电视胸腔镜在脓胸治疗中的应用体会

目的探讨胸腔镜在脓胸治疗中的价值。方法2002年1月～2005年4月我院对16例确诊脓胸在胸腔镜下用卵圆钳、吸引器头、骨膜剥离子等清理和刮除脓苔，剥离纤维膜；对病程稍长，纤维粘连不易剥离者，胸腔镜辅助下小切口手术完成，术后彻底冲洗脓腔。结果10例胸腔镜手术，5例辅助小切口手术，1例中转开胸手术。手术时间50～180min，平均80min；胸腔引流3～21d，平均8d。16例术后随访6～36个月，平均20个月，肺功能恢复良好，无脓胸复发及并发症。结论胸腔镜手术或辅助小切口手术治疗非机化晚期脓胸安全、有效、微创。     

肺结核外科的微创伤疗法(附39例报告)

目的探讨微创伤疗法治疗肺结核病的可行性及治疗效果。 方法收集接受微创伤疗法的肺结核病患者的临床资料进行回顾性分析。其中小切口或者电视胸腔镜下的肺结核肺切除术及脓胸廓清术患者10例(A组),小切口开胸下的肺结核空洞、结核球、曲菌球病灶清除术和不经胸局限性脓胸病灶清除术患者29例(B组)。 结果A组在电视胸腔镜下肺叶切除8例,其中1例术后肺膨胀不良,造成上胸腔残腔积液,其余7例肺复张满意;拔管时间最短3 d,最长10 d;术后第2天患者均可下床活动。电视胸腔镜下结核性脓胸廓清术2例,其中1例肺完全复张,1例复张不完全。B组29例患者全部治愈,无支气管胸膜瘘、结核播散、窦道形成等手术并发症发生病例;住院时间较常规术式明显缩短;术后下床早,呼吸循环系统的恢复明显较肺切除患者快;术后引流量少,拔管时间平均2～4 d;术前局限型慢性纤维空洞型肺结核合并痰菌阳性的6例患者,术后5例转阴、空洞消失;其中1例痰菌量明显减少;2例合并曲菌球的患者术后咯血停止。6例不经胸局限性脓胸病灶清除术患者,术后切口一期愈合。患者随访4个月～12年,平均6.2年,未见复发及播散。 结论微创伤疗法就切口而言,是介于传统开胸切口与微创切口之间的一种切口;就手术而言,比传统手术方式和微创手术方式损伤更小。肺结核病的外科治疗应择机选择微创伤疗法,其方法可行且效果良好。     

前路胸腔镜下松解联合后路矫形对特发性脊柱侧凸患者肺功能早期影响的研究

目的研究前路胸腔镜下脊柱松解联合后路矫形术对特发性脊柱侧凸(idiopathic scoliosis,IS)患者肺功能早期影响。方法对2004年4月-2008年6月行前路胸腔镜下松解联合后路矫形手术治疗的21例IS患者肺功能进行评估。男9例,女12例;年龄12～24岁,平均15.6岁。左侧凸2例,右侧凸19例。Lenke分型:Ⅰ型12例,Ⅱ型9例。发现脊柱侧凸1年6个月～9年,平均2.5年。胸椎冠状面Cobb角为65～125°,平均为79.6°。于术前及术后6个月行肺功能检测,包括肺容量、通气功能、胸廓顺应性三部分。结果前路胸腔镜下松解术中胸腔开放时间为90～150 min,平均127 min。术后切口均Ⅰ期愈合,无胸腔内感染发生。后路矫形术完成后1周患者冠状面Cobb角为36～75°,平均43.7°。术后患者均获随访,随访时间6～36个月,平均13.5个月。术后6个月时,患者肺活量及最大通气量均较术前显著提高(P<0.05),但实测值占预计值的百分比较术前无明显变化(P>0.05);功能残气量较术前下降(P<0.05);残气量实测值及与预计值的百分比均较术前下降(P<0.05)。第1秒用力呼气肺活量及其与用力呼气肺活量比值与术前比较无明显改善(P>0.05),最大自主通气量较术前显著上升(P<0.05)。患者总气道阻力、吸入气道阻力及呼出气道阻力均较术前显著下降(P<0.05)。结论前路胸腔镜下脊柱松解联合后路矫形术对IS患者胸腔有一定干扰,但矫形后随着胸腔形态变化和软组织松解,术后早期患者肺容量、通气功能、胸廓顺应性均得到不同程度改善,肺储备能力提高,但远期肺功能情况仍需进一步观察。     

