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Ann Thorac Surg 2007;84:231
© 2007 The Society of Thoracic Surgeons
Department of Surgery, Virginia Mason Medical Center, 1100 9th Ave, Seattle, WA 98111
(Email: gtsdel{at}vmmc.org).
The timely and appropriate management of complicated fibropurulent pleural effusions and acute and chronic empyemas remains a challenging issue. Chan and colleagues [1] have reported on a significant experience in managing these patients with both open and minimally invasive techniques, and although their series is not randomized, the patients have been arbitrarily directed to two medical centers where either the open or minimally invasive approaches were used exclusively. The outcomes associated with the two techniques are remarkably similar. Treatment success was routinely accomplished in both groups with no requirements for reinterventions, as well as mortality and complication rates that compare very favorably to historic series. It is likely that differences in medical systems and practice patterns explain the differences from previously published reports in patient time on antibiotics (76 and 54 days), mean hospital days (21 and 16 days), and time to return to work (6.4 and 4.6 months), especially because this population was quite young with a mean age in both treatment groups of less than 50 years of age.
The report includes a significant percentage of patients with challenging technical situations in that approximately one third of patients had tuberculosis empyemas, and three quarters were assessed to be in the "organizing phase" of their intrapleural infection. This study does not differentiate, however, between acute and chronic empyemas, especially those with fibrothorax in which true decortication has historically required sharp dissection of restricted lung, not simply blunt stripping of pleural peel.
Although treatment success was routinely achieved, the authors present comparative data obtained at only two points: "immediately" after the surgery and then at a mean of 36 months (range, 6 to 65 months) postoperatively. This does not provide an adequate opportunity to assess outcomes over time, and it is particularly puzzling in that all patients were routinely seen four weeks after discharge for follow-up chest x-ray films, but no intermediate data on dyspnea or postoperative pain was obtained at that point.
The authors use the Medical Research Council dyspnea index and an approach to pain assessment similar to the standard visual analog system. Except for pain scores immediately after surgery, no significant differences were noted. This is not surprising considering that the minimally invasive group used a true thoracoscopic approach, whereas the open group applied a full posterior lateral thoracotomy, not a muscle-sparing or limited rib-spreading approach. In addition, we have no information regarding the various approaches to postoperative pain management in either group.
Assessment of clinical outcomes would have been enhanced not only with more regular symptomatic assessment, but also documentation of quality of life measurements. Instead the authors have provided the more difficult to interpret assessment of "overall satisfaction" and "satisfaction with wounds" as the only long-term differences between treatment groups.
This report appropriately outlined the underlying treatment goals in all patients with acute and chronic empyemas, which is to maximize drainage and to free the trapped lung to completely fill the pleural space. This goal was accomplished with remarkable consistency in both treatment groups. The fact that no patients required reinterventions may be unprecedented. The title asks "Is Video-Assisted Thoracic Surgery Better Than Thoracotomy?" The issue currently is not which approach is better, but the realization that, in experienced hands dedicated to adhering to standard technical outcome principals, minimally invasive approaches can provide excellent outcomes in these complicated patients.
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