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Surgical Treatment for Empyema Thoracis: Is Video-Assisted Thoracic Surgery "Better" Than Thoracotomy? Daniel T.L. Chan, Alan D.L. Sihoe, Shun Chan, Dickson S.F. Tsang, Ben Fang, Tak-Wai Lee and Lik-Cheung Cheng Ann Thorac Surg 2007;84:225-231 DOI: 10.1016/j.athoracsur.2007.03.019

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://ats.ctsnetjournals.org/cgi/content/full/84/1/225

The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association. Copyright © 2007 by The Society of Thoracic Surgeons. Print ISSN: 0003-4975; eISSN: 1552-6259.

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Daniel T. L. Chan, MBBS, Alan D. L. Sihoe, FRCSEd, FCCP, Shun Chan, MBBS, Dickson S. F. Tsang, MBBS, Ben Fang, MBBS, Tak-Wai Lee, FRCSEd, and Lik-Cheung Cheng, FRCSEd

Division of Cardiothoracic Surgery, Grantham Hospital, Department of Radiology, Queen Mary Hospital, The University of Hong Kong, and Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China

Background. Operations for empyema thoracis are conventionally performed by open thoracotomy, whereas the video-assisted thoracic surgery (VATS) approach remains controversial. This study compares the radiologic and functional outcomes of decortication using the two approaches. Methods. During a 5-year period, 77 consecutive patients underwent decortication for empyema thoracis at two university teaching hospitals. The choice of surgical approach was decided by surgeon preference. Preoperative and postoperative empyema management was the same in all patients. Postoperative radiologic improvements were graded by a radiologist blinded to the approach used. Functional improvements were assessed by a questionnaire-based survey conducted at a mean of 36 months after the surgical procedure. Results. The VATS approach was used in 41 patients and the thoracotomy approach in 36 patients. Patients in the two groups had similar preoperative demographic

and clinical features. No patients required conversion from VATS to thoracotomy or reintervention for empyema. Intraoperative blood loss, duration of chest drain, lengths of hospital stay, and postoperative complication rates were all similar in the two groups. The mean operation time in the VATS group was significantly shorter (2.5 versus 3.8 hours, p < 0.001). Decortication using both approaches gave similar degrees of postoperative radiologic and functional improvements. Of the 42 patients available for follow-up, the 21 who received the VATS approach reported significantly less postoperative pain (p 0.04), greater satisfaction with the wounds (p < 0.0001), and greater satisfaction with the operation overall (p 0.006). Conclusions. VATS allows equally effective decortication for empyema as thoracotomy. However, the VATS approach gives less pain and greater patient acceptance. (Ann Thorac Surg 2007;84:225­31) © 2007 by The Society of Thoracic Surgeons

mpyema thoracis remains a significant cause of morbidity and even mortality in modern thoracic practice. A parapneumonic effusion will develop in 50% to 70% of pneumonia patients, and purulent empyema thoracis will develop in up to 20% [1]. If the empyema progresses to the fibropurulent or organized phases, simple antibiotic therapy and drainage may not suffice, and surgical decortication usually becomes necessary [2]. An open thoracotomy is the conventional approach for surgical decortication in empyema thoracis; however, the traditional thoracotomy is associated with substantial postoperative pain and morbidity [3]. Video-assisted thoracic surgery (VATS) has now been established as a safe and effective alternative approach for many thoracic operations, and has been shown to reduce pain and morbidity [4, 5], but its role in the management of empyema thoracis remains to be defined. Early studies

Accepted for publication March 7, 2007. Address correspondence to Dr Sihoe, Division of Cardiothoracic Surgery, Department of Surgery, The University of Hong Kong, Grantham Hospital, Hong Kong SAR, China; e-mail: [email protected]

E

have suggested a role for VATS in the drainage of early fibrinopurulent phase empyemas [6 ­10]. However, owing to concerns about its ability to adequately decorticate the lung, the role of VATS in later organizing phase empyemas is still controversial [11, 12]. Very few studies have directly compared the VATS and open approaches for decortication in later stage empyema thoracis. This current study aims to compare the results of surgical decortication for empyema thoracis performed using the VATS and thoracotomy approaches, gauged in terms of radiologic resolution, functional improvements, postoperative morbidity, and patient satisfaction.