单孔胸腔镜胸膜纤维板剥脱术治疗慢性结核性脓胸

目的探讨单孔胸腔镜胸膜纤维板剥脱术治疗慢性结核性脓胸的手术方法和术后疗效。方法收集2019年3月至2019年12月期间在武汉市肺科医院外科行单孔胸腔镜纤维板剥脱术的53例慢性结核性脓胸患者的临床资料,其中男40例,女13例;年龄16~69岁,平均36岁。病变位于右侧36例,左侧17例;合并肺结核38例;术前抗结核药物治疗疗程2~24个月。所有患者术前胸腔积液或术后标本病原学和病理学检测确诊为结核性脓胸。阐述单孔胸腔镜纤维板剥脱术治疗慢性结核性脓胸的手术方法,评价其临床疗效。结果全组无围手术期死亡,治愈49例(92.45%)。术后发生并发症1例(1.89%),为术后胸腔出血致凝固性血胸,经延长胸腔引流时间,积血溶解排出后治愈。行单孔胸腔镜纤维板剥脱术49例(92.45%),中转开胸手术4例(7.55%)。手术100~370 min,平均(234.53±56.06)min。术中出血量50~1400 ml,中位出血量300(175.0,402.5)ml。胸腔引流管留置3~22天,中位时间8(6.00,11.25)天。结论在围手术期评估、治疗恰当和手术操作熟练的前提下,单孔胸腔镜胸膜纤维板剥脱术治疗慢性结核性脓胸可行、安全、有效。     

早期非小细胞肺癌电视胸腔镜肺叶切除术对患者术后心肺功能的影响

目的探讨电视胸腔镜肺叶切除术与传统的开胸肺叶切除手术对患者术后心肺功能的影响。方法随机将80例早期非小细胞肺癌患者分为观察组和对照组,各40例。观察组接受电视胸腔镜肺叶切除术,对照组应用开胸肺叶切除术。比较2组患者术后第1、4周的心肺功能。结果 2组患者术后第1、4周肺活量、用力肺活量、1秒钟用力呼气容积占用力肺活量的比值、最大自主通气量进行比较,差异具有统计学意义(P0.05);2组患者术后第1、4周心率、左室射血分数、每搏量进行比较,差异具有统计学意义(P0.05)。结论采取电视胸腔镜肺叶切除术治疗早期非小细胞肺癌,比传统开胸手术在减少患者心肺功能损伤、加快患者术后心肺功能恢复方面有较好作用。     

慢性结核性脓胸461例外科治疗回顾性分析

目的 探讨慢性结核性脓胸的外科治疗经验.方法 回顾性分析2006年1月至2011年12月在山东省胸科医院胸外科接受手术治疗的461例慢性结核性脓胸患者的临床资料.其中男性317例,女性144例;年龄6～79岁,平均年龄32岁.术前病程3个月至50年,其中1年以内347例,1～2年61例,2年以上53例.根据患者情况采用不同手术方法.结果 全组患者无围手术期死亡,461例中一次手术治愈445例,分期手术治愈6例.1例脓胸合并支气管胸膜瘘患者,行胸膜剥脱术+肺叶切除术后再发支气管胸膜瘘,引流半年后行瘘修补+肌瓣填塞术+局限性胸廓成形术后治愈.3例切口愈合不良,经过换药治愈.5例出院后3个月内出现同侧切口附近胸壁脓肿,经过病灶清除附加局限性胸廓成形术治愈.1例胸膜全肺切除术患者于手术后1年因支气管残端瘘致余肺播散,死于呼吸功能衰竭.结论 在慢性结核性脓胸的治疗当中,手术治疗仍然有不可替代的作用,根据患者病情及身体状况选择恰当的手术方式能够取得良好的治疗效果.     

