2005;79:1851-1856 Ann Thorac SurgMarkus Furrer and Hans-Beat Ris

Didier Lardinois, Michael Gock, Edgardo Pezzetta, Christian Buchli, Valentin Rousson, for Empyema

Thoracotomy Rate in Patients Undergoing Video-Assisted Thoracoscopic Surgery Delayed Referral and Gram-Negative Organisms Increase the Conversion

http://ats.ctsnetjournals.org/cgi/content/full/79/6/1851located on the World Wide Web at:

The online version of this article, along with updated information and services, is

Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. Copyright © 2005 by The Society of Thoracic Surgeons.

is the official journal of The Society of Thoracic Surgeons and theThe Annals of Thoracic Surgery

by on June 8, 2013 ats.ctsnetjournals.orgDownloaded from

DIPSDVDD

ss1cw

aicIdswvsu

Itsu

PccneAaptltot

A

ARm

©P

GEN

ERA

LT

HO

RA

CIC

elayed Referral and Gram-Negative Organismsncrease the Conversion Thoracotomy Rate inatients Undergoing Video-Assisted Thoracoscopicurgery for Empyemaidier Lardinois, MD, Michael Gock, MD, Edgardo Pezzetta, MD, Christian Buchli, MD,alentin Rousson, PhD, Markus Furrer, MD, and Hans-Beat Ris, MD

ivision of Thoracic Surgery, University Hospital, Zurich, Division of Thoracic Surgery, CHUV, University Hospital, Lausanne,

epartment of Surgery, Kantonspital, Chur, and Department of Biostatistics, University of Zurich, Zurich, Switzerland

tctsoa(aoa

mnHapsag

Background. The role of video-assisted thoracoscopicurgery in the treatment of pleural empyema was as-essed in a consecutive series of 328 patients between992 and 2002. An analysis of the predicting factors foronversion thoracotomy in presumed stage II empyemaas performed.Methods. Empyema stage III with pleural thickening

nd signs of restriction on computer tomography imag-ng was treated by open decortication, whereas a thora-oscopic debridement was attempted in presumed stageI disease. Conversion thoracotomy was liberally useduring thoracoscopy if stage III disease was found aturgery. Predictive factors for conversion thoracotomyere calculated in a multivariate analysis among several

ariables such as age, sex, time interval between onset ofymptoms and surgery, involved microorganisms, andnderlying cause of empyema.Results. Of the 328 patients surgically treated for stage

I and III empyema, 150 underwent primary open decor-ication for presumed stage III disease. One hundredeventy-eight patients with presumed stage II empyema

nderwent a video-assisted thoracoscopic approach. Of

o(lotaCl

tfisshtic

aemistrasse, 100, University Hospital, CH-8091 Zurich-Switzerland; e-ail: didier.lardinois@usz.ch.

2005 by The Society of Thoracic Surgeonsublished by Elsevier Inc

ats.ctsnetjournDownloaded from

hese 178 patients, thoracoscopic debridement was suc-essful in 99 of 178 patients (56%), and conversionhoracotomy and open decortication was judged neces-ary in 79 of 178 patients (44%). The conversion thoracot-my rate was higher in parapneumonic empyema (55%)s compared with posttraumatic (32%) or postoperative29%) empyema; however, delayed referral (p < 0.0001)nd gram-negative microorganisms (p < 0.01) were thenly significant predictors for conversion thoracotomy inmultivariate analysis.Conclusions. Video-assisted thoracoscopic debride-ent offers an elegant, minimally invasive approach in a

umber of patients with presumed stage II empyema.owever, to achieve a high success rate with the video-

ssisted thoracoscopic approach, early referral of theatients to surgery is required. Conversion thoracotomyhould be liberally used in case of chronicity, especiallyfter delayed referral (>2 weeks) and in the presence ofram-negative organisms.