Patients and Methods Patient Selection

The cardiothoracic surgery units in two university teaching hospitals, Grantham Hospital and Prince of Wales Hospital, in Hong Kong collaborated on this study. All consecutive patients receiving decortication operations

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GENERAL THORACIC

Surgical Treatment for Empyema Thoracis: Is Video-Assisted Thoracic Surgery "Better" Than Thoracotomy?

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for empyema thoracis at these two hospitals between January 2001 and December 2005 were eligible for study. Postprocedural and malignancy-related empyemas were excluded. All patients were confirmed to have empyema thoracis by diagnostic thoracocentesis and radiologic imaging. The preoperative management of empyema thoracis in both hospitals was the same and in accordance with the British Thoracic Society guidelines [13]. All patients were given appropriate intravenous antibiotics on confirmation of the empyema, and a drainage procedure was attempted in the first instance in all cases, either by image-guided pigtail drain insertion or by a standard percutaneous chest tube insertion. No fibrinolytic therapy was used in any patient. In both centers, the indications for surgical referral included persistent sepsis, persistent pleural collection despite attempted drainage, or restricted lung expansion on computed tomography (CT) scan [13]. Patients were offered surgical decortication if the guideline indications were fulfilled and if the patient had no significant medical comorbidity rendering the operation prohibitively high risk. In all cases, the procedure proceeded within 1 week after surgical referral. Institutional Review Board approval and individual patient consent for the study was waived for all patients in this study because all patient management was performed according to our normal clinical practice in each hospital, with no added experimental element.

Table 1. Scale Used by the Radiologist to Grade Changes on the Preoperative and Postoperative Chest Roentgenograms

Score 1 2 3 4 5 Change Compared With Pre-op Roentgenogram Worsened Same ( 25%) Small improvement (25%­50%) Moderate improvement (50%­75%) Large improvement ( 75%)

GENERAL THORACIC

Surgical Decortication

During the study period, one center used the thoracotomy approach exclusively, and the other used only the VATS approach in all patients. This reflected only the preferences of the surgeons at each hospital at the time. Admission to either hospital was determined solely by the proximity of the patient's residential address to each hospital, according to the policy of the Hong Kong health care system. All operations were performed by specialist thoracic surgeons of the two hospitals or cardiothoracic surgical trainees under their direct supervision. A standard technique of full posterolateral thoracotomy with rib spreading was used in all patients receiving open thoracotomy. For patients receiving the VATS approach, we routinely use three 10-mm ports and open instruments. Our technique of VATS decortication has been previously reported [14]. With both approaches, all loculations were broken down, the empyema fully drained, and as much visceral peel was removed as possible (decortication) to enable complete reexpansion of the underlying lung during on-table reinflation. For all patients, rib cutting or resection was used only if necessary. In all patients in both groups, reexpansion was considered complete only if the lateral surfaces of the lung could reach the chest wall and the inferior surface reached the diaphragm. Two chest drains are placed in all patients. Drains are removed only after cessation of air leakages, daily drainage volumes become minimal, and confirmation that the drained pleural fluid is free of viable microbes

on culture. Antibiotic therapy is continued postoperatively as guided by microbiologic analysis of intraoperative specimens. Our standard postoperative analgesics regimen for all patients consists of 650 mg of paracetamol, with 65 mg of dextropropoxyphene given orally 5 times a day, starting as soon as the patient is fully awake. Intramuscular opiates are made available to the patient, but are only given upon request. In addition, for patients receiving thoracotomy, intravenous morphine administered by a patient-controlled analgesia system is given for the first 2 postoperative days. Patients are prescribed a generous supply of paracetamol to take as required on discharge. In both hospitals, chest physiotherapy is given twice daily starting on the morning after the operation. All patients are sat out of bed on the morning after the procedure, with VATS patients mobilized as tolerated on the first postoperative day. Patients receiving thoracotomy are mobilized on the second postoperative day, in part because of the use of the patient-controlled analgesia morphine system.

