Alper Toker, MD. VATS decortication. Istanbul University, Istanbul Medical School Department of Thoracic Surgery

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1 VATS decortication Alper Toker, MD Istanbul University, Istanbul Medical School Department of Thoracic Surgery Pleural space infection is a common pathology causing morbidity and mortality. It is a collection of purulent fluid in the pleural space. It has a mortality rate of 20%, up to 35% in the immunocompromised patients. Parapneumonic pleural effusion may occur in almost 20-40% of all children presenting with bacterial pneumonia. Pleural empyema is traditionally classified into three stages: exudative, fibrinopurulent, and organized. The exudative stage can be as short as 24 hours; the fibrinopurulent stage generally occurs within 2 to 10 days, and the organized stage can occur within 2 to 4 weeks. The term empyema means purulent effusion in the pleural space. But, the early use of antibiotics may prevent positive cultures. Generally medical therapy is not sufficient and treatment may require surgical intervention. The primary treatment of the complicated pleural effusions has been chest tube drainage. Recent developments in video-assisted thoracoscopic technique (VATS) enabled the management of fibrinopurulent or organized pleural empyema with less postoperative discomfort and a reduced the length of hospitalization. The aim of this presentation is to discuss the VATS decortication procedure and describe its potential role in the treatment of pleural empyema. Operative technique Operation is performed under general anesthesia with single lung ventilation in adults and single lumen ventilation in pediatric patients. Preferred position is lateral decubitus. The first port place is chosen on the chest wall away from the main collection area. After exploration with finger, the first thoracoscopic port is placed. Some pleural effusion could be suctioned at this stage. With the aid of the thoracoscope from this port, the remaining one port is placed

2 more posteriorly under the direct vision to avoid paranchymal injury. The second port may be located on the exact location of the empyema cavity. After the dissection of the adhesions, and the third port is placed under video guidance. The lung was then blindly dissected from the chest wall using both index fingers and the remainder of the procedure is performed under direct vision. Suction debridement is extremely helpful to breakdown the septae and is facilitated with regular saline washouts. Whole lung was mobilized from the chest wall and mediastinum with giving care to the phrenic nerve, superior vena cava, diaphragm and subclavian artery. Once the lung was completely mobilized, pleural decortication and evacuation of the pleural fluid and jelly material is performed. After debridement, the lung is inflated under direct vision. If the lung is not inflated with regular pressures, decortication is necessary to release inelastic visceral peel which prevents lung reexpansion and apposition of the two pleural surfaces. The visceral peel is sharply incised to obtain a surgical plane and the pleural sheet gently dissected off the lung surface. Dissection is augmented by continuous positive airways pressure on the operated lung. If the peel dissected over the visceral pleura, aerosolized fibrin glue may reduce postoperative air leak. If it is densely adherent, visceral pleurectomy can also be performed, but this maneuver needs experience and care to prevent the lung injury. After completion of decortication, an evaluation for the ability of underlying lung for reexpansion is done by ventilation to a positive pressure 40 cm H2O. The degree of air leak is assessed. Generally two intercostal tube drains are placed through the incisions for ports. Author prefers to keep patients mechanically ventilated for a few hours until the patient is completely awake and adaptable to pulmonary physiotherapy. Video-assisted thoracic surgery provides excellent drainage; patients require less analgesia, and have a shorter stay in hospital. VATS vs Fibrinolytic therapy

