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Awake video-assisted pleural decortication for empyema thoracis☆

2009; Oxford University Press; Volume: 37; Issue: 3 Linguagem: Inglês

10.1016/j.ejcts.2009.08.003

1873-734X

Federico Tacconi, Eugenio Pompeo, Eleonora Fabbi, Tommaso Claudio Mineo,

Lung Cancer Diagnosis and Treatment

Objective: To evaluate feasibility, technical features and results of video-assisted pleural decortication for empyema thoracis performed in awake patients. Methods: This retrospective analysis involved a cohort of 19 patients (median age: 58 years) undergoing awake video-assisted thoracoscopic pleural decortication under epidural anaesthesia (N = 15) or paravertebral blocks (N = 4) between March 2004 and September 2008. Baseline and perioperative data including degree of postoperative lung re-expansion at 48 h, hospital stay, morbidity rate and daily fluid loss were recorded. In addition, intra- and perioperative changes in main pathophysiological variables PaO2/FiO2 ratio, PaCO2, mean arterial pressure and heart rate were analysed. Results: Origin of the empyema was parapneumonic (N = 14), post-traumatic (N = 3) and cancer related (N = 2). All patients underwent previous conservative management. The duration of the symptoms averaged 35 days (quartile range (QR): 28–40). Co-morbidities included chronic obstructive pulmonary disease (COPD) (N = 4), HIV infection (N = 1), diabetes mellitus (N = 2) and cirrhosis (N = 1). Operation was performed videothoracospically in 15 patients whereas four patients with major pleural thickening underwent awake lateral thoracotomy. Operative time averaged 50 min (QR: 40–70). Perioperative data analysis showed no intra-operative deterioration in arterial oxygenation (median-Δ: 0 mmHg, QR: −5/+9, P = 0.6). Transient permissive hypercapnia (≪55 mmHg) developed in three patients with no need of conversion to general anaesthesia. Median pain level assessed by a visual analogue score (VAS) 1 h postoperatively was 4 (QR: 2–5), and it was significantly reduced on postoperative day 1 (median 3, QR: 2–4, P = 0.03). There was neither mortality nor major morbidity. Hospitalisation averaged 6 days (QR: 5–7). At postoperative chest X-ray, lung re-expansion was rated as complete in 16 patients, satisfactory in (>80%) two patients and unsatisfactory in a 86-year-old patient with pleural mesothelioma who has the chest drain still in place 5 months after surgery. No patient had recurrence of the empyema at subsequent follow-ups. Conclusions: In our study, awake video-assisted pleural decortication proved feasible and resulted in satisfactory lung re-expansion in 95% of the patients. We hypothesise that spontaneous ventilation facilitated both identification of the correct plane and dissection, thus resulting in lesser surgical injury on the underlying lung.