(Ann Thorac Surg 2005;79:1851–6)

© 2005 by The Society of Thoracic Surgeons

leural empyema affects a large number of patientsand may lead to severe and disabling sequelae in

ases of inappropriate diagnosis or treatment [1, 2]. Thehoice of the appropriate treatment depends on theature of the underlying disease, the chronicity of thempyema, and the patient’s overall condition [3]. Themerican Thoracic Society staging system has served asguideline for appropriate treatment of patients with

arapneumonic empyema. Stage I empyema is charac-erized by an exudative effusion without appearance ofoculations and is usually treated by antibiotics andhoracocentesis or chest tube drainage. During the fibrin-purulent phase or stage II disease, the pleural fluid isurbid or frankly purulent and there are fibrin deposits

ccepted for publication Dec 21, 2004.

ddress reprint requests to Dr Lardinois, Division of Thoracic Surgery,

ver all pleural surfaces. Computer tomography imagingCT scan) typically reveals pleural enhancement andoculated effusion but no signs of restriction. Treatmentptions consist of fibrinolytic therapy or video-assistedhoracoscopic debridement. Stage III empyema is char-cterized by pleural thickening and signs of restriction onT scan. Decortication is required to free the trapped

ung and to prevent recurrence and late restriction.Several reports have demonstrated that video-assisted

horacoscopic surgery (VATS) is a valid treatment optionor stage II empyema and allows appropriate control ofnfection and restoration of pulmonary function in earlytage empyema [1, 2, 4–6]. Video-assisted thoracoscopicurgery is an attractive minimally invasive approach andas made surgical intervention a more acceptable early

reatment option in this respect [7, 8]. Stage II empyemas a transitory stage between the exudative (stage I) and

hronic (stage III) forms of empyema and represents only

0003-4975/05/$30.00doi:10.1016/j.athoracsur.2004.12.031

by on June 8, 2013 als.org

aUasbtcd

itfwV

P

St[op

PEAch(wateatpb

ssio

pdgceCfi

TDAaiiTcaicb

dAtidrdOydffpassd

cp

TCE

C

PPPTPTAA

V

1852 LARDINOIS ET AL Ann Thorac SurgPREDICTIVE FACTORS FOR CONVERSION THORACOTOMY IN EMPYEMA 2005;79:1851–6

GEN

ERA

LT

HO

RA

CIC

short time frame in the evolution toward chronicity.nfortunately, there is actually no single valid test avail-

ble to distinguish stage II and III empyema on clinicaligns and laboratory measurements. As a consequence, itecame apparent that VATS has its limitations in the

reatment of empyema, especially for the treatment ofhronic empyema, which is still best treated with openecortication.In this study, the role of VATS was critically evaluated

n a consecutive series of 328 patients with surgicallyreated empyema, and a multivariate analysis was per-ormed to determine the predicting factors associatedith a conversion thoracotomy in patients undergoingATS for presumed stage II disease.

atients and Methods

ince 1992, a standardized approach has been used forhe surgical treatment of patients with pleural empyema1, 2]. All patients with stage II or III disease wereperated on according to this initially described ap-roach and were followed in a consecutive manner.

atient Selectionnrollment criteria for surgery in patients with suspectedmerican Thoracic Society stage II and III empyema

onsisted of loculated pleural effusion and pleural en-ancement on CT scan associated with signs of infection

fever, leukocytosis, elevation of C-reactive protein),eight loss, chest pain, and a positive bacterial culture orpH less than 7.1 of the pleural liquid assessed by

horacocentesis or chest tube drainage. Stage III empy-ma was suspected in the presence of pleural thickeningnd signs of restriction on CT scan. All patients had beenreated initially with antibiotics, and 74.7% (245 of 328atients) had thoracocentesis or chest tube drainageefore admission in our institution.A VATS approach was offered to all patients with

uspected stage II empyema, ie, loculated pleural effu-ion and pleural enhancement without pleural thicken-ng or signs of restriction at CT scan associated with signs

able 1. Video-Assisted Thoracoscopic Surgery Debridement,onversion Thoracotomy, and Primary Open Decortication inmpyema According to the Underlying Cause of Empyema

auseVATS Debridement

(n � 99)

ostpneumonic (n � 200) 42ostoperative (n � 52) 25osttraumatic (n � 32) 17uberculosis (n � 20) 9ulmonary embolism (n � 13) 6umor, abscess (n � 5)spergillosis (n � 5)ctinomycosis (n � 1)

ATS � video-assisted thoracoscopic surgery.

f infection. Informed consent was obtained from all

ats.ctsnetjournDownloaded from

atients to proceed to conversion thoracotomy and openecortication if a stage III empyema was found at sur-ery. Exclusion criteria for a primary VATS approachonsisted of the presence of a presumed stage III empy-ma with pleural thickening and signs of restriction onT scan or the suspicion of abscess, bronchopleuralstula, or tumor at initial workup.

