Surgical treatment for empyema thoracis: is video-assisted thoracic surgery "better" than thoracotomy?

BACKGROUND: Operations for empyema thoracis are conventionally performed by open thoracotomy, whereas the video-assisted thoracic surgery (VATS) approach remains controversial. This study compares the radiologic and functional outcomes of decortication using the two approaches.

METHODS: During a 5-year period, 77 consecutive patients underwent decortication for empyema thoracis at two university teaching hospitals. The choice of surgical approach was decided by surgeon preference. Preoperative and postoperative empyema management was the same in all patients. Postoperative radiologic improvements were graded by a radiologist blinded to the approach used. Functional improvements were assessed by a questionnaire-based survey conducted at a mean of 36 months after the surgical procedure.

RESULTS: The VATS approach was used in 41 patients and the thoracotomy approach in 36 patients. Patients in the two groups had similar preoperative demographic and clinical features. No patients required conversion from VATS to thoracotomy or reintervention for empyema. Intraoperative blood loss, duration of chest drain, lengths of hospital stay, and postoperative complication rates were all similar in the two groups. The mean operation time in the VATS group was significantly shorter (2.5 versus 3.8 hours, p < 0.001). Decortication using both approaches gave similar degrees of postoperative radiologic and functional improvements. Of the 42 patients available for follow-up, the 21 who received the VATS approach reported significantly less postoperative pain (p = 0.04), greater satisfaction with the wounds (p < 0.0001), and greater satisfaction with the operation overall (p = 0.006).

CONCLUSIONS: VATS allows equally effective decortication for empyema as thoracotomy. However, the VATS approach gives less pain and greater patient acceptance.