Radiologic Evaluation

All chest roentgenograms before and after the surgical procedures were evaluated by one experienced radiologist (DSFT), who was blinded to the surgical approach used. The preoperative chest roentgenogram on the day preceding the procedure was compared with the last roentgenogram before discharge from the hospital. A further comparison was made between the preoperative chest roentgenograms and the roentgenograms at the outpatient 4-week follow-up. The improvements in both comparisons were graded on a 5-point numeric scale by the radiologist (Table 1). The score was based on the radiologist's estimation of the reduction of pleural thickening and the degree of reexpansion of the lung compared with the preoperative roentgenograms.

Clinical Evaluation

Postoperative pain and paresthesia experienced was documented using a 10-point numeric scale. The immediate postoperative pain and paresthesia scores for the first day after surgery were recorded. For the purposes of this study, paresthesia is defined as chest wall discomforts such as "pins and needles," numbness, or bloating that the patient can distinguish in nature or site, or both, from the sharp wound pain at the incision site(s) [15]. The durations that patients required analgesics after surgery were also noted.

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A postoperative questionnaire-based, cross-sectional survey was conducted for all patients at a mean of 36 months (range, 6 to 65 months). Residual pain and paresthesia at the time of the survey was documented. Patients were asked to estimate what percentage of their preoperative level of normal daily activity could now be achieved and how long it took after surgical treatment before they able to return to work. Patients were asked to report if there was any residual impairment in their normal daily activities and whether there was any subjective improvement in functional capacity compared with the immediate preoperative period. Each patient's respiratory status was assessed using the Medical Research Council (MRC) Dyspnea score [16]. All patients were asked to rate their satisfaction with the wounds (cosmesis and pain) and with the procedure overall on a 10-point numeric scale.

Table 3. Characteristics of the Empyema

Characteristics Causative organisms Tuberculosis Staphylococcus Streptococcus Gram-negative Anaerobes Others None identified Location of empyema Left upper zone Left lower zone Right upper zone Right lower zone Loculations seen on CT Organized phaseb

a

Thoracotomy, n (%) 14 (38.9) 3 (8.3) 4 (11.1) 1 (2.8) 1 (2.8) 1 (2.8) 12 (33.3) 0 14 0 22 25 (69.4) 30 (83.3)

VATS, n (%) 11 (26.8) 6 (14.6) 4 (9.8) 2 (4.9) 0 (0) 2 (4.9) 16 (39.0) 1 16 2 22 28 (68.3) 28 (68.3)

p Value 0.221 0.168 0.877 0.438 0.075 0.438 0.067 0.389 0.265 0.42 0.586 0.555 0.103 GENERAL THORACIC

Statistical Analysis

All statistical analyses were performed using SPSS 11.0 software (SPSS, Chicago, IL). Data were expressed as mean standard deviation. The 2 test, Fisher exact test, or Student t test were used as appropriate for comparison of variables. Results were considered significant if p 0.05.

a b Organisms cultured from intraoperative specimens. Phase of empyema on histological analysis of pleual peel (according to American Thoracic Society classification).

CT computed tomography; surgery.

VATS

video-assisted thoracic

Results

The study recruited 77 adult patients (67 men and 10 women). Of these, 41 had undergone decortication with the VATS approach, and the remaining 36 had the thoracotomy approach. Preoperative demographic and Table 2. Preoperative Demographic and Clinical Characteristics

Characteristicsa Patients (n) Mean age (years) Male History Smoking COPD DM Heart disease Renal failure Liver cirrhosis Presenting symptoms Chest pain Breathlessness Cough/sputum Constitutional symptoms Mean preoperative antibiotic duration (days)

a

clinical characteristics of all patients are summarized in Table 2. No statistical differences were noted in any of these characteristics between the two study groups. The durations between the time of diagnosis (with commencement of antibiotic treatment) and the time of operation were similar in both the VATS and thoracotomy groups. No difference was found in the anatomic and microbiologic characteristics of the empyema at the time of Table 4. Operative and Postoperative Results