79例脓胸外科治疗体会

1994年 6月～ 2 0 0 1年 10月 ,我院共手术治疗脓胸病人 79例 ,现将治疗经验总结报告如下。临床资料本组 79例中男 49例 ,女 30例。年龄最小 1岁 ,最大 74岁 ,1～ 13岁者 2 1例。结核性脓胸 5 1例 ,化脓性 2 6例 (其中腐败脓胸 2例 ) ,血胸继发感染 2例。全组手术时均采用全身麻醉气管插管。脓胸廓清术 2 1例 ,纤维板剥脱术 43例 (其中并支气管瘘修补 5例 ) ,胸膜肺叶切除术 4例 ,胸廓成形术 11例。结果 :全组腐败脓胸死亡 2例 ,并支气管瘘修补后再瘘 2例 ,给予抗炎 ,延长引流时间 ,治愈 1例 ,1例未愈出院。其余 75例均疗效满意出院 ,住院时…     

胸廓造口开窗引流术在结核性脓胸伴支气管胸膜瘘中应用的疗效分析

【摘要】 目的 总结分析胸廓造口开窗引流术(OWT)在结核性脓胸伴支气管胸膜瘘中应用的治疗经验。方法 对我科在2003年至2012年56例结核性脓胸伴支气管胸膜瘘病例采用胸廓造口开窗引流术的外科治疗进行回顾性分析。本组病例胸廓造口开窗换药引流3~12个月后,分别采用Heller胸廓成形术加瘘修补术、胸膜外全肺切除术或余肺切除术、永久的开放性胸廓造口术等方法治疗。结果 全组患者有效地控制胸腔感染后,36例行Heller胸廓成形术加瘘修补术;14例胸膜外全肺切除术或余肺切除术后关闭胸廓造口,其中有5例术后出现围手术期胸腔再次感染并发症发生再次行胸廓造口术;6例患者选择永久的开放性胸廓造口开窗换药引流,无围术期死亡病例发生。结论 对结核性脓胸伴支气管胸膜瘘的患者应用胸廓造口术能有效地控制胸腔感染,降低死亡率,改善身体状况,为二期瘘修补术及消灭残腔手术创造有利条件并提高手术成功率。     

电视胸腔镜在脓胸治疗中的应用体会

目的探讨胸腔镜在脓胸治疗中的价值。方法 2002年1月至2011年11月对98例确诊脓胸在胸腔镜下清理和刮除脓苔,剥离纤维膜;对病程稍长,纤维粘连不易剥离者,胸腔镜辅助下小切口,术后彻底冲洗脓腔。结果 71例胸腔镜手术,18例辅助小切口手术,9例中转开胸手术。手术时间50～180min,平均80min;胸腔引流3～35d,平均12d。出院前胸片复查肺复张良好,无脓胸复发及并发症。结论胸腔镜手术或辅助小切口手术治疗脓胸安全、有效、微创。能达到清除病因、闭合脓腔、恢复肺功能的目的 ,特别是对病程较长、心肺功能差的患者尤为适合。     

胸腔镜辅助小切口手术治疗结核性脓胸的效果研究

目的探讨结核性脓胸患者的胸腔镜辅助小切口手术效果。方法选取2011年5月~2016年1月我院收治的结核性脓胸患者94例,依据随机数表法分为观察组(胸腔镜辅助小切口手术)和对照组(传统开胸手术),每组47例,比较两组患者的术中术后情况、肺功能及术后并发症。结果观察组手术时间、术中出血量、胸管引流时间、引流量、止痛药使用时间及住院时间均明显低于对照组,差异具有统计学意义(P0.05)。术前,两组患者的用力肺活量(FVC)、第一秒用力肺活量(FEV1)、最大呼气流速(PEF)和肺总量(TLC)均无显著差异(P0.05)。术后,观察组患者的FVC、FEV1、PEF、TLC均明显高于对照组,差异具有统计学意义(P0.05)。观察组47例,其中心律失常3例(6.38%),胸腔出血1例(2.13%),肺部感染1例(2.13%),总发生率为10.64%;对照组47例,其中心律失常6例(12.77%),胸腔出血3例(6.38%),胸肺漏气2例(4.26%),肺部感染4例(8.51%),切口感染3例(6.38%),总发生率为38.30%,两组并发症总发生率差异具有统计学意义(P0.05)。结论胸腔镜辅助小切口手术治疗结核性脓胸成效显著,能够明显缩短手术时间及住院时间,改善患者肺功能,具有创伤性小、并发症少的优点。     

Outcomes of Video-Assisted Thoracic Surgical Decortication in 274 Patients with Tuberculous Empyema

