VATS Debridement Versus Thoracotomy in the Treatment of Loculated Postpneumonia Empyema

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1 VATS Debridemen Versus Thoracoomy in he Treamen of Loculaed Pospneumonia Empyema Tom,is A. Angelillo Mackinlay, MD, Gusavo A. Lyons, MD, Domingo J. Chimondeguy, MD, Miguel A. Barboza Piedras, MD, Gusavo Angaramo, MD, and Juan Emery, MD Division of Thoracic Surgery, Briish Hospial Buenos Aires, Argenina Background. There are approximaely 60,000 new cases of pospneumonic empyema every day in he Unied Saes. Usually he fibrinopurulen sage of his complicaion has been reaed by eiher ube horacosomy or horacoomy and debridemen. According o he lieraure, horacoscopic reamen has no been used ofen for his disease. Mehods. Sixy-four cases of pospneumonic fibrinopurulen empyema were operaed on a our insiuion: 33 cases (group I) by means of a formal horacoomy and 31 cases (group II) by horacoscopy. In he horacoscopic subse he daa were colleced prospecively since These resuls were compared wih hose of a hisorical series reaed by horacoomy beween 1985 and Boh populaions were similar in erms of age (mean, 49 years), number of cases (33/31), sex (2.1 male/female), and comorbid saus. Resuls. Mean preoperaive lengh of he medical man- agemen (11.5 versus 17 days) (p = 0.03) and ches ube removal (4.3 versus 6.1 days) were shorer in group II han in group I (p = 0.02). Morbidiy and moraliy were idenical: one deah and five complicaions in each group. Mean operaive ime was similar in boh groups, and hospial say was shorer in he video-assised horacic surgery group (6.8 versus 11.2 days) (p = no significan). Three paiens from group II needed uiliary horacoomies for debridemen compleeness (10% conversion rae). Conclusions. We conclude ha video-assised horacic surgical reamen has he same rae of success as open horacoomy bu offers subsanial advanages over horacoomy in erms of resoluion of he disease, hospial say, and cosmesis. A prospecive and randomized sudy is needed o confirm he findings of his nonrandomized iniial experience. (Ann Thorac Surg 1996;61: ) E ver since Hippocraes (200 BC), empyema horacis has been a well-recognized disease. Is occurrence is mos commonly associaed wih pneumonia [1]. During he Firs World War, empyema cases among Unied Saes miliary forces resuled in an almos wo hirds moraliy (61%). This fac led o he creaion of he "Empyema Commission" made up of disinguished docors, among whom was young Evars Graham [2]. The final recommendaion of he Commission was ha closed surgical drainage was he mos appropriae reamen, lowering he lehal oucome o 9.5%. There are approximaely 1.2 million new cases of pneumonia every year in he Unied Saes. Abou 40% of hem will have an accompanying pleural effusion; 35% will resolve "ad inegrum" wih anibioic reamen (sage I), and 5% (around 60,000 paiens) will be conaminaed by bacerial infecion and develop fibrinopurulen effusion (sage II), complicaed effusion [3], or empyema. The gold-sandard reamen for hese complicaed effusions has been early drainage, eiher by means of a ches ube or hrough a limied horacoomy and de- Acceped for publicaion Jan 30, Presened a he Third Inernaional Symposium on Thoracoscopy and Video-assised Thoracic Surgery, Luxembourg, June 11-13, Address reprin requess o Dr Angelillo Mackinlay, Hospial Bri~nico de Buenos Aires, Perdriel 74, 1280 Buenos Aires, Argenina. bridemen in he fibrinopurulen sage (phase II of Ligh [4]). Organizaion of he fibrinous clos ino fibroic peel causes lung encasemen (phase III of Ligh), which requires a major horacoomy and open decoricaion. Delay in draining hese pleural effusions has resuled, even recenly, in as much as a 22% moraliy rae [5]. The inroducion of video-assised horacic surgery (VATS) in 1991 has offered