Early Thorascopic Surgery Can Resolve Postpneumonic Empyema

MONTREAL — In patients with postpneumonic empyema, early intervention with video-assisted thorascopic surgery can result in immediate and complete resolution, according to Donna E. Maziak, M.D., a thoracic surgeon at Ottawa Hospital.

And if VATS does not solve the problem, thoracotomy should be the logical next step, she added.

“Rather than trying to choose between doing VATS or thoracotomy, we should probably consider them both as a combination approach,” she said at the annual meeting of the Canadian Association of Thoracic Surgeons.

The advantages of early VATS are that it is minimally invasive, requires a short-acting anesthetic, and can often completely resolve the parapneumonic effusion.

With this approach, loculations can also be broken down immediately with no wait-and-see period for assessing success, said Dr. Maziak, also of the department of medicine at the University of Ottawa.

A study comparing VATS to thoracotomy in the treatment of postpneumonic empyema favored VATS for a lower relapse rate (0% versus 12%) and a nonsignificant trend toward shorter hospital stay (7 versus 11 days), with identical morbidity and mortality rates (Ann. Thorac. Surg. 1996;61:1626–30), she said.

Expanded figures from the same group showed much lower morbidity and mortality rates for VATS (6% and 2%, respectively), compared with thoracotomy (15% and 3%).

The authors concluded that “VATS debridement for loculated fibrinopurulent postpneumonic empyema offers better results than thoracotomy in terms of resolution of the disease and length of stay in hospital. It also seems to be more advantageous, resulting in fewer surgical sequelae, lower cost, less labor impediment, and better cosmesis” (World J. Surg. 1999;23:1110–3).

Although early intervention with a minimally invasive technique such as VATS has obvious advantages, clinicians should not hesitate to move immediately on to thoracotomy if necessary, Dr. Maziak advised.

“Don't be afraid to operate. Think thoracotomy earlier rather than later,” she said.

In fact, pooled data in the American College of Chest Physicians consensus statement on the treatment of parapneumonic effusions suggest that mortality is actually higher with VATS (4.8%) than with thoracotomy (1.9%), she said (Chest 2000;118:1158–71).

Balancing this, however, the statement also shows evidence that no VATS patients need a second intervention to resolve the effusion, while 10.7% of thoracotomy patients do, she said.

The ACCP statement says that existing evidence is equally supportive of VATS, surgery, or fibrinolytics as acceptable approaches for managing complicated empyema.

A randomized trial comparing VATS with chest-tube pleural drainage and streptokinase therapy favored VATS for higher efficacy and shorter hospital stay (Chest 1997;111:1548–51). However, the numbers in this study, as well as in the VATS versus thoracotomy studies, are too small to draw firm conclusions, according to the ACCP statement.