Resultsa Operation time (hours) Blood loss (mL) Chest drain duration (days) Duration of air leak (days) Post-op hospital stay (days) Post-op complications Air leak 7 days Pneumonia Ventilatory support 24 hours Reexploration for bleeding Cardiac complications

a

Thoracotomy, n (%) 36 48.6 16.0 34 (94.4) 8 (22.2) 3 (8.3) 1 (2.8) 4 (11.1) 2 (5.6) 3 (8.3) 16 (44.4) 14 (38.9) 19 (52.1) 20 (55.6) 76 103.4

VATS, n (%) 41 46.1 14.7 33 (80.5) 11 (26.8) 1 (2.4) 3 (7.3) 7 (17.1) 2 (4.9) 1 (2.4) 24 (66.7) 17 (41.5) 15 (36.6) 27 (65.9) 54 90.7

p Value -- 0.506 0.321 0.305 0.482 0.618 0.528 0.642 0.335 0.257 0.818 0.153 0.335 0.059

Thoracotomy, n (%) 3.8 872 8.5 3.5 21 1.4 692.7 4.4 5.6 14.2

VATS, n (%) 2.5 881 7.9 3.1 16 0.96 1606.0 5.7 5.5 6.5

p Value 0.001 0.977 0.609 0.749 0.052

5 (13.9) 3 (8.3) 1 (2.8) 0 (0) 0 (0)

4 (9.8) 3 (7.3) 1 (2.4) 1 (2.4) 0 (0)

standard deviation.

0.573 0.868 0.926 0.346 1

Continuous data presented as mean

standard deviation. DM diabetes

COPD mellitus;

chronic obstructive pulmonary disease; VATS video-assisted thoracic surgery.

Continuous data presented as mean video-assisted thoracic surgery.

VATS

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Table 5. Radiologic Improvement Compared With Preoperative Chest Roentgenogram Using 5-Point Scale

Scorea GENERAL THORACIC Predischarge At 4-week post-op follow-up

a

Table 7. Postoperative Subjective Reporting of Functional Status

Report at Time of Surveya Perceived improvement in exercise tolerance compared with immediately before Estimated percentage of pre-op daily activities currently achievable MRC dyspnea scoreb Mean time to return to full work (months) Thoracotomy, n (%) 9 (42.9) VATS, n (%) 13 (61.9) p Value 0.357

Thoracotomy 2.69 3.48 1.0 0.9

VATS 3.18 3.9 0.9 1.0

p Value 0.059 0.103

Mean score

standard deviation using grading system in Table 1.

VATS

video-assisted thoracic surgery.

88.1

14.7

88.1

16

1.0

operation (Table 3). The causative organism profiles are similar in the two groups. From the intraoperative findings and the histopathologic reports of the removed pleural peel, we determined 75% of patients overall were in the organizing phase (phase III) of empyema thoracis according to the American Thoracic Society classification [17]. There was no difference in proportions of patients with each phase of empyema between the two study arms. Moreover, the incidences of loculations and thickened pleura seen on CT scan were similar in both groups.

2.1 6.4

2.0 3.2

0.9 4.8

1.9 8.8

0.069 0.446

a Conducted a mean of 36 months after surgery. Continuous data reb ported as mean standard deviation. Medical Research Council dyspnea score.

VATS

video-assisted thoracic surgery.

Surgical Outcomes

Table 4 summarizes the operative and postoperative data. Decortication was considered complete by the operating surgeon (as defined above) in all patients. None of the 41 patients receiving VATS decortication required conversion to an open procedure. No patients required further operation for treatment of empyema. All patients were discharged home after a complete course of antibiotics as dictated by microbiologic findings. The mean volume of intraoperative blood loss, the mean durations of air leak and chest drainage, and the mean lengths of postoperative hospital stay were similar in the two groups. However, the mean operation time in the VATS group was significantly shorter than in the thoracotomy group (2.5 versus 3.8 hours, p 0.001). There was no in-hospital mortality in this series. One or more complications occurred in 17 patients (22%). The most common were air leakage for more than 7 days and ongoing pneumonia. The complication rates between the Table 6. Postoperative Pain and Paresthesia