a less raumaic alernaive by means of closed ches debridemen of fibrinopurulen loculaed cases (early decoricaion). The purpose of his presenaion is o assess he role of VATS debridemen in he reamen of pospneumonia fibrinopurulen empyema (phase If) and o compare is resuls wih hose of a previous similar series deal wih by open horacoomy and debridemen. Paiens and Mehods Paiens Sixy-four cases of pospneumonia empyema in clinical phase II [3] were operaed on by our eam during he las decade (1985 o 1994). Thiry-hree of hem (group I) were reaed by means of a horacoomy beween 1985 and 1991 (7-year span) a a rae of 4.7 per year. The daa concerning his group were obained rerospecively from he medical records. The oher 31 cases (group II) were reaed horacoscopically in a 3-year period (1992 o 1996 by The Sociey of Thoracic Surgeons /96/$15.00 Published by Elsevier Science Inc PII S (96)

2 Ann Thorac Surg ANGELILLO MACKINLAY ET AL ;61: VATS DEBRIDEM ENT OF EMPYE MA Table 1. Paien Feaures Group l: Thoracoomy Group lh VATS p Variable (n - 33) (n = 31) Value Sex (F/M) 13/20 8/23 NS Age (y) Mean NS Range SD Side (R/L/Bil) 15/18/0 13/17/1 NS Preoperaive lengh (days) Mean Range SD Hypoproeinemia 9/33 (27.2%) 3/31 (9.6%) NS Comorbid saus 11/33 (33.3%) 8/31 (25.8%) NS Bil = bilaeral; L lef; NS no significan; R righ; SD -= sandard deviaion; VATS - video-assised horacic surgery. 1994) a a rae of 10.3 per year. They were recorded prospecively ino a compuer program using he same iems available in he hisorical series. These wo series were operaed on during differen ime periods and herefore were no randomized. Sex, age, localizaion, preoperaive lengh of he disease and oher comorbid facors are expressed in Table 1. In all cases he diagnosis was esablished (1) on clinical grounds (fever, cough, dyspnea, and ches pain), (2) by horacocenesis (ph less han 7.00, glucose level less han 40 mg/dl, and lacae dehydrogenase level greaer han 1,000 IU/L), and (3) by compued omographic (CT) scans showing a loculaed effusion. In he firs group only 28 of 33 were sudied by CT scans. The 5 remaining paiens underwen horacoomy before our insiuion had a scanner, so hey had linear omographic evaluaion insead. Surgical Technique The whole series (64 paiens) was operaed on under general aneshesia, using a double-lumen ube for selecive venilaion. This was preceded by fiberopic endoscopy for anaomic assessmen and bronchial oile. The usual vial parameers (eg, median arerial pressure, arerial blood gases, elecrocardiogram, hourly urinary oupu) were always regisered. In group I he horax was approached hrough muscle, sparing laeral horacoomies wih or wihou rib resecion long enough (15 cm) o allow he surgeon o inroduce one hand for manual exploraion of he whole pleural caviy. By his raher blind mehod all fibrin sepae were disroyed and he fissures were liberaed compleely. Afer digial and insrumenal debridemen was accomplished, one or wo large-bore ches ubes were placed in he lower par of he caviy hrough separae incisions. In group II he firs incision was placed raher high (fourh or fifh inercosal space) o permi adequae visual exploraion of he base of he lung and diaphragm as well as cosophrenic and cosoverebral recesses. The firs rocar was hen insered afer digial exploraion. Addiional pors (usually wo or hree) were placed according o he locaion of he loculaions. Only one rocar was used for he elescope; in he res of he pors he insrumens were inroduced direcly hrough he skin incision. Long bowel forceps (Pfoerser), curees, and specially designed highpressure sucion cannulas were used o genly remove fibrin clos and sepae from boh visceral and parieal pleural surfaces, including all issues and recesses. Grea care was exered o avoid damage o he lung, especially when he parenchyma