echnique of Video-Assisted Thoracoscopic Surgeryebridementfter double-lumen intubation, the patient was placed inlateral position. A standard posterolateral thoracotomy

ncision was drawn on the skin of the patient, and a 3-cmncision was performed in the ventral aspect of this line.he operator’s index finger was introduced into the chestavity. This digital exploration was found to be helpful tossess the chronicity of empyema; a rigid and narrowedntercostal space and palpable peel on the lung surfaceorrelated with stage III empyema, which was unlikely toe successfully treated by VATS [1].The pleural space was freed circumferentially by finger

issection and by use of a Senning suction device (UlrichG, St. Gallen, Switzerland). The optic was inserted

hrough an additional 7-mm thoracic port placed onentercostal space above the initial incision but within theissected area, and fluid, loculations, and septa wereemoved under endoscopic vision by use of the suctionevice and endoscopic Kaiser forceps (OP-Medical AG,berägeri, Switzerland). Material for microbiologic anal-

sis was collected in all patients. The chest cavity wasebrided, and the lung was freed circumferentially and

rom the apex to the diaphragm. An endoscopic lungorceps was inserted through a third thoracic port in theosterior aspect of the sixth intercostal space, whichllowed the exposure of the lung surfaces and the fis-ures. Debridement of the visceral pleura and the fis-ures was performed by use of an Ulrich endoscopicissector device (Ulrich AG, St. Gallen, Switzerland) [1].Conversion thoracotomy and open decortication was

onsidered in the presence of incapability to dissect theeel from the underlying lung surfaces.

o-Assisted Thoracoscopic Surgery Attempt Followed byPatients Undergoing Surgery for Stage II and III Pleural

VATS Followed byConversion Thoracotomy

(n � 79)

Primary OpenDecortication

(n � 150)

51 (55%) 10710 (29%) 17

8 (32%) 73 (25%) 84 (40%) 31 (100%) 42 (100%) 3

1

Vide328

After completion of the debridement of the parietal

by on June 8, 2013 als.org

atvdstebaocw

DDtbea

SS�vdifpbta

aac

R

Bfa9

UTmitii

SOewc

swtVwptwiwp

Fgp

TTEbM

ASE

B

T

a

Ts

1853Ann Thorac Surg LARDINOIS ET AL2005;79:1851–6 PREDICTIVE FACTORS FOR CONVERSION THORACOTOMY IN EMPYEMA

GEN

ERA

LT

HO

RA

CIC

nd visceral pleura, two 28F chest tubes were insertedhrough the ventral ports and placed under endoscopicision in the costodiaphragmatic sulcus and the pleuralome, respectively. The pleural cavity was rinsed witheveral liters of warm saline solution through the chestubes, and the lung was reexpanded. The patients werextubated as soon as they fulfilled the criteria for extu-ation, and respiratory physiotherapy was instituted. Thentibiotic regimen was discontinued 14 days after theperation except in the presence of a lung abscess. Thehest tubes were removed in the absence of air leaks andhen the drainage volume was less than 100 mL/day.

ata Collectionemographic data, time interval between onset of symp-

oms and surgery, underlying cause of empyema, micro-iologic findings, postoperative morbidity, and the pres-nce or absence of recurrent empyema up to 6 monthsfter surgery were recorded in every patient.

tatistical Analysisummaries of continuous variables were given as mean

standard deviation, whereas summaries of binaryariables were given as counts and proportions. Toetermine predictive factors for conversion thoracotomy

n presumed stage II empyema accessed by VATS for theactors age, sex, presence of bacteria, presence of gram-ositive and gram-negative organisms, and time intervaletween onset of symptoms and surgery, as well as for

he different etiologic groups (postpneumonic, postoper-

able 2. Identification of Predictors for Conversionhoracotomy in 178 Patients With Presumed Stage IImpyema Accessed by Video-Assisted Thoracoscopic Surgeryy Use of a Univariate and a Multivariate Analysis With aultiple Stepwise Logistic Regression

Risk Factors

UnivariateAnalysis

MultivariateAnalysis

p ValueOddsRatioa p Value

OddsRatioa

ge 0.07 0.98 0.62 0.99ex (male) 0.01 0.44 0.54 0.69tiologyPostpneumonic 0.004 2.47 0.56 0.72Postoperative 0.04 0.43Posttraumatic 0.18 0.54Postembolic 0.77 0.83Tuberculosis 0.18 0.40

acteria 0.78 0.92Gram positive 0.03 0.51 0.08 0.29Gram negative �0.0001 6.60 �0.01 5.77

ime intervalT �0.0001 2.17 �0.0001 2.35

Odds ratio � 1 indicates a risk factor for conversion thoracotomy.