Objective: The present work aimed to retrospectively assess the outcomes associated with decortication by video-assisted thoracic surgery (VATS) in patients with tuberculous empyema.Methods: Patients (n = 274) who underwent decortication by VATS for surgical management of pleural empyema between January 2000 to 2010 were included. Pre-, intra-, and post-operative characteristics were observed for all patients, which were followed up for 12 months to evaluate surgical outcomes such as postoperative complications and disease recurrence.Results: No patients required conversion to thoracotomy, and no death or postoperative bleeding was reported. The mean operation time was 104.5 ± 20.4 min, with 271.5 ± 41.3 ml intraoperative blood loss and median length of hospital stay of 7.2 ± 3.4 days. Of the 274 patients, 262 were followed up for 12 months; 26 (9.9%) patients showed complications, including incomplete lung re-expansion (11 patients) and persistent air leak (6 patients). While early disease recurrence was observed in 3 (1.1%) patients after surgery, late recurrence was reported for 6 (2.3%) individuals. Interestingly, the complication rate was much higher in patients with chronic empyema (15/34, 44.1%) than in subjects with acute empyema (11/228, 4.8%).Conclusions: Decortication by VATS decreases postsurgical complications, and results in decreased disease recurrence. This study demonstrated improved outcomes by decortication by VATS, even in patients with stage III tuberculous empyema.     

Video-assisted thoracoscopic surgery for children with stage II empyema

Children with stage II empyema often fail traditional medical management, frequently succumbing to the effective albeit morbid clutches of thoracotomy. Video-assisted thoracoscopic surgery (VATS) has been recently introduced as a viable and potentially less morbid alternative to open thoracotomy. We review our VATS experience in children with empyema, assessing surgical outcome. Between August 1996 and March 1999, 13 patients at our institution with stage II empyema that did not respond to conventional medical management underwent a modified VATS with decortication. Data from retrospective chart review reflects intraoperative findings and postoperative course, including average time to defervescence, removal of thoracostomy tube, and hospital discharge. VATS was completed in all 13 patients. All intraoperative cultures of pleural fluid and fibrinopurulent debris obtained at VATS showed no growth. The average time to defervescence was 2.2 days (range, 0-4 days) and to removal of thoracostomy tube 3.6 days (range, 2-5 days). Average total chest tube days in patients with pre-VATS thoracostomy (n = 6) was 14.5 days (range, 8-37 days) versus 3.1 days (range, 2-5 days) in patients (n = 7) who underwent primary VATS (t test, p < 0.05). The average time to surgical discharge after VATS was 5.8 days (range, 3 to 19 days). All patients were well on follow-up clinic visits without delayed complications. VATS can be performed safely and effectively in children with stage II empyema, thus avoiding the morbidity of open thoracotomy and decortication. Importantly, early application of VATS significantly relieves patients of unnecessary days of thoracostomy drainage.     

Video-thoracoscopic and open surgical management of thoracic empyema

PURPOSE: To evaluate the outcomes of video-thoracoscopic and open surgical management of patients with thoracic empyema. METHODS: We studied 122 patients retrospectively who underwent surgery for thoracic empyema in our hospital between January, 1999 and January, 2005. Patients' medical records, surgical procedures, and outcomes were reviewed. The study identified 97 affected men and 25 affected women with a mean age of 54 years (range 16-78 years). The empyema was parapneumonic in 95 patients (78%). RESULTS: Forty-four patients who had stage II empyema underwent video-assisted thoracic surgery (VATS). The procedure was converted to thoracotomy in 13 patients (29.5%); the morbidity and mortality rates of VATS were 13% and 0, respectively. Seventy-eight patients had stage III empyema and, along with those 13 who were converted, underwent thoracotomy for decortication. The associated morbidity rate was 12%, and the mortality rate was 6.6%. Thoracotomy was considered successful in 90 of 91 patients (99%); one patient needed a reoperative thoracotomy for an organ space/surgical site infection with pus in the pleural cavity. CONCLUSIONS: Many treatment modalities are available for thoracic empyema, depending on the results of appropriate clinical and laboratory investigations. In fibrinopurulent empyema, VATS debridement is safe and effective, with minimal morbidity and no deaths. Lung decortication via thoracotomy is the only option for organized empyema and is associated with a substantial mortality rate.     

