Video Assisted Thoracoscopic Surgery Emerging as a Primary Treatment for Empyema Thoracis

Introduction: The current treatments of empyema include tube thoracostomy with or without the instillation of fibrinolytics, Video Assisted Thoracoscopic Surgery (VATS), and an open thoracotomy with decortication. Success has been reported for all of these techniques. VATS has been suggested as the best method because of decreased length of stay and least postoperative morbidity. Conversion to Open Thoracotomy for Decortication (OD) is more frequent in the setting of complex, chronic empyema. Aim: To determine the indications, its efficacy, postoperative pain (VAS/CHEOPS), for VATS in the management of empyema. Materials and Methods: This was a prospective study conducted in Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India, for a period of 24 months from October 2011 to October 2013. A total of 37 cases (21 paediatric cases and 16 adult cases) were studied. Based on the duration of symptoms the patients were divided into three clinical stages of empyema. Depending on the radiological findings (CT Scan/USG Thorax), 19 patients were subjected to primary VATS. The rest of the patients (n = 18) who did not respond to ICD tube thoracostomy were subjected to VATS later. VATS debridement or decortication was attempted according to intraoperative findings. If successful debridement/decortication was not possible then conversion to open thoracotomy was done. In all patients who underwent surgery ICD tube was inserted postoperatively. Results: VATS was successful in 30 (81%) cases and conversion to open thoracotomy was done in 7 (19%). VATS decortication was successfully and effectively done in seven patients. All the stages of empyema were effectively treated through VATS. Conversion to thoracotomy was done because of dense fibrous strands and thickened pleura, which were unable to be managed by VATS. VATS lead to earlier recovery, reduced hospital stay and less morbidity. Stage III empyema was found statistical significant for VAS scores on postoperative day 1 {F(1,24)= 26.14, p<0.001} and day 7 {F(1,24)= 28.09, p<0.001} in VATS group compared to thoracotomy group using one way ANOVA. Decortication done by both methods (VATS/ thorocostomy) gave similar degree of postoperative radiological and functional improvements. Most of the pleural fluid culture yielded Pneumococcus and Staphylococcus aeurus. Five patients (17%) had complications after VATS i.e., uncomplicated pleural effusion, surgical site infection. Conclusion: The VATS is a safe, efficacious and feasible procedure which can be done in all the stages of empyema. Early primary VATS should be performed in patients with Stage I empyema with multiloculations. Open thoracotomy should be reserved when VATS fails. However, the VATS approach gives less pain and greater patient acceptance.