. 2 Although the incidence of empyema decreased significantly in the first half of the 20 th century with the widespread introduction of effective antibiotics, this trend changed in the 1990s and since then the incidence of empyema in the United States has been increasing. The management of empyema has historically varied significantly from hospital to hospital and across the many different medical specialists who may care for patients with this disease. Towe and colleagues 3 have analyzed 16 years of data from the Society of Thoracic Surgeons General Thoracic Surgery Database to provide a contemporaneous snapshot of the state of surgical management of parapneumonic empyema and pleural effusion in the United States. Based on an analysis of over 7000 patients undergoing surgical treatment for acute parapneumonic empyema and pleural effusion they report that a video assisted thoracoscopic (VATS) approach was utilized in 60% of the cases and the utilization rate of the VATS approach increased during the study period. Patient treated with a thoracotomy were found to have increased operative mortality, major morbidity, prolonged hospitalization, and need for rehabilitation compared to those who had a VATS approach. Regardless of the surgical approach, the overall morbidity and mortality for this group of patients was significant with an overall mortality rate of 3.1% and a complication rate of 39.3%. The strength of this study is that it represents the largest contemporaneous report of the results of surgical management of patients in the United States undergoing treatment for acute parapneumonic empyema and pleural effusion. Yet as the authors appropriately caution, one cannot come to any conclusions about the superiority of VATS vs thoracotomy based on the analysis of the data presented. The retrospective observational nature of the study design as well as the inherent limitations of the data fields collected by the STS database, that do not have the granularity to capture differences in disease severity or duration of disease between patients, create the potential for significant confounding bias. Furthermore, in many cases the differences between VATS and thoracotomy approach outcomes are quite small but reach statistical significance due to the large size of the dataset. However, that being said, it appears that there is a growing consensus, at least amongst thoracic surgeons who contribute data to the STS GTS database, that when possible, a VATS approach is feasible and appropriate treatment for a large number of patients with acute empyema and parapneumonic pleural effusion. This view has also been supported by the recent publication of the AATS Consensus guidelines for the management of empyema which recommended that VATS should be the first-line approach for all patients with stage II acute empyema. 4

4 References: 1. Maskell, N. A., S. Batt, et al. (2006). "The bacteriology of pleural infection by genetic and standard methods and its mortality significance." American journal of respiratory and critical care medicine 174(7): Ahmed, R. A., T. J. Marrie, et al. (2006). "Thoracic empyema in patients with communityacquired pneumonia." The American journal of medicine 119(10): Towe CW, Carr SR, Donahue JM, Burrows W, Perry Y, Kim S, Kosinski A, Linden PA. (2018) Morbidity and 30-day Mortality after Decortication for Parapneumonic Empyema and Pleural Effusion among patients in the Society of Thoracic Surgeons General Thoracic Surgery Database. J Thorac Cardiovasc Surg 4. Shen KR, Bribriesco A, Crabtree T, Denlinger C, Eby J, Eiken P, Jones DR, Keshavjee S, Maldonado F, Paul S, Kozower B. The American Association for Thoracic Surgery Consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg Jun;153(6):e129-e146. doi: /j.jtcvs Epub 2017 Feb 4.

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