Uniportal thoracoscopic decortication: start away from empyema approach

Abstract

Aim: Video-assisted thoracoscopic surgery (VATS) is now a gold standard in treating early-stage empyema, while much debate still exists considering the effectiveness of this approach for late-stage empyema. Most concerns arise from the crowded rib cage, narrow working space, and ability to free trapped lungs quickly, mainly if uniportal VATS is used. However, unlike uniportal VATS lobectomy, there is no consensus about standard steps for uniportal VATS decortication to ensure smooth and effective surgery. We try to offer standard, easy-to-replicate steps for this approach to evaluate the efficacy and safety of the “start away from empyema” approach for uniportal VATS decortication in the management of stage II and III empyema.

Methods: A prospective case series study has been conducted on 25 patients. All patients with stage II and III empyema were admitted to the Cardiothoracic Surgery Department between October 2017 and March 2020. VATS procedure was done under general anesthesia by a double-lumen tube for selective ventilation. Demographic data, preoperative diagnosis, intraoperative findings, hospital stay, and complications were recorded.

Results: Twenty-five patients were enrolled in this study with a median age of 35 years. The duration of illness ranged between 14 and 60 days, with a median (IQR) of 25 (17) days. In (88%) of the patients, there was a successful outcome defined as a near-complete resolution on Chest X-ray (scoring of 3 or 4) and chest US (scoring of 2 or 3). Only three (12%) patients had a partially successful outcome. All patients with partial success suffered from infection associated with malignant effusion.

Conclusion: “Start away from empyema” approach for uniportal VATS decortication in stage II and III empyema could be safe and effective in treating loculated nonmalignant pleural effusion.

Keywords

Empyema / video-assisted thoracoscopic surgery (VATS) / uniportal / decortication / infection / thoracic

References

[1] Bobbio A,Frenkiel J.Epidemiology and prognostic factors of pleural empyema.Thorax2021;76:1117-23

[2] Bongiolatti S,Borgianni S.Uniportal thoracoscopic decortication for pleural empyema and the role of ultrasonographic preoperative staging.Interact Cardiovasc Thorac Surg2017;24:560-6

[3] Elkhayat H.Uniportal VATS approach for treatment of empyema: Challenges and recommendations.Multimed Man Cardiothorac Surg2018;2018

[4] Elkhayat H,Kamal M.Thoracoscopic decortication for stage III empyema; a minimal invasive approach in a delayed presentation disease.Journal of the Egyptian Society of Cardio-Thoracic Surgery2018;26:301-7

[5] van Middendorp LB,Gillissen S.Uniportal video-assisted thoracoscopy is a safe approach in patients with empyema requiring surgery.J Thorac Dis2020;12:1460-6 PMCID:PMC7212173

[6] Yang PC,Chang DB,Yu CJ.Value of sonography in determining the nature of pleural effusion: analysis of 320 cases.AJR Am J Roentgenol1992;159:29-33

[7] Migliore M.A single-trocar technique for minimally-invasive surgery of the chest.Surg Endosc2001;15:899-901

[8] Migliore M.Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease.The Journal of Thoracic and Cardiovascular Surgery2003;126:1618-23

[9] Rocco G,Passera E.Uniportal VATS wedge pulmonary resections.The Annals of Thoracic Surgery2004;77:726-8

[10] Gonzalez D,Garcia J.Single-port video-assisted thoracoscopic lobectomy.Interact Cardiovasc Thorac Surg2011;12:514-5

[11] Lyscov A,Ryabova V,Zuiev V.Double-sleeve and carinal resections using the uniportal VATS technique: a single centre experience.J Thorac Dis2016;8:S235-41 PMCID:PMC4783727

[12] Elkhayat H.Non-intubated uniportal video-assisted thoracoscopic surgery.J Thorac Dis2019;11:S220-2 PMCID:PMC6424729

[13] Scarci M,Solli P.EACTS expert consensus statement for surgical management of pleural empyema.Eur J Cardiothorac Surg2015;48:642-53

[14] Bibby AC,Psallidas I.ERS/EACTS statement on the management of malignant pleural effusions.Eur Respir J2018;52:1800349

[15] Zhou Y,Dai J.Uniportal Thoracoscopic Decortication for stage III tuberculous empyema with severe rib crowding.Ann Thorac Surg2021;112:289-94

[16] Nafady, Magda Ahmed Mohammed, Sahra Zaki Azer, Hussein El Khayat. Effect of educational nursing protocol on minimizing patients’ complications after thoracoscopic surgery.Assiut Scientific Nursing Journal2019;7:69-77

[17] Ismail M,Meacci E.Uniportal video-assisted thoracic surgery in the treatment of pleural empyema.J Thorac Dis2018;10:S3696-703 PMCID:PMC6258650