3 Fibrinolytic therapy has been demonstrated to be an effective treatment modality in fibrinopurulant phase of empyema. VATS is mainly reserved for the same empyema stage and the procedure could be named as deloculation. Proponents for VATS are concerned about fibrinolytic therapy because of discomfort during instillation, prolonged therapy, prolonged hospitalization and failure rate. However, the failure rate has been shown to be modest and almost similar with some earlier VATS studies. On the other hand, proponents of fibrinolysis claim most patients could be easily treated without the morbidity of a thoracic operation. In 2005, the Cochrane Collaboration analyzed the clinical evidence of operative vs. nonoperative management of empyema. VATS with decortication was demonstrated to have a higher primary treatment success and lower length of stay when compared with drainage with streptokinase. This study, as a conclusion, confirmed that it was difficult to make any firm recommendations based upon 1 small study. They suggested not to devaluate the role of drainage with fibrinolytics in the early stages of empyema. In another study (Doski, 2000), It was also reported that children who underwent VATS had a shorter hospital stay as compared with those in whom fibrinolytics were used. In 2006, Sonnappa published a randomized prospective trial comparing urokinase to VATS with decortication for pediatric empyema. In this study, hospital stay (median = 6 days for both groups) and treatment failure were found to be similar. Four of 30 (13%) VATS patients were converted to a minithoracotomy, and one required a redo VATS. Of the fibrinolytic group, 5 of 28 (18%) were eventually operatively managed. Conclusion was urokinase treatment is the better economic option. A multicenter randomized controlled trial demonstrated that the intrapleural urokinase reduced hospital stay from 9.5 to 7.4 days. However, significant adverse effects of fibrinolytics were reported, as pain, bleeding, and allergy. In most studies, fibrinolytic therapy is associated with a failure rate higher than 10%. As a result, intrapleural fibrinolytic is not accepted universally. A nonrandomised study compared VATS with thoracotomy. VATS was recommended on the basis of reduced hospital stay, duration of postoperative antibiotics and chest drain requirements. A case series of VATS for empyema in children

4 demonstrated a failure rate of 7% and after a median follow-up of 8 months, 91% of children had full resolution of symptoms. Experience of the surgeons with endoscopic surgery is claimed to be important in the outcome. This point is particularly important because VATS decortication has been performed in few centers employing high volume endoscopic surgery. Another important point is the stage of disease in the study populations. When most of the patients are in stage 2, success rate is higher. There is also evidence that outcome is better when VATS is performed within 1 week of diagnosis. The duration of illness before referral is also an important parameter in evaluating the success rate. The open conversion rate was 5 (4%) of the 114 patients and the recurrence rate was 3 (2.7%) of 114 in one of the major series. It should be emphasized that a very important objective of empyema treatment is to achieve full lung expansion. If this is not achieved during VATS, converting to an open should not be considered as a complication and failure. VATS appears to be considered the rescue, or more definitive, treatment when lytic therapy failed. Conclusion Although, as a surgeon; debridement and removal the fibrotic peel is considered to be necessary for return of normal lung function, some physicians claim that in long term follow-up this may not be the case. Certainly there are some patients who have a restrictive component to their illness and have an immediate benefit from VATS and decortication. Video-assisted thoracoscopic surgery should remain the mainstay of therapy for the most the patients who have significant symptoms. These patients may have benefit from immediate removal of fibrin deposition and a constrictive peel, and it remains the most rapid and direct way to drain loculated fluid collections. The choice of first-line treatment of childhood empyema remains controversial, with no clear consensus. As a conclusion; we claim that VATS decortication in the experienced hands, has an excellent the outcome. Video-assisted thoracoscopic surgery combines the advantages of a mini-thoracotomy. It is definitely superior to thoracotomy in terms of thoracic wall trauma and postoperative pain. It has a certain therapeutic role to in the management of early empyema.

5 References 1- Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med 2006;174: Kurt BA, Winterhalter KM, Connors RH, et al. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics Doski JJ, Lou D, Hicks BA, et al. Management of parapneumonic colletions in infants and children. J Pediatr Surg 2000;35: Bishay M, ShortM, Shah K, et al.efficacy of video-assisted thoracoscopic surgery in the mamagement of childhood empyema: A large single center study Journal of Pediatric Surgery 2009;44: Kokoska E, Chen M. The new technology committee. Position paper on videoassisted thoracoscopic surgery as treatment of pediatric empyema. Journal of Pediartic Surgery 2009;44:289-93

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