Patient Reporta Immediately after surgery Pain scorea Paresthesia scorea Duration of analgesic use (days) At time of surveyb Residual paina Residual paresthesiaa Pain affects normal daily activities Thoracotomy, n (%) 5.3 3.5 9.2 2.0 2.8 6.9 VATS, n (%) 3.9 2.2 6.1 2.3 2.9 6.8 p Value 0.041 0.176 0.321

two groups were similar (Table 4). Six late deaths occurred after a mean follow-up period of 36 months (range, 6 to 65 months). All deaths were unrelated to the empyema or the operation: 4 patients died from carcinoma and 2 from subsequent recurrent pneumonia unrelated to the original infection.

Radiologic Evaluation

In all 77 patients, the roentgenograms taken before discharge home after the operation and at the postoperative outpatient follow-up at 4 weeks showed improvement compared with the preoperative films (Table 5). The degrees of improvement at both time points were similar in the two study arms.

Clinical Evaluation

After a mean of 36 months after operation, 42 of the surviving 71 patients (21 in each group) responded to the questionnaire survey (overall response rate, 59.2%). The reasons for failure to respond included change of telephone number or address in 26, and 3 patients refused. The high number of patients who could not be contacted is, unfortunately, not uncommon in Hong Kong, where younger patients change phone numbers and addresses frequently and no long-term family physician follow-up is available within the health care system framework [15]. The results for postoperative pain and paresthesia are summarized in Table 6. Immediately after operation, the mean pain score in the VATS group was significantly lower than that in the thoracotomy group (3.9 2.3 versus 5.3 2.0, p 0.041). The difference between the two groups in terms of postoperative paresthesia and duration of oral analgesics required was not significant. After a mean of 36 months after operation, no statistical difference was found between the two groups in terms of mean pain and paresthesia scores or in the number of patients claiming that residual pain affected their normal daily activities. Functional improvements compared with the immediate preoperative status were similar in the VATS and

1.3 1.5 1.8 1.9 3 (14.3)

0.8 1.3 1.2 2.5 2 (9.5)

0.201 0.176 0.5

a Patient self-reported scores (mean standard deviation) on 10-point b numeric scale. Survey was conducted a mean of 36 months after surgery.

VATS

video-assisted thoracic surgery.

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Table 8. Patient Satisfaction With Surgery

Patient Report at Time of Surveya Satisfaction with wounds Satisfaction with surgery overall Thoracotomy 6.4 7.5 1.7 1.3 VATS 8.3 8.6 1.4 1.3 p Value 0.001 0.006

a Patient self-reporting (mean of 36 months after surgery) on 10-point numeric scale (scores presented as mean standard deviation).

VATS

video-assisted thoracic surgery.

thoracotomy groups (Table 7). No statistical difference could be found in terms of MRC Dyspnea scores, subjective improvement in functional status, and time to return to work. Patients in the VATS group were significantly more satisfied with the wounds and with the operation overall compared with those in the thoracotomy group (Table 8).

Comment

The aim of surgical treatment for fibrinopurulent and organized phases of empyema thoracis is to drain all loculated collections and enable full lung reexpansion by removal of pleural peel from the lung surface [2, 18 ­20]. Decortication by an open thoracotomy is proven superior to medical treatment for advanced empyema [2, 18, 20]. Compared with thoracotomy, the potential advantages of the VATS in empyema surgical procedures include less pain and perioperative morbidity, better visualization of the entire pleural cavity, and extending decortication to patients with poor respiratory reserve [4 ­ 6, 11, 18]. VATS has previously been demonstrated to allow effective drainage of empyemas in the fibrinopurulent stage [6 ­10, 18], although its role in the organizing phase empyema remains controversial [8, 10]. Most of the patients in our study were in the organized phase of empyema. The relatively long antibiotic durations before operation suggest that the patients in our current series were referred for surgical treatment comparatively late in the disease process. The operations involved a combination of drainage, deloculation, and decortication in every case. In this context, the VATS approach still conferred the same radiologic and functional improvement as the thoracotomy approach, without requiring conversion to an open procedure in any patient. Our results suggest that in experienced hands, satisfactory results can be achieved with the VATS approach regardless of the phase of empyema. Even so, for those less familiar with the technique, we would strongly advise conversion to open thoracotomy should adequate lung reexpansion not be achieved on-table. Few direct comparisons of the VATS and thoracotomy approaches for empyema decortication have been published. In 1996, Angelillo Mackinlay and coauthors [6] found similar perioperative morbidity rates among 31 patients receiving VATS decortication for empyema compared with a historical group of 33 patients undergoing thoracotomy. More recently, Waller and Rengarajan [11] compared a series of 36 VATS decortications with a