was sill pneumonic. In some insances, one of he por incisions had o be exended a few cenimeers o faciliae digial maneuvers, eiher o permi he use of sandard insrumens for he removal of large quaniies of semiorganized fibrin or o perform limied decoricaions. When fibroic peel was found (3 cases), one of he pors was exended up o 10 cm, allowing enough room o remove he encasing membrane using combined open and videoscopic maneuvers. The lung was reexpanded and checked for air leakage; one or wo drainage ubes were lef in place under endoscopic vision. Paiens from boh series were sen eiher o he inensive care uni or o he room floor depending only on he degree of illness, no on he procedure iself. Anibioics were adminisered for a leas 3 weeks; clinical course, body emperaure, leukocye coun, and duraion of ches ube were always recorded. Ches roengenograms were obained a differen inervals, from immediaely posoperaive up o 6 monhs laer, when paiens were definiively discharged. Saisical Analysis Resuls are expressed a mean values _+ sandard deviaion. Suden's es for paired daa was employed for quaniaive variables and eiher he )(2 or Fisher's es for qualiaive variables. Saisical significance was deermined a a p value of less han Resuls Table 2 compares for boh groups: he lengh of preoperaive reamen and posoperaive ches ube duraion, hospial say, operaing ime, baceriology, and morbidiy and moraliy. Six paiens in each group were reaed preoperaively by unsuccessful ches drainage during a mean period of 6.3 days in group I (range, I o 12 days) and 6.3 days in group II (range, 2 o 13 days) (p = no significan). The mean preoperaive duraion of he effu~ sion was longer in he horacoomy subse (17.5 days versus 11.4 days). Three paiens required a 10-cm uiliary horaeoomy for complee debridemen (10% conversion rae). Culure and gram saining revealed baceria in 31.2% of he whole series (33.3% in group I and 29% in group II). Table 3 shows he idenified baceria in boh groups. Morbidiy and moraliy were idenical: 1 paien died and 5 paiens had complicaions in each group. In he horacoomy subse, he deah was an 82-year-old male paien who had a cerebrovascular acciden wih righ

3 1628 ANGELILLO MACKINLAY ET AL Ann Thorac Surg VATS DEBRIDEMENT OF EMPYEMA 1996;61: Table 2. Resul~ Group I: Group II: Thoracoomy VATS p Variable (n 33) (n - 31) Value Tube duraion (days) Mean Range SD Hospial say (days) Mean Range SD Operaive ime (min) NS Mean Range SD Overall duraion (days) <0.001 Mean Range SD Germ idenificaion 11/33 (33.3%) 9/31 (29%) NS Morbidiy 5/33 (15.1%) 5/31 (16.1%) NS Relapse 4/33 (12%) 0/31 (0%) NS Moraliy 1/33 (3%) 1/31 (3.2%) NS NS = no significan; VATS video-assised horacic surgery. hemiplegia on he fifh posoperaive day and died 49 days laer. The complicaions were 4 cases of residual collecions ha had o be drained by CT scan-guided ube inserion (12% relapse rae) and 1 case of wound infecion. In he VATS subse an 83-year-old man, severely ill wih bilaeral parapneumonic empyema, died 4 days afer VATS debridemen on he righ side and ches ube drainage on he lef. The complicaions were requiremen of mechanical respiraory assisance for 5 days posoperaively in a 63-year-old woman wih bilaeral debridemen, 2 cases of prolonged febrile syndrome (>7 days), and 2 cases of mild wound infecion. In no case did empyema recur afer VATS echnique was applied. All complicaions in boh groups resolved well wihou furher consequences. Commen The reamen of posoperaive empyema should achieve permanen conrol of he infecion by evacuaing locu- Table 3. Baceriology Germ Group I: Group li: Thoracoomy VATS (n 33) (n 31) Saphylococcus aureus 5 2 Srepococcus pneumoniae 4 5 Pseudomonas aeruginosa 1 1 Oher a 1 1 Toal 11/33 (33%) 9/31 (29%).i Mixed culures. laed pus and fibrin debris, hus