Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic

versus open decortication

Giuseppe Cardillo, Francesco Carleo, Luigi Carbone, Marco Di Martino, Lorenzo
Salvadori, Lea Petrella and Massimo Martelli
Eur J Cardiothorac Surg 2009;36:914-918
DOI: 10.1016/j.ejcts.2009.06.017

This information is current as of March 21, 2011

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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The European Journal of Cardio-thoracic Surgery is the official Journal of the European Association
for Cardio-thoracic Surgery and the European Society of Thoracic Surgeons. Copyright © 2009 by
European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved. Print
ISSN: 1010-7940.

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 European Journal of Cardio-thoracic Surgery 36 (2009) 914—918
www.elsevier.com/locate/ejcts

Chronic postpneumonic pleural empyema: comparative merits of

thoracoscopic versus open decortication
Giuseppe Cardillo a,*, Francesco Carleo a, Luigi Carbone a, Marco Di Martino a,
Lorenzo Salvadori a, Lea Petrella b, Massimo Martelli a
a
Unit of Thoracic Surgery, Carlo Forlanini Hospital, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
b
Department of Studi Geoeconomici, Linguistici, Statistici, Storici per l’Analisi Regionale, La Sapienza University of Rome, Rome, Italy

Received 16 February 2009; received in revised form 23 May 2009; accepted 12 June 2009; Available online 25 July 2009

Abstract
Objective: We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with
chronic postpneumonic pleural empyema. Methods: From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3
years, range: 17—82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment.
Results: Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality
was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do
surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed
statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain ( p < 0.0001), postoperative air leak
( p = 0.004), operative time ( p < 0.0001), hospital stay ( p = 0.020) and time to return to work ( p < 0.0001). The analysis of postoperative pain at
6 months follow-up showed no significant differences among the different groups. Conclusions: In the light of our experience, videothoracoscopic
decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial
should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.
# 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Keywords: Empyema; Thoracoscopic surgery; Pleural diseases

1. Introduction (stages II and III) in which organisation of the fibrinous clots

Every year, approximately 1 million patients with
pneumonia require hospitalisation in the United States [1].
Up to 40% of them develop an associated pleural effusion:
most of such cases (around 85%) will completely resolve with
antibiotic treatment and the remaining (15%, around 60 000
patients) will develop pleural empyema. According to the
American Thoracic Society classification [2], pleural
empyema are staged as stage I, uncomplicated exudative
effusion without loculation; stage II, fibrinopurulent effusion
with loculation, also called Light’s complicated pleural
effusion; and stage III, pleural thickening with entrapment of
the underlying lung [1—5].
The appropriate management of pleural empyema
remains controversial: pleural drainage is effective in stage
I patients and surgery is reserved for complicated cases
Abbreviations: VATS, video-assisted-thoracoscopy; CH, Charrier.
* Corresponding author. Address: Unit of Thoracic Surgery, Carlo Forlanini
Hospital, Via Portuense 332, 00149 Rome, Italy. Tel.: +39 06 55180681;
fax: +39 06 6638734.
E-mail address: gcardillo@scamilloforlanini.rm.it (G. Cardillo).
1010-7940/$ — see front matter # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcts.2009.06.017
into fibrotic peel could determine lung encasement.
In these cases, lung decortication is necessary. Currently,
the most favoured approach for decortication is open
thoracotomy, although in the past decade some series with
small samples have been published in favour of the VATS
approach [6—9]. In this article, we seek to evaluate the
comparative results of videothoracoscopic versus open
decortication in a series of 308 patients with chronic
postpneumonic pleural empyema treated at our institution.
2. Materials and methods
We retrospectively analysed the clinical records of 308
patients with chronic postpneumonic pleural empyema
(stages II and III) who underwent pleuropulmonary decortica-
tion through open thoracotomy or videothoracoscopy after
failing of conservative treatments from January 1996 to
December 2006 at the Unit of Thoracic Surgery, Carlo
Forlanini Hospital, Rome.
All patients had a clinical history of pneumonia no more
than 6 months before surgery. Patients with HIV were not

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 G. Cardillo et al. / European Journal of Cardio-thoracic Surgery 36 (2009) 914—918 915

Table 1
Patients data according to surgical approach.