Palliative surgical debulking in malignant mesothelioma : Predictors of survival and symptom control

Objective: Malignant mesothelioma (MM) typically presents at an advanced stage. In the UK surgical intervention has been mostly reserved for tissue diagnosis or chemical pleurodesis. However, the role of debulking surgery in symptom control has not been fully explored. Methods: In a prospective cohort study, 51 consecutive patients presenting with MM underwent palliative surgical debulking for symptomatic relief (all patients presented with dyspnoea, 39 also had pain and two had a co-existing pleural empyema). Patients with early disease who underwent extrapleural pneumonectomy were excluded. The treatment aims were pleural drainage, lung re-expansion, pleurodesis and pleural debulking for symptom control. If the lung re-expanded after drainage of the effusion a subtotal parietal pleurectomy was performed via Video Assisted Thoracic Surgery (VATS). If the lung remained entrapped, a parietal and visceral decortication using VATS or thoracotomy was performed. The changes in subjective dyspnoea and pain scores were recorded at 6 weeks and 3, 6 and 12 months after surgery. Prognostic factors were analyzed to determine their influence on survival and symptom control. Results: VATS pleurectomy was possible in 17 patients (34%), whilst decortication was required in the remainder (three by VATS and 31 by thoracotomy). Median postoperative stay was 7 days (range 2–17) with 30-day mortality of 7.8% (four of 51 patients). Morbidity included postoperative empyema in two patients (4%) and prolonged air-leak in five (9.8%). Overall significant symptomatic benefit was obtained up to 3 months after surgery but subsequently increasing mortality offset these benefits. Epithelial cell type and absence of weight loss prior to surgery were found to predict longer survival and successful symptom control. Conclusions: Debulking surgery has a beneficial role in symptom control for unresectable MM. However, this surgery should be reserved for those patients who present with epithelial cell type and before significant loss of weight.     

Surgical treatment of pleural empyema--changing priorities

The surgical management of pleural empyema and post-traumatic clotted haemothorax is described. The study included 15 cases of post-thoracotomy empyema, 23 of empyema of other aetiology and five of post-traumatic haemothorax. Chest-tube drainage was the first measure in most cases. Post-pneumonectomy empyema was treated with partial thoracoplasty plus omentoplasty (8 cases) or plus myoplasty (1 case). Empyema after lobectomy or bilobectomy (4 cases) or after failed decortication (1 case) was managed with thoracoplasty or, in cases of concomitant wound infection, with open-window thoracostomy followed by thoracoplasty. Empyema after subclavian artery reconstruction (1 case) was cleared by removal of a previously unrecognized foreign body. For early empyema of other aetiology or haemothorax (10 cases in total), treatment comprised debridement by video-assisted thoracoscopic surgery (VATS). VATS was also used to establish suitable pleural drainage prior to elective thoracotomy (2 cases). Decortication and partial parietal pleurectomy were performed for organizing-stage empyema (16 cases). Three of the 15 patients with post-thoracotomy empyema died perioperatively, one died two months postoperatively and one had recurrence of bronchopleural fistula during follow-up. One patient with VATS debridement subsequently required thoracotomy and lobectomy for lung abscess. All the others with VATS or decortication recovered without complications. During follow-up there was no mortality or recurrence of empyema.     

Usefulness of thoracoscopic surgery in the diagnosis and management of thoracic diseases

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been recently utilised in the diagnosis and management of thoracic diseases. In this article we report our series of patients with established indications for VATS treatment. METHODS: Over the past 6 years we performed 104 VATS procedures for diagnostic and therapeutic purposes in 95 men and 39 women. The specific indications for VATS were: lung biopsy for undiagnosed diffuse lung disease, mediastinal biopsy and cysts, pleural effusion, empyema, pneumothorax and bullous lung disease, pericardial effusion and cyst, parvertebral abscess and solitary pulmonary nodules. RESULTS: There was no operative mortality. Postoperative non-fatal complications were seen in 7 cases. The overall median duration of chest tube drainage was 2.5 days and the mean postoperative stay 3 days. In diffuse lung disease a tissue diagnosis was obtained in all cases. Definitive diagnosis in the patients with undiagnosed pleural effusion was obtained in 90% of cases and the overall diagnostic rate was 98.5%. The success rate of the empyema (stage II) treatment and the therapeutic procedures is 100% after a mean follow-up of 12 months (range 6-30). Conversion to thoracotomy was needed in 6 cases. In all patients the postoperative pain was controlled with intake of non-narcotic analgesics with satisfactory results. CONCLUSIONS: VATS is worth considering and has been established as procedure of choice, with exceptional results in various chest diseases such as undiagnosed pleural effusions, recurrent, post-traumatic or complicated spontaneous pneumothorax, stage II empyema, accurate staging for lung cancer in the resection of peripheral solitary pulmonary nodule less than 3 cm, and lung biopsy for pulmonary diffuse disease.     