historical series of 12 open thoracotomy decortications. The operating times and lengths of stay were shorter in the VATS group. However, both studies were limited by the chronologic differences between the VATS and thoracotomy groups and the lack of postoperative radiologic or functional improvements assessment of empyema resolution. Furthermore, in most other series including both VATS and thoracotomy cases, the indications for using each of the two approaches were different and no meaningful comparisons can be made [21, 22]. We recognize that ideally, a randomized control trial would be best to compare the two techniques; however, this may not be practically feasible. Given the options of minimally invasive surgical treatment and open thoracotomy, it has been our experience that many patients would request the former and refuse to be randomized for a study. Nonetheless, our study design may represent a crude approximation of randomization. One hospital in this study used the thoracotomy approach for all decortications during the study period, and the other used the VATS approach exclusively, with no conversions required. Which approach was used was therefore dependent only on which hospital the patient was admitted to. This in turn was determined only by proximity of the residential address to each hospital, virtually a random event. In a city as compact as Hong Kong, the socioeconomic variability between residential regions is small. This is corroborated by the similarity between the two study groups in demographic and clinical features, preoperative duration of antibiotic treatment, causative organism profile, and the stage of disease. Furthermore, the protocols for preoperative and postoperative management at both hospitals are the same, with standard guidelines of empyema management adhered to in all patients. A comparison between the two groups is hence basically valid. It should be noted that tuberculosis is still relatively common in Hong Kong. In our experience, confirmation of tuberculosis preoperatively in patients requiring surgical treatment for empyema is not always possible, and this probably accounts for the relatively high proportion of patients with tuberculosis in our series. In the absence of preoperatively confirmed tuberculosis, our surgical management for these patients was the same as for other patients with nontuberculous empyema, and hence, we have not excluded them from this study. Previous studies on the surgical management of empyema thoracis have tended to focus on postoperative reintervention rates as an indicator of successful management [18, 21, 22]. Compared with indications for the initial procedure, however, the indications for reintervention are poorly defined and can vary considerably between centers. Other studies have also looked at postoperative lung function as an outcome measure [8, 9, 23]. This too is limited because baseline premorbid lung function test results (before onset of the empyema) are usually unavailable for comparison. In contrast, we have looked at both radiologic and reported functional improvements after surgical treatment. We acknowledge that our assessment of radiologic