OT patients, n: 123 VT patients, n: 185 p value

Sex (males/females) 79/44 95/90 0.03

Age (years) (range) 57  12.9 (17—79) 55.8  10.6 (31—82) 0.3
Empyema stage 0.3
II 85 118
III 38 67
Procedures performed before surgery 0.09
One or more thoracentesis 32 30
Chest tube drainage 50 80
Thoracentesis + chest tube drainage 41 75
Interval between hospital admission and surgery 0.2
3 weeks 51 60
3 < weeks > 6 54 98
6 weeks 18 27
Co-morbidities (total) 0.06
Diabetes mellitus 32 38
Alcoholism 7 8
Cardiovascular diseases 60 80
Liver cirrhosis 9 11
Positive pleural fluid culture or Gram’s stain or pus like-effusion 91 126 0.3

included in this study. To confirm empyema’s stage, data
pertaining to all patients were reviewed according to the
lasting of symptoms (from in-hospital admission to surgery),
and to the following radiological features on computed
tomography (CT) scan of the thorax which was performed on
all patients: loculations of pleural fluid, air—fluid levels,
pleural enhancement or thickening, chest deformation and
mediastinic shift. Patients’ data are shown in Table 1.
A multidisciplinary team (MDT) meeting (thoracic sur-
geons, pneumologists, pathologists, anaesthesiologists,
health-care professionals and the Review Board) in the light
of the increasing use of VATS at our institution pushed
thoracic surgeons in September 2000 to start thoracoscopic
decortication and to progressively leave open thoracotomy
decortication in October 2001. The results of such experience
have been progressively presented and validated at our MDT
meetings.
Patients undergoing thoracotomy (OT group) were treated
from January 1996 to October 2001; patients undergoing VATS
(VT group) were treated from September 2000 to December
2006. After surgery, air leak was assessed by registrars and
staff surgeons according to the Macchiarini’s visual scale
during morning and afternoon clinical rounds [10]. All
patients were followed up 1 month, 3 and 6 months after
surgery with clinical interview and chest radiograph. Post-
operative pain was assessed using a 10-point numeric scale
questionnaire (1 being no pain at all), recorded on day 1 and
day 6 after surgery, and at 6-month follow-up clinics
(Table 2).
Institutional Review Board approval and individual patient
consent were obtained.
2.1. Surgical technique
All patients underwent general anaesthesia using double-
lumen endotracheal tube for selective ventilation and were
then placed in the lateral decubitus position.
2.1.1. Thoracotomy
A postero-lateral serratus anterior-sparing thoracotomy
with rib spreading (but without rib resection) was performed.
All fibrin septae were cut and fissures were dissected free. A
complete decortication (including visceral and parietal
pleura) was carried out to enable lung expansion to be
obtained in all patients. At the end of the procedure, two
large-bore (28 CH and 32 CH) chest tubes were placed
through separate incisions.

Table 2
Postoperative outcomes.

OT patients, n: 123 VT patients, n: 185 p value

a
Postoperative pain
In-hospital pain level (median) (at 1 and 6 days after surgery) 6 5 <0.0001
6 months pain level (median) 2 2 0.7
Postoperative air leak (days) 3.9  4.3 2.8  2.4 0.004
Hospital stay (days) 10  7.8 8.6  1.8 0.020
Time to return to work (days) 34.1  9.9 25  5.2 <0.0001
Operative time (days) 79.7  6.8 70  7.4 <0.0001
a
Postoperative pain was assessed using a 10-point numeric scale questionnaire (1 being no pain at all), recorded on day 1 and day 6 after surgery, and at 6-month
follow-up clinics.