� time interval between onset of symptoms and referral to thoracicurgeons.

tive, posttraumatic, postembolic, tuberculosis), univari- a

ats.ctsnetjournDownloaded from

te logistic regression and then multivariate analysis withmultiple logistic regression model was used. Signifi-

ance was accepted at p less than 0.05.

esults

etween 1992 and 2002, 328 patients underwent surgeryor stage II or III pleural empyema; there were 227 mennd 101 women, with a mean age of 55 years (range, 18 to0 years).

nderlying Cause of Empyemahe underlying cause of empyema (Table 1) was pneu-onia in 200 patients (61%), previous thoracic or abdom-

nal operations in 52 (16%), chest trauma in 32 (10%),uberculosis in 20 (6%), pulmonary embolism in 13 (4%),ntrathoracic malignancy in 5 (2%), pleural aspergillosisn 5 (2%), and pleural actinomycosis in 1 (0.3%).

urgical Procedurene hundred fifty patients (46%) with suspected stage III

mpyema (long-lasting history and pleural thickeningith signs of restriction on CT scan) underwent decorti-

ation by thoracotomy without VATS attempt.One hundred seventy-eight patients (54%) with pre-

umed stage II disease underwent a VATS approach,hich had to be converted to open decortication in 79 of

hese patients (44%) because of chronicity of disease;ATS debridement without the need for thoracotomyas performed in 99 patients (56%). In patients withresumed stage II empyema, VATS debridement without

horacotomy was achieved in 68% (17 of 25) of patientsith posttraumatic, in 71% (25 of 35) with postoperative,

n 75% (9 of 12) with tuberculous, and in 60% (6 of 10)ith postembolic empyema, but only in 45% (42 of 93) ofatients with parapneumonic empyema (Table 1). As a

ig 1. Probability of conversion thoracotomy in 178 patients under-oing video-assisted thoracoscopic surgery for presumed stage II em-yema according to the time interval between onset of symptoms

nd surgery.

by on June 8, 2013 als.org

compT

edsier

MBipS1gEf2mb

P1Uebgagtuwteesdgsnpso(bcabd

MT3df

t3iimt

ateoAa

C

Toippmiaavcp

rssorioVitpftCodtwtuviboeawtsc

1854 LARDINOIS ET AL Ann Thorac SurgPREDICTIVE FACTORS FOR CONVERSION THORACOTOMY IN EMPYEMA 2005;79:1851–6

GEN

ERA

LT

HO

RA

CIC

onsequence, the conversion rate for thoracotomy andpen decortication was higher in patients with parapneu-onic empyema (55%) as compared with those with

osttraumatic (32%) or postoperative empyema (29%;able 1).In patients undergoing surgery for parapneumonic

mpyema, a trend toward increased chronicity of theisease requiring a primary open decortication was ob-erved since 1997. Primary thoracotomy was performedn 45% and 56% of patients with parapneumonic empy-ma between 1992 and 1996, and 1997 and 2002,espectively.

icrobiologic Assessmentacteriologic examination of the collected material dur-

ng surgery revealed negative cultures in 40% of theatients. Streptococcus pneumoniae was found in 25%,taphylococcus aureus in 15%, and other streptococci in0% of the patients. Infections caused by gram-negativeerms (Haemophilus influenzae, Pseudomonas aeruginosa,scherichia coli, Proteus mirabilis, Enterobacter cloacae) wereound in 6% of the patients between 1992 and 1996, and in8% between 1997 and 2002 (p � 0.0001). Anaerobicicroorganisms were not found between 1992 and 1996,

ut in 5% of the patients since 1997.