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improvement is not perfect: it is based on a subjective scoring by a blinded, experienced radiologist of twodimensional chest roentgenograms only. No other more objective scoring system for empyema severity on a radiologic image is yet in common use, however. A comparison of preoperative and postoperative CT scans may have represented a more sophisticated means of assessment. However, postoperative CT scans are not always performed in all patients, and in everyday clinical practice, most clinicians assess postoperative progress based on the chest roentgenogram. For the assessment of functional outcome, we acknowledge that there are limitations in this study. We relied heavily patient self-reporting to determine dyspnea scores and perceived functional status. This is admittedly vulnerable to subjective bias by the patients and errors in recollection of preoperative status. The relatively long period of 36 months from the surgical procedure to the reassessment of pain and functional status was due to a flaw in our follow-up system during the study period, and may possibly compound this problem. We also note that more sophisticated systems of scoring pain, dyspnea and quality of life are available, but we ultimately favored the simpler numeric scales in this study. Both our own experience and the experience of others suggest that when using such systems in similar studies, there may be considerable practical difficulties, such as patient noncompliance or inability to understand the questionnaires [15, 24]. It has also been suggested that the more sophisticated pain scoring systems may be more reliable for chronic pain syndromes rather than acute postoperative pain [24]. More objective and quantitative lung function measurements (such as spirometry) are also potentially unreliable as an indicator of preoperative status given the ongoing pneumonic elements in many empyema patients. In lieu of such objective measures, each patient becomes his or her own best judge of how functional status compares before and after the operation, and hence, we have relied considerably on self-reporting as a key outcome measure. The primary finding in this study is that both the thoracotomy and VATS approaches gave equally effective treatment for empyema in terms of radiologic and functional outcomes, even when patients with organizing phase disease are included in the comparison. The safety aspects of both approaches were also equivalent, with no differences observed in terms of blood loss, chest drain durations, lengths of stay, and rates of complications. The conventionally held belief that advanced, organizing empyema necessarily requires an open surgical procedure is therefore not supported by our results. We note that postoperative lengths of hospital stay in our patients tend to be longer than in some other reported series. As can be seen from the results, patients typically stay for 1 to 2 weeks, even after chest drain removal. This length of stay is due to the preference of our hospitals for continuing intravenous antibiotic therapy for 2 to 4 weeks after surgery in all patients rather than to postoperative complications. The secondary finding is that VATS may be better accepted by patients. This study adds empyema decortication to the growing list of operations for which VATS is

proven to give significantly less immediate postoperative pain than open thoracotomy. Patient satisfaction with the wounds and with the procedure overall were also significantly greater in the VATS group. There were also observed trends for shorter hospital stays, less paresthesia, less pain at 36 months, and lower dyspnea scores in the VATS group. Given the many patient, clinical, and surgeon factors involved in each case of empyema, it is not realistic to conclude that any one surgical option is categorically "better" than another. However, our findings suggest that the VATS approach may have advantages for surgeons proficient with both approaches to empyema surgery. For equally effective decortication as the open approach, VATS causes less postoperative pain and potentially less morbidity. The greater patient acceptance and satisfaction with VATS decortication may encourage the lowering of thresholds to refer empyema patients for earlier surgical intervention.

GENERAL THORACIC

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17. 18. 19.

INVITED COMMENTARY

The timely and appropriate management of complicated fibropurulent pleural effusions and acute and chronic empyemas remains a challenging issue. Chan and colleagues [1] have reported on a significant experience in managing these patients with both open and minimally invasive techniques, and although their series is not randomized, the patients have been arbitrarily directed to two medical centers where either the open or minimally invasive approaches were used exclusively. The outcomes associated with the two techniques are remarkably similar. Treatment success was routinely accomplished in both groups with no requirements for reinterventions, as well as mortality and complication rates that compare very favorably to historic series. It is likely that differences in medical systems and practice patterns explain the differences from previously published reports in patient time on antibiotics (76 and 54 days), mean hospital days (21 and 16 days), and time to return to work (6.4 and 4.6 months), especially because this population was quite young with a mean age in both treatment groups of less than 50 years of age. The report includes a significant percentage of patients with challenging technical situations in that approximately one third of patients had tuberculosis empyemas, and three quarters were assessed to be in the "organizing phase" of their intrapleural infection. This study does not differentiate, however, between acute and chronic empyemas, especially those with fibrothorax in which true decortication has historically required sharp dissection of restricted lung, not simply blunt stripping of pleural peel. Although treatment success was routinely achieved, the authors present comparative data obtained at only two points: "immediately" after the surgery and then at a mean of 36 months (range, 6 to 65 months) postoperatively. This does not provide an adequate opportunity to assess outcomes over time, and it is particularly puzzling in that all patients were routinely seen four weeks after discharge for follow-up chest x-ray films, but no intermediate data on dyspnea or postoperative pain was obtained at that point. The authors use the Medical Research Council dyspnea index and an approach to pain assessment similar to the standard visual analog system. Except for pain scores immediately after surgery, no significant differences were noted. This is not surprising considering that the minimally invasive group used a true thoracoscopic approach, whereas the open group applied a full posterior lateral thoracotomy, not a muscle-sparing or limited rib-spreading approach. In addition, we have no information regarding the various approaches to postoperative pain management in either group. Assessment of clinical outcomes would have been enhanced not only with more regular symptomatic assessment, but also documentation of quality of life measurements. Instead the authors have provided the more difficult to interpret assessment of "overall satisfaction" and "satisfaction with wounds" as the only long-term differences between treatment groups. This report appropriately outlined the underlying treatment goals in all patients with acute and chronic empyemas, which is to maximize drainage and to free the trapped lung to completely fill the pleural space. This goal was accomplished with remarkable consistency in both treatment groups. The fact that no patients required reinterventions may be unprecedented. The title asks "Is Video-Assisted Thoracic Surgery Better Than Thoracotomy?" The issue currently is not which approach is better, but the realization that, in experienced hands dedicated to adhering to standard technical outcome principals, minimally invasive approaches can provide excellent outcomes in these complicated patients. Donald Low, MD Department of Surgery Virginia Mason Medical Center 1100 9th Ave Seattle, WA 98111 e-mail: [email protected]

