Tomás A Angelillo Mackinlay

VATS debridement versus thoracotomy in the treatment of loculated postpneumonia empyema

BACKGROUND There are approximately 60,000 new cases of postpneumonic empyema every day in the United States. Usually the fibrinopurulent stage of this complication has been treated by either tube thoracostomy or thoracotomy and debridement. According to the literature, thoracoscopic treatment has not been used often for this disease. METHODS Sixty-four cases of postpneumonic fibrinopurulent empyema were operated on at our institution: 33 cases (group I) by means of a formal thoracotomy and 31 cases (group II) by thoracoscopy. In the thoracoscopic subset the data were collected prospectively since 1992. These results were compared with those of a historical series treated by thoracotomy between 1985 and 1991. Both populations were similar in terms of age (mean, 49 years), number of cases (33/31), sex (2.1 male/female), and comorbid status. RESULTS Mean preoperative length of the medical management (11.5 versus 17 days) (p = 0.03) and chest tube removal (4.3 versus 6.1 days) were shorter in group II than in group I (p = 0.02). Morbidity and mortality were identical: one death and five complications in each group. Mean operative time was similar in both groups, and hospital stay was shorter in the video-assisted thoracic surgery group (6.8 versus 11.2 days) (p = not significant). Three patients from group II needed utilitary thoracotomies for debridement completeness (10% conversion rate). CONCLUSIONS We conclude that video-assisted thoracic surgical treatment has the same rate of success as open thoracotomy but offers substantial advantages over thoracotomy in terms of resolution of the disease, hospital stay, and cosmesis. A prospective and randomized study is needed to confirm the findings of this nonrandomized initial experience.