redictive Factors for Conversion Thoracotomy in the78 Patients With Presumed Stage II Empyemanivariate analysis showed that postpneumonic empy-

ma (p � 0.003), male sex (p � 0.013), prolonged timeetween onset of symptoms and surgery (p � 0.0001), andram-negative organisms (p � 0.0001) were significantlyssociated with conversion thoracotomy (Table 2). In thisroup of 178 patients, the time between onset of symp-oms and surgery was 9.8 � 3.2 days for the patients whonderwent thoracoscopic debridement in comparisonith 17.3 � 3.8 days in the patients with conversion

horacotomy. The patients with postpneumonic empy-ma were referred to surgery later than the patients withmpyema of other causes, with a time between onset ofymptoms and surgery of 14.9 � 4.8 days versus 11.2 � 4.6ays. Multivariate analysis using a stepwise logistic re-ression model identified the time interval between on-et of symptoms and surgery (p � 0.0001) and gram-egative microorganisms (p � 0.01) as significantredictive factors for conversion thoracotomy in pre-umed stage II empyema accessed by VATS, whereas agef the patient, sex, and underlying cause of empyemaparapneumonic, postoperative, posttraumatic, postem-olic, tuberculosis) were not (Table 2). The probability foronversion thoracotomy in presumed stage II empyemaccessed by VATS strongly increased after a time intervaletween onset of symptoms and surgery greater than 14ays (Fig 1).

ortality and Morbidityhe postoperative 30-day mortality rate was 4% (13 of28), 3% after VATS debridement, and 4% after openecortication. Ten patients died of sepsis and multiorgan

ailure, 2 of metastatic cancer, and 1 of mesenteric infarc- s

ats.ctsnetjournDownloaded from

ion. Postoperative complications were found in 9% of28 patients: prolonged air leak (�5 days) in 4.8%, renalnsufficiency requiring dialysis in 1.5%, bleeding requir-ng reoperation in 0.9%, wound dehiscence in 0.9%,

yocardial infarction in 0.6%, and cholecystitis in 0.6% ofhe patients.

Recurrent empyema was found in 2.4% (8 of 328), 2%fter VATS debridement and 2.6% after open decortica-ion. All 8 patients had initially a parapneumonic empy-ma, and recurrence was diagnosed after an average timef 25 days (range, 10 to 42 days) after the initial operation.ll patients underwent reoperation by thoracotomy, andll had an uneventful recovery.

omment

he mainstay of treatment of pleural empyema is controlf ongoing infection and the prevention of recurrent

nfection and late restriction. Incomplete drainage of theleural space with persistent signs of infection shouldrompt surgical intervention. Delaying surgical treat-ent in these situations is responsible for functional

mpairment and is associated with substantial morbiditynd mortality [9, 10]. However, the decision making forppropriate treatment (surgical and nonsurgical) is aexing clinical problem owing to the absence of specificlinical, radiologic, and laboratory characteristics for ap-ropriate preoperative staging of empyema [8].The advent of VATS for the management of fibrinopu-

ulent stage II empyema has shown rewarding results ineveral reports [2, 11–13]. Video-assisted thoracoscopicurgery has the advantage of being less invasive thanpen decortication and having a better acceptance by theeferring physician and the patient [6, 7, 14]. However, its obvious that VATS has its limitations for the treatmentf stage III disease [1, 3]. To overcome these limitations ofATS in the treatment of empyema and the problem of

nability to accurately predict the stage of empyema inhe preoperative phase, we have adapted a simple andragmatic approach in patients with empyema referred

or surgery since 1992. Patients with a long-lasting his-ory, a thickened pleural peel, and signs of restriction onT scan and those with an additional pathologic findingn CT scan such as an abscess or a tumor underwentecortication by primary thoracotomy. In all other situa-

ions, the patients were informed that a VATS approachould be attempted, and informed consent was obtained

o proceed to thoracotomy if VATS was likely to benrewarding. A 3-cm-long incision was made in theentral aspect of a presumed thoracotomy line, andntraoperative evaluation of the pleural space was madey finger palpation and endoscopic exploration. In casef an organizing stage III empyema, the incision wasnlarged to a standard thoracotomy. This pragmaticpproach allowed a rapid distinction between patientsho were likely to profit from a VATS debridement and

hose who required formal decortication. The currenttudy summarizes our experience in this respect on aonsecutive series of 328 patients referred for surgery of

tage II and III empyema between 1992 and 2002.

