Video-Thoracoscopic Management of Postpneumonectomy Empyema

Our plain-English summary of Video-Thoracoscopic Management of Postpneumonectomy Empyema, by D. Galetta, L. Spaggiari (The Thoracic and Cardiovascular Surgeon, 2018).

The study

• Authors: D. Galetta, L. Spaggiari
• Journal: The Thoracic and Cardiovascular Surgeon
• Published: 2018;66(8):701-706
• Cited by: 9 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Postpneumonectomy empyema (PPE) is a serious complication even when it is not associated with bronchopleural fistula (BPF). Besides irrigation, an aggressive treatment is usually applied for removing infected material. However, a minimally invasive approach might achieve satisfactory results in selected patients.

Methods: We retrospectively identified 18 patients presenting with PPE receiving video-thoracoscopic approach. Of these 18 patients, pneumonectomy was performed for nonsmall cell lung cancer in 15 cases, for mesothelioma in 2, and for trauma in 1 case. There were 14 males and 4 females, (mean age, 62 years; range, 44-73 days). Empyema was confirmed by thoracentesis and bacteriological examination. All patients had immediate chest tube drainage and underwent thoracoscopic debridement of the empyema. Fifteen patients had no proven BPF; two had suspicious BPF, and one had a minor (<3 mm) BPF.

Results: Median time from pneumonectomy to empyema diagnosis was 129 days (range, 7-6205 days). Median time from drain position to video-assisted thoracoscopic surgery (VATS) procedure was 10 days (range, 2-78 days). A bacterium was isolated in 13 cases (72.2%). There was no mortality and no morbidity related to the procedure. The average duration of thoracoscopic debridement was 56 minutes (range, 40-90 minutes). Median postoperative stay was 7 days (range, 6-18 days). Only in one patient an open-window thoracostomy was performed. Median follow-up of the 18 patients receiving thoracoscopy was 41.5 months (range, 1-78 months). None had recurrent empyema. The patient with a minor BPF remained asymptomatic and is doing well at 48 months follow-up.

Conclusions: Thoracoscopy might be a valid approach for patients presenting with PPE with or without minimal BPF. Video-thoracoscopic debridement of postpneumonectomy space is an efficient method to treat PPE.

Georg Thieme Verlag KG Stuttgart · New York.

In plain English

This was a retrospective review of patients treated at the European Institute of Oncology in Milan, Italy, for empyema (infection of the chest cavity) after pneumonectomy, the surgical removal of a whole lung. It did not study asbestos exposure. Of seven hundred fifty-five pneumonectomies from January 1999 to March 2016, 53 patients (7.0%) developed empyema. The study covered the 18 treated by video-thoracoscopy, a keyhole operation to clean out infected material; none had a large bronchopleural fistula (a leak at the airway stump). Their lung had been removed for non-small cell lung cancer (15), mesothelioma (2) or chest trauma (1). No deaths or complications were related to the procedure; two patients died later, at 34 and 47 months, after their malignant disease progressed. One patient's persistent infection was treated with a larger open operation. Over a median 41.5 months of follow-up, the authors saw no late recurrences; they called that infection an early recurrence. The authors concluded the approach is valid and effective with or without a minor fistula; they named the small sample and retrospective design as limitations.

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 case series (retrospective analysis of a prospective surgical database), with a comparison of early versus late empyema
• Who was studied: 18 patients at one surgical division in Milan, Italy, who developed empyema after pneumonectomy between 1999 and 2016 and were treated by video-thoracoscopy. Their pneumonectomies were done for non-small cell lung cancer (15), mesothelioma (2) or trauma (1). There were 14 men and 4 women, with a mean age of 62 years (range 44 to 73 years).
• Exposure: No asbestos exposure was studied. The study evaluated a treatment: video-thoracoscopic debridement and washing of the infected chest cavity after pneumonectomy.
• Main results:
  • Of seven hundred fifty-five pneumonectomies, 53 patients (7.0%) developed empyema. 18 (2.4%) were treated by video-thoracoscopy.
  • Among the 18 treated patients, there were no deaths and no complications related to the thoracoscopic procedure.
  • In 17 of the 18 patients (94.4%), the chest tube was removed after a median of 6 days (range 4 to 16 days).
  • In 1 of the 18 patients (5.6%), signs of infection persisted, and an open window thoracostomy was decided on at day 10.
  • Median follow-up was 41.5 months. The Results section states that none had recurrence of pleural infection. Two patients died, at 34 and 47 months, after progression of their malignant disease.
  • In their conclusion, the authors described the one treatment failure as an early recurrence and reported no late recurrences.
  • A bacterium was identified in 13 of the 18 patients (72.2%).
  • Comparing early empyema (under 90 days, 8 patients) with late empyema (over 90 days, 10 patients), the early group had significantly more patients with no bacterial colonization (5 compared with 0, p equal to 0.04). The authors noted that only limited conclusions can be drawn from these two small groups.
• The authors' conclusion: The authors concluded that video-thoracoscopy is a valid and effective approach for patients with empyema after pneumonectomy, with or without a minor bronchopleural fistula. They added that thoracoscopic skills are needed because the procedure may be challenging in some cases.
• Limitations the authors state:
  • The study was a retrospective consecutive case series in which treatment did not follow a protocol.
  • The sample size was small, which the authors called probably the main limitation.
  • There was possible time-selection bias favoring more recent patients, who may have benefited from improved procedures, a learning effect and general improvements in care.

Topics

Medical terms in this study, explained in our Lexicon: Empyema, Pneumonectomy, Lung Cancer, Mesothelioma, Thoracentesis, Video-Assisted Thoracoscopic Surgery (VATS), Thoracoscopy.

Related studies

• Awake video-assisted pleural decortication for empyema thoracis — F. Tacconi, E. Pompeo, et al. (2010)
• 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)
• Value of autofluorescence in video-assisted thoracoscopic surgery in pleural diseases — S.T. Liman, A. Elicora, et al. (2013)
• Video-assisted management of malignant pleural effusion in breast carcinoma — R. Gasparri, F. Leo, et al. (2006)
• Chronic empyema: importance of preventing complications in the management of pleural effusions — V. Molander, M. Diakopoulou, et al. (2013)

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