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916 G. Cardillo et al. / European Journal of Cardio-thoracic Surgery 36 (2009) 914—918
2.1.2. VATS
The procedure was performed by means of a three-port
access. Based on preoperative CT scan, suitable intercostal
sites were selected for port placement. The first 1-cm port
was placed in the area of pleural collection by aspiration of
the fluid collection with a needle. Once a pleural space was
created, the remaining two ports (1 cm each) were placed
under thoracoscopic vision to avoid injury to underlying lung
parenchyma. No utility incision was performed. No Weitlaner
retractor was used. Fluid, loculations and septa were
removed under endoscopic vision by use of the sucker, a
ring clamp and endoscopic forceps. Material for microbio-
logical analysis was collected in all patients. Adherent peel
was carefully removed from visceral pleural surface and the
lung was freed circumferentially from the apex to the
diaphragm. Complete decortication of the visceral pleura
and the fissures was performed by use of an endoscopic
dissector device and a peanut dissector as in open
decortication. Parietal pleural was removed at the level of
empyematic collection. Conversion to thoracotomy and open
decortication was considered if it was not possible to dissect
completely the peel from the underlying lung surfaces. At the
end of the procedure, two chest tubes (28 CH and 32 CH) were
placed. In case of air leak or bleeding along the parenchymal
surface, fibrin glue was used (Tisseel, Baxter, Deerfield, MA,
USA) either in open or in VATS procedure.
2.2. Statistical analysis
Continuous variables were reported as mean standard
deviation (SD) when normally distributed, otherwise as
median.
To evaluate the homogeneity between VT patients and OT
patients according to preoperative patients’ characteristics
showed in Table 1, the proportion test (multinomial when
appropriate) was used for categorical variables (sex,
empyema stage, procedures performed before surgery,
interval between hospital admission and surgery, co-morbid-
ities, positive pleural fluid culture or Gram’s stain or pus like-
effusion) and the Student’s t-test for a continuous variable
(age).
Statistical analysis of surgical outcomes (operative time,
postoperative stay, postoperative pain on day 1 and day 6 and
6 months after surgery, postoperative air leak, in-hospital
stay and time to return to work) was performed in group OT
and group VT. Unpaired t-test was used for operative time,
postoperative stay, postoperative air leak, in-hospital stay
and time to return to work. Mann—Whitney U test was used
for postoperative pain at 1 and 6 days and at 6 months after
surgery.
All tests were two-tailed with a significance level of
p = 0.05 and were performed on statistical software NCSS
2004.
3. Results
In this study, 123 patients were treated by open
thoracotomy and 185 by VATS, of which 174 patients
underwent videothoracoscopy alone, and 11 were intra-
operatively converted to open thoracotomy. In 91 cases
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(29.5%), no organisms were isolated from pleural debris or
fluid. Conversion from VATS to open thoracotomy was
needed in 11 patients (5.9%) all of whom had stage III
pleural empyema, with a delay between hospital admission
and surgery of more than 4 weeks in three patients and
more than 6 weeks in eight patients. The overall
postoperative mortality was 1.2% (4/308 cases). All of
them were OT patients who achieved a 3.2% mortality rate
(4/123): one patient died of sepsis 41 days after the
operation and three patients died of unrelated disease
(one of ictus cerebri and two of myocardial infarction,
respectively, on the 13th, 17th and 26th postoperative
days). Operative time was 79.6  6.8 min and 70 
7.4 min, respectively, in OT and VT ( p < 0.0001). Re-
operation was performed in eight patients (six OT patients
and two VT patients) because of bleeding. Postoperative
overall morbidity was 21.1% (65/308), respectively, 25.2%
(31/123) in OT patients and 18.3% (34/185) in VT patients
( p = 0.1). Prolonged air leak, renal insufficiency requiring
dialysis, wound dehiscence of open thoracotomy incision,
loculated pleural effusion and residual pleural space were
the most common complications.
After VATS, three patients showed recurrent empyema
and underwent re-do surgery on the 42nd, 51st and 65th
postoperative day by performing, respectively, a re-VATS and
two open thoracotomies. No recurrence was seen in patients
undergoing thoracotomy. Postoperative outcome (shown in
Table 2) was evaluated according to postoperative air leak,
operative time, in-hospital stay, time to return to work and
postoperative pain between patients treated by open
thoracotomy and VATS.
4. Discussion
In chronic pleural empyema, both perfusion and gas
exchange in the lungs are decreased even if experimental
studies stress that lung perfusion is much more impaired after
decortication; vital capacity (VC) and forced expiratory
volume in 1 s (FEV1) partly recover, perfusion through the
affected side significantly improves and oxygen pressure and
saturation increase [7,11]. Moreover, the occurrence of
infection in the pleural cavity has a substantial morbidity
despite decreased incidence due to effective antibiotic
treatment [8].
Intrapleural fibrinolytic therapy, which has been proposed
by some authors, [12,13] in our opinion, has no or a very little
role in the clinical setting of patients with pleural empyema
mostly due to the incomplete control of the infection and to