by on June 8, 2013 als.org

duapmoaia

VspV5erwd

bsbphaefibfsvprfrwp

spweptTaa[brlIspwamp

ws

pgflaFcpntst

prsaw

soerahteo

mprep

R

1855Ann Thorac Surg LARDINOIS ET AL2005;79:1851–6 PREDICTIVE FACTORS FOR CONVERSION THORACOTOMY IN EMPYEMA

GEN

ERA

LT

HO

RA

CIC

Of the 328 patients, 150 underwent primary openecortication owing to chronic stage III empyema or thenderlying cause of empyema requiring thoracotomynd resection such as abscessing lung tumors, broncho-leural fistula, or abscessing lung infarctions after pul-onary embolism. Computed tomographic scan may not

nly help to estimate the chronicity of an empyema butlso help to determine its underlying cause, which ismportant to define treatment strategy and the surgicalpproach [3].One hundred seventy-eight patients underwent a

ATS attempt for presumed stage II disease, but conver-ion thoracotomy was judged necessary in another 79atients because of chronicity of the disease. In fact, aATS debridement seemed feasible and rewarding in6% of the referred patients with suspected stage IImpyema. These findings are similar to those from aecently published report in which 38% of the patientsith empyema were managed by VATS and 62% by openecortication [14].Our results confirm the importance of the interval

etween onset of symptoms or pleural effusion andurgery on the chronicity of empyema and the accessi-ility to a VATS treatment [5, 6, 15, 16]. Patients withresumed stage III disease had a long-lasting (�3 weeks)istory and presented with a thickened enhanced pleurand signs of restriction on CT scan. A chronic stage IIImpyema inaccessible to a VATS approach was con-rmed in all these patients during surgery. The intervaletween onset of symptoms and surgery was also crucial

or the accessibility of VATS in patients with presumedtage II empyema. Our results emerging from a multi-ariate analysis demonstrated that it was the most im-ortant predictor for conversion thoracotomy in thisespect. The probability of conversion thoracotomy roserom 22% to 86% between an interval of 12 and 16 days,espectively. The importance of early referral of patientsith suspected empyema to surgery cannot be overem-hasized if a minimal invasive approach is considered.In patients with clinical stage II empyema, the conver-

ion thoracotomy rate was higher in the patients withostpneumonic empyema (55%) as compared with thoseith posttraumatic (32%) and postoperative (29%) empy-

ma. We speculate that this was related to a longereriod of unsuccessful medial treatment before referral

o surgery in patients with parapneumonic empyema.he conversion thoracotomy rate in patients undergoingVATS approach for parapneumonic empyema has beennalyzed in several reports and ranged from 18% to 59%3, 6, 7, 17, 18]. Again, this discrepancy may be explainedy a difference in referral pattern for surgery between theeported series and a stage migration phenomenon re-ated to the policy of medical treatment before surgery.ndeed, the underlying cause of empyema was not aignificant predictor for conversion thoracotomy in ouratients as assessed by multivariate analysis in a step-ise multiple logistic regression model. In contrast, this

nalysis revealed that VATS debridement could even beore successful in that group of patients than in the

atients with other causes of empyema if the patients

ats.ctsnetjournDownloaded from

ith postpneumonic empyema had been referred tourgery earlier.

The second predictor for conversion thoracotomy inatients with presumed stage II was the presence ofram-negative microorganisms in the collected pleuraluid. The presence of E coli and E cloacae was alwaysssociated with conversion thoracotomy in our series.urthermore, we observed an increased incidence ofonversion thoracotomy in the second part of our studyeriod, which paralleled an increased incidence of gram-egative and anaerobic microorganisms found at opera-

ion. It has been suggested that the rapidity of progres-ion and stage transition of empyema are affected by theype and virulence of the involved organisms [8].

The 30-day postoperative mortality was 4% for allatients, which is in accordance with the results of othereports ranging from 1.3% to 6.6% [3, 7, 14, 15]. In oureries, postoperative complications were observed in 9%nd a reoperation rate for recurrent empyema in 2.4%,hich is also comparable to other studies [7].Although the results of our study and other series

uggest that appropriate control of infection may bebtained by VATS debridement for stage II pleuralmpyema, the results regarding prevention of lateestriction and restoration of pulmonary function stillwait further confirmation. In an earlier report, weave shown some degree of restriction in about 30% of

he patients undergoing VATS debridement for empy-ma at pulmonary function testing 6 months after theperation [1].In conclusion, VATS debridement offers an elegantinimal invasive approach in a number of patients with

resumed stage II empyema. However, conversion tho-acotomy should be liberally used in case of chronicity,specially after delayed referral (�2 weeks) and in theresence of gram-negative organisms.

eferences

1. Striffeler H, Gugger M, Im Hof V, Cerny A, Furrer M, Ris HB.Video-assisted thoracoscopic surgery for fibrinopurulentpleural empyema in 67 patients. Ann Thorac Surg 1998;65:319–23.