微小N2非小细胞肺癌胸腔镜肺叶切除与同期开胸手术对照研究

目的 研究分析临床分期Ⅰ期接受胸腔镜肺叶切除,术中意外发现微小纵隔淋巴结转移(N2)的非小细胞肺癌患者的近、远期预后.方法 回顾性分析2004年1月至2007年12月术前诊断为早期非小细胞肺癌(cT1-2N0M0,Ⅰ期),而术中或术后意外发现微小纵隔淋巴结转移(pT1-2N2M0,Ⅲa期)患者263例的临床资料.全部患者接受肺叶切除术+系统淋巴结清扫根治性治疗.其中接受胸腔镜肺叶切除术63例(腔镜组),男性37例,女性26例,平均年龄(58±11)岁.同期接受开胸肺叶切除术治疗的为200例(开胸组),男性132例,女性68例,平均年龄(59±11)岁.对比上述两组患者的临床特征及近、远期预后.结果 全部263例患者平均生存时间(34.9±1.2)个月,中位生存时间31个月.腔镜组平均生存时间(40.3±2.2)个月,中位生存时间37个月;开胸组平均生存时间(33.1±1.3)个月,中位生存时间29个月.全部患者1、2、3年生存率为92.0%、57.4%、29.3%,腔镜组1、2、3年生存率为92.1%、82.5%、41.3%,开胸组1、2、3年生存率为92.0%、49.5%、25.5%,两组间差异有统计学意义(x2=5.58,P=0.018).结论 VATS肺叶切除治疗微小N2非小细胞肺癌是安全、有效的.患者经过术前严格的评估,手术中出现意料之外的纵隔淋巴结转移,通过系统的淋巴结清扫后没有必要中转开胸完成手术.

Abstract：

Objective To assess early and late outcomes of patients with minimal mediastinal lymph nodes metastasis N2 non-small cell lung cancer disease unexpectedly detected during the operation, who underwent video-assisted thoracic surgery lobectomy for clinical stage I. Methods This study retrospectively reviewed and analyzed the medical records of 263 patients underwent surgery between January 2004 and December 2007, who were diagnosed as having early-stage non-small cell lung cancer (clinical stage was cT1-2N0M0, stage Ⅰ) before the surgery, but were found to have mini mediastinal lymph nodes metastasis disease (clinical stage was pTI-2N2M0, stage Ⅲa) unexpectedly detected during the operation and after the operation. All patients underwent lobectomy and systematic lymph nodes dissection as radical treatments. Among them, 63 patients underwent video-assisted thoracic surgery (VATS) lobectomy,including 37 male patients (58. 7%) with a mean age of (58 ± 11) years old. Two hundred patients underwent open thoracotomy lobectomy, including 132 male patients (66%) with a mean age of (59 ± 11) years old. To compare and analyze clinical features, early and late outcomes of patients in these two groups.Results A total of 263 patients with an average survival time (34. 9 ± 1.2) months (median 31 months),63 cases in VATS lobectomy group with an average survival time (40. 3± 2. 2) months (median 37 months), 200 cases in open pulmonary lobectomy group with an average survival time (33.1 ±1.3)months (median 29 months). The 1 -, 2-, 3-year over survival rate of all the patients was 92.0%, 57.4%,29. 3%. The 1-, 2-, 3-year survival rate of patients in VATS lobectomy group was 92. 1%, 82. 5%,41.3%. The 1,2,3 year survival rate of patients in thoracotomy lobectomy group was 92. 0%, 49. 5%,25.5%. There was significant difference between the two groups in this factor (x2 =5.58, P =0.018).     