prevening lae funcional resricion, which resuls from lung fibrous encasemen. Afer reviewing he medical lieraure, several facs emerge clearly: (1) Operaion should be indicaed early [4-10]. (2) Conservaive reamens using lyic agens are of lile value and are associaed wih long hospializaions and greaer morbidiy and moraliy han operaion [11]. (3) There are few publicaions regarding he use of VATS for reamen of loculaed pleural empyema [12-15]. Low-pH (<7.00) parapneumonic effusions wih or wihou posiive bacerial culures and radiologic evidence of fibrinous loculaion are likely o evolve ino fibroic organizaion resuling in lung encasemen. This is he fibrinopurulen sage, Ligh phase II complicaed effusion or empyema. Ligh [3] makes a disincion beween complicaed effusion and empyema depending on wheher bacerial culures are negaive or posiive. Because he lower ph seems o be caused [16] by boh leukocye phagocyosis and bacerial meabolism, i consiues in our view a consisen indirec evidence of pleural fluid infecion. By far, mos of hese paiens have been reaed previously wih anibioics, which may preven bacerial isolaion, making pleural fluid Gram sains negaive. Consequenly we prefer he erm "empyema" because i is indicaive of pleural fluid infecion; i also suggess more srongly he indicaion for early operaion even when he bacerial culives are negaive. The evoluion of a parapneumonic pleural effusion from he exudaive sage o he fibroic encasemen represens a coninuous specrum and has no sharply defined boundaries. Fibrin deposiion wihin he pleural caviy is variable and may ake only a few days [17]. This variabiliy would depend on individual biological reacion, bu seems o be earlier and more pronounced when anaerobic baceria alone or in combinaion wih aerobic germs are he causaive agens [18]. This explains he similar surgical findings in boh series having differen preoperaive lenghs. The mos suggesive sign of empyema on a ches radiograph is an encapsulaed effusion in an aypical posiion. On CT scans empyemas usually are encapsulaed and biconvex, showing hickening of he parieal pleura and he endohoracic fascia along wih increased conras upake of he parieal pleura as shown by Kirsh and colleagues [191. In heir experience CT scans were unable o differeniae beween early and lae phases of empyema. Sricly speaking, many of hese loculaed effusions or empyemas conain no frank pus bu a lo of fibrin clos and membranes forming several comparmens filled wih seropurulen fluid. Wheher frank pus exiss or no, he final oucome will be he same: fibroblas invasion and fibroic peel lung encasemen. Therefore, early operaion remains he gold sandard of reamen. Long before we sared he series described here we had developed he concep ha any loculaed empyema will no respond o ube horacosomy. In hose cases he indicaion was a limied laeral horacoomy, long

4 Ann Thorac Surg ANGELILLO MACKINLAY ET AL ;61: VATS DEBR1DEMENT OF EMPYEMA l PHASE I ANTIBIOTICS I COMPLETE I 'NCOMPLETE RESOLUTION RESOLUTION POST- PNEUMONIC PLEURAL EFFUSION // THORACENTESIS I 1 PHASE II 1 EARLY CT SCANS 1 l FREE EFFUSION LOCULATED EFFUSION l LARGE CHEST." VATS DEBRIDEMENT TUBE DRAINAGE.." k I,L...,,L INCOMPLETE -'~ FIBRIN FIBROTIG PEEL RESOLUTION" DEBRIS PHASE III Fig l. Sraegic algorihm. (CT = compued omographic; VATS = video-assised horacic surgery.) OPEN DECORTICA7[ION COMPLETE 1 I RESOLUTION I enough o inroduce one hand and perform a raher blind debridemen o achieve (1) complee evacuaion of fibrin clos, sepae, and fluid from he pleural caviy including fissures and recesses; (2) a fully expansible lung; and (3) proper posiioning of dependen ube drainage. If fibroic peel was found, he horacoomy was exended as much as necessary o allow a complee pulmonary decoricaion. In 1992 we realized ha hese