2. Striffeler H, Ris HB, Würsten HU, Im Hof V, Stirnemann P,Althaus U. Videoassisted thoracoscopic treatment of pleuralempyema. A new therapeutic approach. Eur J CardiothoracSurg 1994;8:585–8.

3. Weissberg D, Refaely Y. Pleural empyema: 24-year experi-ence. Ann Thorac Surg 1996;62:1026–9.

4. Cheng YJ, Wu HH, Chou SH, Kao EL. Video-assisted thora-coscopic surgery in the treatment of chronic empyemathoracis. Surg Today 2002;32:19–25.

5. Waller DA, Rengarajan A, Nicholson FH, Rajesh PB. De-layed referral reduces the success of video-assisted thoraco-scopic debridement for post-pneumonic empyema. RespirMed 2001;95:836–40.

6. Cassina PC, Hauser M, Hillejan L, Greschuchna D, StamatisG. Video-assisted thoracoscopy in the treatment of pleuralempyema: stage-based management and outcome. J ThoracCardiovasc Surg 1999;117:234–8.

7. Angelillo Mackinlay TA, Lyons GA, Chimondeguy DJ, Pie-dras MA, Angaramo G, Emery J. VATS debridement versus

thoracotomy in the treatment of loculated postpneumoniaempyema. Ann Thorac Surg 1996;61:1626–30.

by on June 8, 2013 als.org

1

1

1

1

1

1

1

1

1

I

EiaamtpTtr

tapdre

twpppasiaaeisd

1856 LARDINOIS ET AL Ann Thorac SurgPREDICTIVE FACTORS FOR CONVERSION THORACOTOMY IN EMPYEMA 2005;79:1851–6

©P

GEN

ERA

LT

HO

RA

CIC

8. Cameron RJ. Management of complicated parapneumoniceffusions and thoracic empyema. Int Med J 2002;32:408 –14.

9. Anstadt MP, Guill CK, Ferguson ER, et al. Surgical versusnonsurgical treatment of empyema thoracis: an outcomeanalysis. Am J Med Sci 2003;326:9–14.

0. Rzyman W, Skokowski J, Romanowicz G, Lass P, Dziadzi-uszko R. Decortication in chronic pleural empyema—effect on lung function. Eur J Cardiothorac Surg 2002;21:502–7.

1. Hurley JP, McCarthy J, Wood AE. Retrospective analysisof the utility of videoassisted thoracic surgery in 100consecutive procedures. Eur J Cardiothorac Surg 1994;8:589 –92.

2. Liu HP, Chang CH, Lin PJ, Hsieh HC, Chang JP, Hsieh MJ.Video-assisted thoracic surgery. The Chang Gung experi-ence. J Thorac Cardiovasc Surg 1994;108:834–40.

3. Silen ML, Nauheim KS. Thoracoscopic approach to the

irected catheter fails to resolve the problem. Unfortu-

nai

vmtttsctcrfd

dtsWcot

R

DU9Oe

2005 by The Society of Thoracic Surgeonsublished by Elsevier Inc

ats.ctsnetjournDownloaded from

management of empyema thoracis. Indications and results.Chest Surg Clin North Am 1996;6:491–9.

4. Roberts JR. Minimally invasive surgery in the treatment ofempyema: intraoperative decision making. Ann Thorac Surg2003;76:225–30.

5. Landreneau RJ, Keenan RJ, Hazelrigg SR, Mack M, NauheimKS. Thoracoscopy for empyema and hemothorax. Chest1995;109:18–24.

6. Bouros D, Antoniou KM, Chalkiadakis G, Drositis J, PetrakisI, Siafakas N. The role of video-assisted thoracoscopic sur-gery in the treatment of parapneumonic empyema after thefailure of fibrinolytics. Surg Endosc 2002;16:151–4.