Reference

1. Chan DTL, Sihoe ADL, Chan S, et al. Surgical treatment for empyema thoracis: is video-assisted thoracic surgery "better" than thoracotomy? Ann Thorac Surg 2007;84:225­31.

© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc

0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.04.009

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GENERAL THORACIC

spontaneous pneumothorax. Eur J Cardiothorac Surg 2004; 25:1054 ­ 8. Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 1999;54: 581­ 6. Andrews NC, Parker EF, Shaw RR, Wilson NJ, Webb WR. Management of non-tuberculous empyema: a statement of the subcommittee on surgery. Am Rev Respir Dis 1962;85:935­ 6. Wait A, Sharma S, Hohn J, Nogare AD. A randomized trial of empyema therapy. Chest 1997;111:1548 ­51. Yim APC. Paradigm shift in empyema management. Chest 1999;115:611­2.

20. Anstadt MP, Guill CK, Ferguson ER, et al. Surgical versus nonsurgical treatment of empyema thoracis: an outcomes analysis. Am J Med Sci 2003;326:9 ­14. 21. Roberts JR. Minimally invasive surgery in the treatment of empyema: intraoperative decision making. Ann Thorac Surg 2003;76:225­30. 22. Luh SP, Chou MC, Wang LS, Chen JY, Tsai TP. Videoassisted thoracoscopic surgery in the treatment of complicated parapneumonic effusions or empyemas: outcome of 234 patients. Chest 2005;127:1427­32. 23. Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1994;107:1079 ­ 86.

Surgical Treatment for Empyema Thoracis: Is Video-Assisted Thoracic Surgery "Better" Than Thoracotomy? Daniel T.L. Chan, Alan D.L. Sihoe, Shun Chan, Dickson S.F. Tsang, Ben Fang, Tak-Wai Lee and Lik-Cheung Cheng Ann Thorac Surg 2007;84:225-231 DOI: 10.1016/j.athoracsur.2007.03.019

Updated Information & Services References Citations Subspecialty Collections including high-resolution figures, can be found at: http://ats.ctsnetjournals.org/cgi/content/full/84/1/225 This article cites 21 articles, 12 of which you can access for free at: http://ats.ctsnetjournals.org/cgi/content/full/84/1/225#BIBL This article has been cited by 9 HighWire-hosted articles: http://ats.ctsnetjournals.org/cgi/content/full/84/1/225#otherarticles This article, along with others on similar topics, appears in the following collection(s): Lung - other http://ats.ctsnetjournals.org/cgi/collection/lung_other Requests about reproducing this article in parts (figures, tables) or in its entirety should be submitted to: http://www.us.elsevierhealth.com/Licensing/permissions.jsp or email: [email protected] For information about ordering reprints, please email: [email protected]

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