Why is Video-Assisted Thoracic Surgery (VATS) with decortication recommended for empyema?

VATS with Decortication for Empyema: Rationale and Recommendations

VATS with decortication is recommended for empyema because it effectively removes infected material, breaks down loculations, and promotes lung re-expansion with less postoperative pain, shorter hospital stays, and better cosmetic results compared to open thoracotomy. 1

Stages of Empyema and Surgical Approach

Empyema progresses through three stages, each requiring different management approaches:

1. Exudative stage (early, fluid accumulation)
2. Fibrinopurulent stage (loculations forming)
3. Organized stage (thick fibrous peel formation)

Timing of Surgical Intervention

• Early intervention is preferred: Patients with symptom duration less than 4 weeks show better outcomes than those with longer symptom durations 2
• Failure of medical management: Consider surgical consultation if sepsis fails to resolve within 7 days of medical management (antibiotics, chest tube drainage, and fibrinolytics) 1

Advantages of VATS over Open Thoracotomy

VATS offers several advantages over traditional open thoracotomy:

• Less postoperative pain
• Shorter hospital stay
• Better cosmetic results
• Effective evacuation of infected material
• Ability to break down loculations
• Targeted chest drain placement 1, 3

Non-randomized studies comparing VATS to conventional thoracotomy have shown reduced:

• Duration of hospital stay
• Postoperative antibiotic requirements
• Chest tube drainage duration 1

Surgical Decision Algorithm

1. Stage II (Fibrinopurulent) Empyema:

   • VATS is the method of choice
   • Allows for removal of infectious focus and targeted drainage 3
   • Conversion rate to open thoracotomy is low (approximately 13%) 4

2. Early Stage III (Organized) Empyema:

   • VATS decortication can be attempted first 3, 5
   • Technique involves removing the fibrous peel at the lung surface via 2-3 incisions 5
   • Be prepared to convert to open thoracotomy if needed

3. Advanced Stage III (Chronic) Empyema:

   • Open thoracotomy with formal decortication is often required 1, 3
   • However, even in chronic cases, VATS may still show benefits over open procedures with shorter chest tube duration 2

Contraindications for VATS

• Inability to develop a pleural window to access the pleural cavity
• Presence of thick pyogenic material
• Fibrotic pleural rinds that cannot be managed thoracoscopically 1

Special Considerations

• Organized empyema with thick fibrous peel: May require formal thoracotomy and decortication if symptomatic with fever and chronic sepsis 1
• CT scanning with contrast: Useful before surgery to define pleural peel thickness and check for intralobar pathology 1
• Conversion to open procedure: Surgeon should be ready to convert from VATS to thoracotomy when technical difficulties related to inflammation are encountered 1

Postoperative Management

• Median time for postoperative intercostal drainage: 5 days (range 3-30 days) 4
• Adequate analgesia is essential to keep the patient comfortable and aid mobilization 1
• Follow patients until complete recovery and normalization of chest radiography 6

VATS decortication has proven to be safe and effective with success rates of approximately 87% and low complication rates (13%) 4, making it the preferred initial approach for most empyema cases when performed by experienced thoracic surgeons.