7. Waller DA, Rengarajan A. Thoracoscopic decortication: arole for video-assisted surgery in chronic postpneumonicpleural empyema. Ann Thorac Surg 2001;71:1813–6.

8. Lackner RP, Hughes R, Anderson LA, Sammut PH, Thomp-son AB. Video-assisted evacuation of empyema is the pre-ferred procedure for management of pleural space infec-

tions. Am J Surg 2000;179:27–30.

NVITED COMMENTARY

mpyema continues to be a significant cause of morbid-ty and mortality, complicating community and hospitalcquired pulmonary infections, as well as many thoracicnd abdominal surgical procedures. The early manage-ent of empyema may be as simple as antibiotics and

horacentesis, whereas late intervention may be as com-licated as decortication with interposition of tissue flaps.ypically these procedures have required a thoracotomy

o achieve full expansion of the lung and obliteration ofesidual pleural space.

Thoracoscopy has added a minimally invasive alterna-ive to these traditional approaches. Early in the video-ssisted thoracoscopic surgery (VATS) era a complexleural space was considered at least a relative contrain-ication to a minimally invasive procedure, but as expe-ience increased the VATS approach proved its utilityven in the most inflamed pleural space.One key question that remains largely unanswered in

he management of empyema is the optimal timing athich to initiate surgical intervention. The exudativehase of an empyema can last as little as 48 hours beforerogressing onto the fibrinopurulent phase at whichoint the pleural space can be extensively loculated, andthick peel envelops the lung. Clearly thoracic surgeons

ee an insignificant percentage of empyemas complicat-ng community acquired pneumonias at this early stage,s most are treated as outpatients. Even when they aredmitted with dyspnea and radiographic evidence ofmpyema, a pulmonologist or interventional radiologists the next “specialist” called to manage the pleuralpace. A surgeon only becomes involved when the image

ately, this may be weeks into the course of the empyemat which point the interventions become increasinglynvasive.

The current study by Lardinois and colleagues pro-ides further evidence that delayed referral for surgicalanagement of empyema will limit the number of pa-

ients amenable to a minimally invasive approach. Al-hough not stated in the article, one would speculate thathe patients with earlier surgical referrals who wereuccessfully managed with VATS would have a signifi-antly shorter hospital stay and decreased morbidity. It isempting to infer from the data that those patients withulture proven gram negative infections that progressapidly between phases would likely benefit the mostrom an early VATS evacuation of empyema andecortication.Although the authors encourage liberal use of open

ecortication for the more chronic pleural space infec-ion, despite being excruciatingly tedious, even the mostcarred lung can be freed in a minimally invasive fashion.

ith radiographic evidence of stage often being equivo-al, it is not unreasonable to attempt a VATS in all casesf empyema and convert only the densest fibrothorax tohoracotomy.

udy Lackner, MD

epartment of Surgeryniversity of Nebraska Medical Center

82315 Nebraska Medical Centermaha, NE 68198-2315

-mail: rlackner@unmc.edu

0003-4975/05/$30.00doi:10.1016/j.athoracsur.2005.02.014

by on June 8, 2013 als.org

2005;79:1851-1856 Ann Thorac SurgMarkus Furrer and Hans-Beat Ris

Didier Lardinois, Michael Gock, Edgardo Pezzetta, Christian Buchli, Valentin Rousson, for Empyema

Thoracotomy Rate in Patients Undergoing Video-Assisted Thoracoscopic Surgery Delayed Referral and Gram-Negative Organisms Increase the Conversion

& ServicesUpdated Information

http://ats.ctsnetjournals.org/cgi/content/full/79/6/1851including high-resolution figures, can be found at:

References http://ats.ctsnetjournals.org/cgi/content/full/79/6/1851#BIBL

This article cites 18 articles, 10 of which you can access for free at:

Citations

shttp://ats.ctsnetjournals.org/cgi/content/full/79/6/1851#otherarticleThis article has been cited by 9 HighWire-hosted articles:

Permissions & Licensing

.healthpermissions@elsevier.comemail: orhttp://www.us.elsevierhealth.com/Licensing/permissions.jsp

in its entirety should be submitted to: Requests about reproducing this article in parts (figures, tables) or

Reprints reprints@elsevier.com

For information about ordering reprints, please email:

by on June 8, 2013 ats.ctsnetjournals.orgDownloaded from