Awake video-assisted pleural decortication for empyema thoracis

Our plain-English summary of Awake video-assisted pleural decortication for empyema thoracis, by F. Tacconi, E. Pompeo, E. Fabbi, et al (European Journal of Cardio-thoracic Surgery, 2010).

The study

• Authors: F. Tacconi, E. Pompeo, E. Fabbi, T.C. Mineo
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2010;37(3):594-601
• Cited by: 68 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

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 loss were recorded. In addition, intra- and perioperative changes in main pathophysiological variables PaO(2)/FiO(2) ratio, PaCO(2), 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). Co-morbidities included chronic obstructive pulmonary disease (COPD) (N=4), HIV infection (N=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-Delta: 0 mm Hg, QR: -5/+9, P=0.6). Transient permissive hypercapnia (<55 mm Hg) developed in three patients with no need of conversion to general anaesthesia. Median pain level assessed by a visual analogue score (VAS) 1h 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 still 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.

Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

In plain English

This retrospective study from Rome, Italy, covered 19 adults with empyema (pus in the chest cavity) operated on in 2004 to 2008. Awake patients under epidural anaesthesia (15) or paravertebral blocks (4) had the thickened lining removed (decortication): by video-assisted keyhole surgery in 15, and by open thoracotomy in four with major pleural thickening. None needed general anaesthesia. During surgery the blood oxygen measure showed no significant overall change; carbon dioxide rose slightly. No patient died around surgery or had major complications; median hospital stay was 6 days. By day 2 the lung had fully re-expanded in 16 of 19 patients. Two patients died of cancer during follow-up, at 2 and 6 months. One of them, an 86-year-old with unsuspected pleural mesothelioma, had an unsatisfactory result. Compared with a separate retrospective group of 19 patients given general anaesthesia, there were no significant differences except less day-1 pain, which the authors called a trend (table P = 0.04). The authors called the procedure feasible but said the sample was too small to judge effects on complications or hospital stay. The article does not discuss asbestos.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of a prospectively kept database (single-institution case series), with comparison to a retrospective control group treated under general anaesthesia
• Who was studied: 19 adults with empyema thoracis treated at Fondazione Policlinico Tor Vergata, Rome, Italy, March 2004 to September 2008 (13 males, 6 females; median age 58). Causes: parapneumonic (14), post-traumatic (3), cancer-related (2: one small-cell lung cancer, one unsuspected epithelial mesothelioma). Comparison group: the last 19 empyema patients treated by VATS under general anaesthesia, between 2003 and 2008.
• Exposure: No asbestos exposure was studied. The intervention studied was awake pleural decortication under epidural anaesthesia (15 patients) or paravertebral blocks (4 patients), with spontaneous breathing. It was done by videothoracoscopy in 15 patients and by awake lateral thoracotomy in 4.
• Main results:
  • Of the 19 patients, 15 had a totally videothoracoscopic operation. Four needed an awake lateral thoracotomy because of major pleural thickening. No patient required conversion to general anaesthesia.
  • During surgery, the group's arterial oxygenation (PaO2/FiO2 ratio) showed no significant change from baseline (median change 0 mmHg, P = 0.6). PaCO2 rose slightly but significantly (median change 2 mmHg, P = 0.01), and no patient developed symptomatic hypercarbia.
  • Complete lung re-expansion was seen in 16 of 19 patients (84%) on postoperative day 2. Table 3 gives a success rate of 18/19 in the awake group versus 17/19 in the control group.
  • In the postoperative period there were no deaths and no major complications in the awake group. Minor complications included urinary retention (2), transient hypotension (2), prolonged air leak (1) and retained bronchial secretions needing bronchoscopic aspiration (1).
  • Median hospital stay in the awake group was 6 days (QR 5 to 7).
  • The patient with unsuspected malignant pleural mesothelioma had an unsatisfactory radiological outcome. This patient was discharged with a Heimlich valve because of persistent fluid loss and died 6 months later from disease progression.
  • Among the 15 patients with spirometry data, lung volumes improved in all. The median increase versus preoperative values was 150 cc in FEV1 and 600 cc in FVC (both P < 0.001).
  • The awake group was compared with a separate, non-randomized retrospective group of 19 patients treated under general anaesthesia. The authors found no significant difference in main outcomes except what they called a trend toward less pain on postoperative day 1. Table 3 gives VAS scores of 3 (QR 2 to 4) in the awake group versus 4 (QR 3 to 5) in the control group, P = 0.04.
  • Over a median follow-up of 18 months, there were two cancer-related deaths, at 2 and 6 months after surgery.
  • No patient needed re-operation for empyema during follow-up.
• The authors' conclusion: The authors concluded that awake video-assisted decortication had a high success rate in patients with fibrinopurulent empyema. They found it safely feasible and well tolerated, even when conversion to awake thoracotomy was needed, with acceptable hospital stay and complication rates. They said further evaluation is warranted.
• Limitations the authors state:
  • The sample was too small to draw definitive conclusions about possible advantages of awake anaesthesia on complication rates and length of stay.
  • Outcomes were compared with a retrospective control group, which the authors say could be criticised methodologically.
  • The authors caution that being able to treat empyema under loco-regional anaesthesia does not mean it always should be, and that trained anaesthesia and nursing staff are required.

Topics

Medical terms in this study, explained in our Lexicon: Empyema, COPD, Pleural Thickening, Thoracotomy, Chest X-Ray, Pleural Mesothelioma.

Related studies

• Video-Thoracoscopic Management of Postpneumonectomy Empyema — D. Galetta, L. Spaggiari (2018)
• MesoTRAP: a feasibility study that includes a pilot clinical trial comparing video-assisted thoracoscopic partial pleurectomy decortication with indwelling pleural catheter in patients with trapped lung due to malignant pleural mesothelioma designed to address recruitment and randomisation uncertainties and sample size requirements for a phase III trial — C. Matthews, C. Freeman, et al. (2019)
• Should all patients who have mesothelioma diagnosed by video-assisted thoracoscopic surgery have their intervention sites irradiated? — M. Nagendran, A. Pallis, et al. (2011)
• Video-assisted management of malignant pleural effusion in breast carcinoma — R. Gasparri, F. Leo, et al. (2006)
• Value of autofluorescence in video-assisted thoracoscopic surgery in pleural diseases — S.T. Liman, A. Elicora, et al. (2013)
• Malignant pleural mesothelioma presenting as acute empyema with severe leukocytosis — K. Matsuoka (2014)

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