same goals could be obained by he use of VATS insead of a limied horacoomy bu wih he following advanages: (1) more accurae magnified inspecion of he whole pleural caviy, (2) direc vision for all surgical maneuvers, and (3) avoidance of a horacoomy and is sequelae. Modified liposucion cannulas angled in differen curvaures aached o a high negaive pressure source are he mos effecive ools ha permi expediious removal of parieal and visceral debris wihou injuring he lung parenchyma. On comparing he resuls of boh series he superioriy of he VATS reamen (group II) over he horacoomy approach becomes eviden. Definiive resoluion was obained in all paiens in group II, whereas in group 1 4 paiens (12%) had o be rereaed for debridemen compleion. Three paiens in he VATS group required he exenion of one por up o 10 cm as a uiliary horacoomy (10% conversion rae) because of firmly adheren fibrinous membranes; earlier referral of paiens o operaions could have avoided his undesirable coningency. Mean operaive ime, morbidiy, and moraliy were idenical in he wo groups. Pain was no assessed in eiher group; neverheless, clinical impression would favor group II. Cosmeic resuls were far beer in group II. The mos sriking difference beween he wo surgical modaliies was he duraion of he enire process, resuling from he sum of he preoperaive lengh of medical managemen plus he posoperaive hospial say. The daa so colleced rendered a mean value of 33,72 days for horacoomized paiens and 18.3 days for he horacoscopy group (p < 0.001). This difference was due o a much quicker accepance of operaion by boh he referring physician and he paien when a mini-invasive procedure was proposed. In general, when comparing VATS echnique versus radiional open procedures, higher cos is one of he main objecions o his mini-invasive approach. This is no rue in empyema, where expenses are in fac lower han in he horacoomy group because (1) no special insrumens are needed (cheap reusable cannulas and forceps are he mos appropriae ools), (2) operaive ime is equal, (3) here is no need for or fewer inensive care uni admissions, (4) hospial say is shorer, and (5) paiens reurn o work earlier. Even hough hese wo series are no sricly comparable because of heir chronologic difference and he lack of randomizaion, we conclude ha for he reamen of fibrinopurulen low-ph empyema (1) complee surgical debridemen has proved o be he mos successful reamen, (2) CT scans are he bes mehod o deec fibrin sepae and mus be obained early whenever a pleural effusion complicaes any pneumonic process, and (3) VATS debridemen offers resuls equal o hose of horacoomy in erms of resoluion of he disease bu seems o be more advanageous in erms of surgical sequelae, cosmesis, coss, and labor impedimen. A our insiuion, VATS is a presen he reamen of choice for loculaed pospneumonic empyema (Fig 1). A prospecive and randomized muliinsiuional sudy is needed o confirm he findings of our iniial experience. References 1. Major RH. Hippocraes. In: Major classic descripions of disease. Springfield, IL: Charles C. Thomas, Graham EA. Some fundamenal consideraions in he reamen of empyema horacis. S. Louis: Mosby, 1925: Ligh RW. Parapneumonic effusions and empyema. Clin Ches Med 1985;6: Pohula V, Krellensein DJ. Early aggressive surgical managemen of parapneumonic empyemas. Ches 1994;105:

