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Ann Thorac Surg 2005;79:1856
© 2005 The Society of Thoracic Surgeons
Department of Surgery University of Nebraska Medical Center 982315 Nebraska Medical Center, Omaha, NE 68198-2315
(E-mail: rlackner{at}unmc.edu).
Empyema continues to be a significant cause of morbidity and mortality, complicating community and hospital acquired pulmonary infections, as well as many thoracic and abdominal surgical procedures. The early management of empyema may be as simple as antibiotics and thoracentesis, whereas late i ntervention may be as complicated as decortication with interposition of tissue flaps. Typically these procedures have required a thoracotomy to achieve full expansion of the lung and obliteration of residual pleural space.
Thoracoscopy has added a minimally invasive alternative to these traditional approaches. Early in the video-assisted thoracoscopic surgery (VATS) era a complex pleural space was considered at least a relative contraindication to a minimally invasive procedure, but as experience increased the VATS approach proved its utility even in the most inflamed pleural space.
One key question that remains largely unanswered in the management of empyema is the optimal timing at which to initiate surgical intervention. The exudative phase of an empyema can last as little as 48 hours before progressing onto the fibrinopurulent phase at which point the pleural space can be extensively loculated, and a thick peel envelops the lung. Clearly thoracic surgeons see an insignificant percentage of empyemas complicating community acquired pneumonias at this early stage, as most are treated as outpatients. Even when they are admitted with dyspnea and radiographic evidence of empyema, a pulmonologist or interventional radiologist is the next "specialist" called to manage the pleural space. A surgeon only becomes involved when the image directed catheter fails to resolve the problem. Unfortunately, this may be weeks into the course of the empyema at which point the interventions become increasingly invasive.
The current study by Lardinois and colleagues provides further evidence that delayed referral for surgical management of empyema will limit the number of patients amenable to a minimally invasive approach. Although not stated in the article, one would speculate that the patients with earlier surgical referrals who were successfully managed with VATS would have a significantly shorter hospital stay and decreased morbidity. It is tempting to infer from the data that those patients with culture proven gram negative infections that progress rapidly between phases would likely benefit the most from an early VATS evacuation of empyema and decortication.
Although the authors encourage liberal use of open decortication for the more chronic pleural space infection, despite being excruciatingly tedious, even the most scarred lung can be freed in a minimally invasive fashion. With radiographic evidence of stage often being equivocal, it is not unreasonable to attempt a VATS in all cases of empyema and convert only the densest fibrothorax to thoracotomy.
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