Thoracoscopic management of early stages of empyema: is this the golden standard?

Background: Empyema is a well-known disease that significantly increases the morbidity and mortality associated with pneumonia. There are a number of treatment modalities available but recently video assisted thoracoscopic surgery (VATS) has been suggested as a reliable tool in management of empyema; particularly in early stages. The aim of this study is to assess the safety and effectiveness of using initial VATS for all surgically fit patients with early stages of empyema.

Methods: Sixty-six patients with early stage empyema were prospectively studied between December 2013 and March 2016. Patients were divided into two groups: group A (28 patients) were managed conservatively without surgery for stage I (exudative) phase empyema by the chest physicians; and group B (38 patients) were managed by the thoracic surgeons by VATS for stage I (exudative) and stage II (fibrino-purulent) empyema. Comparison was made between both groups.

Results: There was no statistically significant difference between the groups from the point of view of age, sex or pre-intervention comorbidities (P>0.05). Average hospital stay in group A was 22 days (7-131 days), it was 4.1 days (2-14 days) in group B (P=0.004; 95% CI: 10.3-25.5) with a resultant lower cost. Three patients (10.7%) in group A suffered from major morbidity during treatment while none in group B suffered a major postoperative morbidity (P=0.039). There were 2 mortalities (7.1%) in group A and no deaths in group B (P=0.094). During a mean follow up period of 8 months [6-14] in group A 14.3% of the patients underwent open decortication, whereas in group B, 5.3% of the patients underwent the same procedure (P=0.047).

Conclusions: Thoracoscopic management of early stages of empyema should be the golden standard of management in surgically fit patients; particularly in the fibro-exudative phase of empyema. It is an effective and safe technique that reduces hospital stay, cost, complications and avoids the need for a decortication via a thoracotomy in most cases.