the high number of side effects such as anaphylaxis,
haemorrhage or pulmonary oedema [14,15]. The surgical
treatment of chronic pleural empyema should achieve
permanent control of the infection by evacuating loculated
pus and fibrin debris, and prevent late pulmonary restriction
resulting from lung fibrous encasement by removing the
encasing membrane. The results of treatment must be
independent from the surgical approach, either open or
videothoracoscopic. The most effective tool should permit
expeditious removal of parietal and visceral debris without
injuring the lung with a low morbidity and mortality rate and
a fast recovery.
 G. Cardillo et al. / European Journal of Cardio-thoracic Surgery 36 (2009) 914—918
From a theoretical point of view, VATS decortication
should be the gold standard for pleural empyema: high
magnification rate with precise debridement and breakage
of fibrinous septa or band; identification of debris and lung
parenchyma with a very meticulous decortication. In a
previous article, Angelillo-Mackinlay and colleagues [3]
compared 33 patients surgically treated by thoracotomy
versus 31 patients treated by VATS for pleural empyema; the
conversion rate was 10%. The authors stated that video-
assisted thoracic surgical treatment has the same rate of
success as open thoracotomy, with an identical morbidity
and mortality rate, but offers substantial advantages over
thoracotomy in terms of resolution of the disease, hospital
stay and cosmetic outcome. A recent retrospective article
by Luh and colleagues [8] evaluating the outcome of 234
patients who underwent VATS for chronic pleural empyema
showed the safety and efficacy of such procedure with a
significantly lower morbidity and mortality rate compared to
open thoracotomy: respectively, 5.6% in the VATS group
versus 20% in the open thoracotomy group for morbidity
rate, and 2% versus 10% for mortality rate; the conversion
rate was 10.3%. Lardinois and colleagues [15] compared 150
patients undergoing open thoracotomy versus 178 patients
undergoing VATS (with a 3-cm utility incision) for the
treatment of pleural empyema. The conversion rate was
extremely high (44%). Postoperative mortality showed a
slight difference between the different approaches (3% in
the VATS group versus 4% in the open thoracotomy group). A
recent article by Chan and colleagues [9] compared 41
patients undergoing VATS decortication versus 36 under-
going open thoracotomy decortication. They reported no
conversion rate, and found statistically significant less
operative time, less postoperative pain, greater satisfaction
with wounds and with the operation overall for patients
undergoing VATS.
In our series, the conversion rate was 5.9% (11/185): all
procedures were performed without any utility incision and
without finger dissection (only instrumental decortication).
Videothoracoscopic procedures were mostly (96.7%, 179/
185) performed by the senior surgeon (MM). The overall
operative mortality was extremely low (1.29%) and occurred
only in cases belonging to the OT group. The videothoraco-
scopic approach showed statistically significant better results
in terms of in-hospital postoperative (day 1 and day 7) pain
( p < 0.0001), operative time ( p < 0.0001), postoperative air
leak ( p = 0.004), hospital stay ( p = 0.02) and time to return
to work ( p < 0.0001). The analysis of postoperative pain at 6
months follow-up showed no significant differences among
the different groups.
Re-operation for bleeding was higher in OT patients (4.8%;
6/123) than in VT patients (1%; 2/185) ( p = 0.09). Recurrence
of empyema (1.6%; 3/185) was seen only in patients treated
by VATS approach: all patients had a stage III empyema, with
an interval from onset to surgery longer than 6 weeks in all
patients. Operative time was statistically significantly less in
VT than in OT patients. A greater cosmetic satisfaction and a
greater patient acceptance was also reported in patients
treated by videothoracoscopy. The recurrence of empyema,
observed in 1.6% of the VT patients, is the only drawback of
videothoracoscopic decortication but in selected recur-
rences re-do VATS can be safely performed, as we have
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917
done in one case. Recurrence has been linked to a stage III
empyema and to a late interval from onset of symptoms to
surgery.
The homogeneity of our series is stressed by the high and
comparable number of patients in both groups and the
common aetiology in all cases (postpneumonic empyema).
Last but not least, almost all VATS cases (96.7%) were
performed by the same surgeon.
In conclusion, in the light of the great majority of the
recent reported articles [6,9,16—22] and of the present
series, the minimally invasive approach appears to be the
treatment of choice for pleural empyema, even if a
multicentric-randomised trial should be performed before
videothoracoscopic decortication becomes the gold standard
for the treatment of pleural empyema.
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Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic
versus open decortication
Giuseppe Cardillo, Francesco Carleo, Luigi Carbone, Marco Di Martino, Lorenzo
Salvadori, Lea Petrella and Massimo Martelli
Eur J Cardiothorac Surg 2009;36:914-918
DOI: 10.1016/j.ejcts.2009.06.017
This information is current as of March 21, 2011

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& Services http://ejcts.ctsnetjournals.org/cgi/content/full/36/5/914
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