Awake video-assisted pleural decortication for empyema thoracis

Objective: To evaluate feasibility, technical features and results of video-assisted pleural decortication for empyema thoracis performed in awake patients. Methods: This retrospective analysis involved a cohort of 19 patients (median age: 58 years) undergoing awake video-assisted thoracoscopic pleural decortication under epidural anaesthesia (N = 15) or paravertebral blocks (N = 4) between March 2004 and September 2008. Baseline and perioperative data including degree of postoperative lung re-expansion at 48 h, hospital stay, morbidity rate and daily fluid toss were recorded. In addition, intra- and perioperative changes in main pathophysiological variables PaO2/FiO(2) ratio, PaCO2, mean arterial pressure and heart rate were analysed. Results: Origin of the empyema was parapneumonic (N = 14), post-traumatic (N = 3) and cancer related (N = 2). All patients underwent previous conservative management. The duration of the symptoms averaged 35 days (quartile range (QR): 28-40). Comorbidities included chronic obstructive pulmonary disease (COPD) (N = 4), HIV infection IN = 1), diabetes mellitus (N = 2) and cirrhosis (N = 1). Operation was performed videothoracospically in 15 patients whereas four patients with major pleural thickening underwent awake lateral thoracotomy. Operative time averaged 50 min (QR: 40-70). Perioperative data analysis showed no intra-operative deterioration in arterial oxygenation (median-A: 0 mmHg, QR: -5/+9, P = 0.6). Transient permissive hypercapnia (<55 mmHg) developed in three patients with no need of conversion to general anaesthesia. Median pain level assessed by a visual analogue score (VAS) 1 h postoperatively was 4 (QR: 2-5), and it was significantly reduced on postoperative day 1 (median 3, QR: 2-4, P = 0.03). There was neither mortality nor major morbidity. Hospitalisation averaged 6 days (QR: 5-7). At postoperative chest X-ray, lung re-expansion was rated as complete in 16 patients, satisfactory in (>80%) two patients and unsatisfactory in a 86-year-old patient with pleural mesothelioma who has the chest drain stilt in place 5 months after surgery. No patient had recurrence of the empyema at subsequent follow-ups. Conclusions: In our study, awake video-assisted pleural. decortication proved feasible and resulted in satisfactory lung re-expansion in 95% of the patients. We hypothesise that spontaneous ventilation facilitated both identification of the correct plane and dissection, thus resulting in lesser surgical injury on the underlying lung. (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.