Video-assisted thoracic surgery in the treatment of pleural empyema

BACKGROUND: The use of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has been proposed since the early 1990s, but among surgeons, its use varies considerably, and the results are discordant. This report aims to provide a retrospective assessment of the authors' experience and the literature on VATS in an effort to ascertain rational criteria for the use of this technique. METHODS: Over a period of 12 years, a total of 120 cases of pleural empyema were recorded. The patients were assessed with chest x-ray, computed tomography, ultrasound, and thoracentesis. On the basis of clearly defined clinical and radiographic parameters, 38 patients underwent VATS immediately, whereas the remaining 82 were treated initially by means of tube thoracostomy. The latter was found to be sufficient for only 10 patients. Consequently, for the remaining 72 patients, it was decided to proceed also with VATS. RESULTS: The procedure was performed completely by VATS in 101 patients (91.8%), whereas in 9 patients (8.2%) it was necessary to convert to thoracotomy. The postoperative course was uneventful for 98 of the 110 patients (89%), whereas the remaining 12 patients experienced complications, including one case of persistent empyema (0.9%) treated by thoracotomy. The mean chest tube duration was 6 days (range, 3-25 days). The mean postoperative hospital stay was 7.1 days (range, 5-17 days). Of the 80 patients completing a 6-month follow-up evaluation, the results were considered good for 72, moderately good for 8, and less than satisfactory for 2 patients. CONCLUSIONS: In conclusion, the authors consider VATS to be the technique of first choice for the treatment of pleural empyema when the disease is advanced or tube thoracostomy fails. It provides excellent results with a low level of invasiveness and considerably reduces the need for thoracotomy. These results can be achieved with good videothoracoscopic experience and the use of a very precise technique.     

Thoracoscopic-assisted management of postpneumonic empyema in children refractory to medical response

Background: Empyema frequently complicates the hospitalization of children; and in advanced stages, it often requires surgical intervention. In this study, we investigated the use of video-assisted thoracic surgery (VATS) for the management of postpneumonic empyema in children who have had an unsatisfactory medical response. Methods: We did a retrospective review of the medical records of 51 consecutive patients with loculated empyema (mean age, 5 years; range, 2 months to 15 years) hospitalized at Chang Gung Memorial Hospital between 1995 and 2000. All patients underwent debridement of the necrotic lung tissue and evacuation of the loculated empyema cavity using a VATS approach. Results: The mean operating time for the 51 patients was 90 min (range, 50–210); mean blood loss was 70 cc. Fever subsided within 72 h postoperatively in all patients. On average, chest tubing was removed on the 7th postoperative day (range, 4–18 days). However, in one patient who suffered from a prolonged air leak, the chest tube was not removed until day 18. The mean postoperative stay for all patients was 13.7 days (range, 9–23). No deaths occurred, and all of the children made a good recovery. A follow-up revealed that one of the 51 children patient suffered a left upper lung abscess 7 months after discharge. Left upper lobectomy was performed in this case, and the patient was discharged uneventfully 10 days after the operation. Conclusions: VATS is a safe and effective treatment for pediatric empyema. Thoracoscopic-assisted surgery facilitates visualization, evacuation, and debridement of the necrotizing lung tissue. Early surgical intervention can avoid lengthy hospitalization and prolonged intravenous antibiotic therapy, and it can accelerate clinical recovery.     

Video-assisted thoracoscopic surgery for thoracic empyema: primarily, or after fibrinolytic therapy failure?

BACKGROUND: Traditional and modern treatments are proposed for thoracic empyema. The efficacy of video-assisted thocoscopic surgery (VATS) has been studied when the method is applied either as primary treatment for thoracic empyema or after the failure of fibrinolytic therapy. METHODS: Thirty-eight patients treated with VATS for thoracic empyema have been reviewed. Of those, 20 patients (group 1) with empyema thoracis were referred to VATS after failure of the fibrinolytic treatment. Another 18 patients (group 2) with primary empyema thoracis were treated thoracoscopically immediately when empyema was diagnosed. Both groups were staged 5, 6, or 7 according to Light's criteria. RESULTS: The group 2 patients showed a higher empyema resolving rate (95% versus 85%), shorter hospital stay (4.5 versus 7.5 days), and significantly shorter duration of the procedure (70 +/- 14 versus 62 +/- 10 minutes) in comparison with the patients of group 1. CONCLUSIONS: The VATS technique for thoracic empyema is a well-tolerated, minimally invasive technique, with excellent therapeutic results, mild postoperative complications, and reduced hospitalization. VATS should be considered as the treatment of choice for thoracic empyema, in the fibrinopurulent stage, as it is more effective when applied primarily than when applied after fibrinolytic therapy.