5 1630 ANGELILLO MACKINLAY ET AL Ann Thorac Surg VATS DEBRIDEMENT OF EMPYEMA 1996;61: Kelly JW, Morris MJ, Empyema horacis: medical aspecs of evaluaion and reamen. Souh Med J 1994;87: Benfield JR. Invied commenary on Ridley PD, Braimbridge MV. Thoracoscopic debridemen and pleural irrigaion in he managemen of empyema horacis. Ann Thorac Surg 1991;51: Chain CW, Haq SM, Rahamin J. Empyema horacis: a problem wih lae referral? Thorax 1993;48: Hoover EL, Hsu HK, Webb H, Toporoff B, Minnard E, Cunningham JN. The surgical managemen of empyema horacis in subsance abuse paiens: a 5-year experience. Ann Thorac Surg 1988;46: Kaplan DK. Treamen of empyema horacis. Thorax 1994; 49: Miller JI. Empyema horacis. Ann Thorac Surg 1990;50: Huer JA, Harari D, Braimbridge MV. The managemen of empyema horacis by horacoscopy and irrigaion. Ann Thorac Surg 1985;39: Sriffeler H, Ris HB, WiJrsen HU, Hof VI, Sirnemann P, Alhaus U. Video-assised horacoscopic reamen of pleural empyema. A new herapeuic approach. Eur J Cardiohorac Surg 1994;8: Ferguson MK. Thoracoscopy for empyema, bronchopleural fisula and chylohorax. Ann Thorac Surg 1993;56: Liu HP, Chang CH, Lin PJ, Hsieh HC, Chang JP, Hsieh MJ. Video-assised horacic surgery. The Chang Gung experience. J Thorac Cardiovasc Surg 1994;108: Hurley JP, McCarhy J, Wood AE. Rerospecive analysis of he uiliy of video-assised horacic surgery in 100 consecuive procedures. Eur J Cardiohorac Surg 1994;8: Sahn SA, Reller LB, Taryle DA, e al. The conribuion of leukocyes and baceria o he low ph of empyema fluid. Am Rev Respir Dis 1983;128: Landay MJ, Chrisensen EE, Bynum LJ, Goodman C. Anaerobic pleural and pulmonary infecions. AJR 1980; 134: Brook I, Frazier EH. Aerobic and anaerobic microbiology of empyema. A rerospecive review in wo miliary hospials. Ches 1993;103: Kirsh E, Guckel C, Kaim A, Seimbrich W. The findings and value of compued omography in pleural empyema. Rofo Forschr Geb Ronsgensr Neuen Bildgeb Verfahr 1994;162: INVITED COMMENTARY This aricle illusraes several imporan poins. Firs, he key is o inervene early in he fibrinopurulen sage (sage II of Ligh) before organizaion ses in. Our approach would be o obain a compued omographic scan when loculaion is suspeced and a he same ime inser a compued omography-direced caheer ino he space. If he loculaion did no resolve and he lung expanded wihin 48 hours (wih or wihou mucolyics) hen horacoscopy would be he approach. Once organizaion ses in and a peel begins o form, hen an open approach is required. The algorihm given by Angelillo Mackinlay and associaes is an excellen sepwise approach o his problem. Almos all loculaed pediaric pleural empyemas can be reaed horacoscopically. Our pediaric surgeons now inervene wihin he firs week when iniial drainage wih a ches ube is unsuccessful. Approximaely 30 cases have been reaed as such wihin he pas 2 years wih no significan morbidiy or moraliy. This is an excellen aricle, and is auhors are o be congraulaed. Joseph L Miller, Jr, MD Deparmen of Cardiohoracic Surgery The Emory Clinic 25 Presco S, NE Suie 3420 Alana, GA The Sociey of Thoracic Surgeons: Thiry-hird Annual Meeing Mark your calendars for he Thiry-hird Annual Meeing of The Sociey of Thoracic Surgeons, which will be held a he San Diego Convenion Cener in San Diego, California, February 3-5, Members may regiser for he Scienific Sessions a no charge. There will be a $250 regisraion fee for nonmember physicians excep for Scienific and Poser Session preseners and residens. Regisraion for he Posgraduae Course is separae from he Annual Meeing. There will be a $70 regisraion fee for aendees of he Posgraduae Program, which will be held Sunday, February 2. The Posgraduae Course will provide in-deph coverage of horacic surgical opics seleced o enhance and broaden he knowledge of pracicing horacic and cardiac surgeons. Advance regisraion forms, hoel reservaion forms, and deails regarding ransporaion arrangemens, as well as he complee meeing program, will be mailed o Sociey members his fall (1996). Nonmembers wishing o receive informaion on aending he meeing should wrie o he Sociey's Secreary, Peer C. Pairolero. Peer C. Pairolero, MD Secreary The Sociey of Thoracic Surgeons 401 N Michigan Ave Chicago, IL (312)