Thoracoscopy for Empyema and Hemothorax

Thoracoscopy for Empyema and
Rodney J. Landreneau, Robert J. Keenan, Stephen R. Hazelrigg,
Michael J. Mack and Keith S. Naunheim
Chest 1996;109;18-24
DOI 10.1378/chest.109.1.18
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for Empyema and
Robert J. Keenan, MD;
Rodney J.R.Landreneau, MD;Michael
J. Mack, MD; and
StephenS. Hazelrigg,MDMD;
Video-assisted thoracic surgery (VATS) has assumed
greater importance in the management of pleural
disease. Since 1990, we have performed VATS proce¬
dures to manage a variety of pathologic pleural pro¬
cesses in 306 patients. The 99 patients with complex
empyemas or hemothoraces are the focus of this
report. Seventy-six patients with complex empyemas
(including 26 chronic) were approached with VATS
after inadequate chest tube drainage. The causes
associated with the thoracic empyemas were parap¬
neumonic collections in 47, after hemothorax in 8, in¬
fected sympathetic effusions associated with intra-abdominal sepsis in 6, postresectional in 5, prolonged
fistula following spontaneous pneubronchopleural
mothorax in 4, chronic drainage of malignant pleural
effusions in 4, and chronic drainage of pleural effusion
in 2 patients undergoing chemotherapy. Ages ranged
from 14 to 78 years. Sixty-three patients (83%) were
treated with thoracoscopic drainage ±decortication
alone. Thirteen patients (17%) required subsequent
thoracotomy for decortication, including 12 of the 26
(46%) chronic empyemas known to be greater than 3
weeks old. Chest tubes were removed 3.3 ±2.9 days
tal stay for these patients with empyema averaged
7.4 ±7.2 days. There were five deaths, all related to
progressive sepsis from associated pneumonia (6.6%).
Twenty-three patients underwent thoracoscopic evac¬
uation of hemothoraces that resulted following open
heart surgery in 6, thoracic trauma in 7, were iatrogenic in 7, and bleeding into malignant effusions in 3.
All were successfully treated by thoracoscopic drain¬
age and pleural debridement alone. Chest tubes were
removed 2.8 ±0.5 days postoperatively and hospital
stay averaged 4.3 ±1.9 days. There were no complica¬
tions; one patient with a hemothrax (after heart trans¬
plant) died of unrelated causes. In our experience,
VATS has been highly successful in the early manage¬
ment of empyemas and hemothoraces. Conversion to
open thoracotomy must always be anticipated, espe¬
cially when approaching chronic empyemas.
(CHEST 1995; 109:18-24)
VATS=video-assisted thoracic surgery
postoperatively in 67 patients; 9 patients (12%) were
sent home with empyema tubes. Postoperative hospi¬
Key words: empyema; hemothorax; thoracoscopy/pleuros-
T oculated empyemas and hemothoraces recalcitrant
-¦--1 to tube
thoracostomy drainage continue to be
difficult management problems. The frequent associ¬
ation of other significant medical illnesses among pa-
prolongation of the patient's illness and the ultimate
need for more extensive surgical interventions.1"12
Although thoracoscopy's utility in the evaluation and
treatment of pleural disease processes has been rec¬
ognized for many years,13,14 relatively little has been
described about the role of thoracoscopy, or videoassisted thoracic surgery (VATS), as an alternative to
thoracotomy for definitive management of empyema
or hemothorax.15"24 The recent development of wide-
For editorial comment
page 2
tients with empyema and the presence of coexisting
multisystem injuries in trauma victims with hemotho¬
rax often lead us away from considering early definitive
open surgical management of these processes. Thoracentesis or repeated tube thoracostomy drainage are
often chosen as the primary treatments of these prob¬
lems. Delays in accurately diagnosing and effectively
managing these pleural problems, however, can result
*From the Section of Thoracic Surgery, University of Pittsburgh
(Drs. Landreneau and Keenan); and the Divisions of Cardiotho¬
racic Surgery, University of Southern Illinois Medical School,
Carbondale (Dr. Hazelrigg); St. Louis (Mo) University (Dr.
Naunheim); and Medical City Hospital-Dallas (Dr. Mack).
Presented at the 1993 Western Surgical Society Annual Meeting,
Manuscript received March 6, 1995; revision accepted May 2.
copy; video-assisted thoracic surgery (VATS)
angled video-optical endoscopic equipment and more
effective endosurgical instrumentation has expanded
the role of this minimally invasive surgical approach to
a wide variety of thoracic surgical problems previously
requiring thoracotomy for their management.2526 This
report focuses on our recent experience with the VATS
approach as primary management of complex he¬
mothoraces and thoracic empyema.
Patient Profile
From December 1990 to November
1994, we have used videoassisted thoracic surgical approaches to manage pleural pathologic
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Clinical Investigations
Table 2.Etiology of Empyema (n=76)
1.Thoracoscopic Management of Pleural
Effusions (n-306)
Diagnosis of idiopathic effusions
(systemic disease)
Treatment of known malignant effusions
Treatment of empyema
Treatment of hemothorax
patients (Table 1). Sixty-seven percent of these
patients (n=207) underwent VATS for the diagnosis of idiopathic
of known malignant
pleural processes or for the management
tube thoracostomy
pleural effusions that had failed to respond tounderwent
remaining patients
approach complex empyemas and hemothoraces recalcitrant to
simple tube thoracostomy management. when standard chest
The empyemas were considered "complex"
chest CT identified significant multiloculated
radiographs and/or
fluid collections with associated pulmonary parenchymal compres¬
sion or consolidation (Fig 1). The clinical etiologies of the empye¬
mas are detailed in Table 2. The bacteriologic profile of the pleu¬
ral infections was quite broad with staphylococcal species being the
most common pathogens (41%). Mixed aerobic/anaerobic infec¬
tions were seen in 26% of patients and a variety of infectious agents
were cultured in 18% of cases. No growth on pleural fluid culture
occurred in 15% of patients. The patients ranged in age from 14 to
78 years (mean, 47 years). The median duration of the pleural pro¬
cess for these patients prior to the VATS management was 9 days;
however, 26 patients had chronic pleural space infections persist¬
ing for greater than 3 weeks. All of these empyema patients treated
with VATS had previously been approached with systemic antibi¬
otic therapy and primary tube thoracostomy drainage of the pleu¬
ral collection. The duration of tube thoracostomy drainage ranged
from 1 to 11 days prior to consultation for the VATS intervention.
A significant minority of patients (n=21,28%) had numerous (range,
Parapneumonic 47
Postresectional 5
Chronic drainage of malignant effusion
Spontaneous pneumothorax 4
Infected sympathetic effusion-abdominal sepsis
Postchemotherapy 2
processes in 306
3.Etiology of Hemothoraces (n=23)
After open heart surgery
2 to 4) attempts at tube thoracostomy drainage before the referral
for "surgical" intervention.
The causes associated with the hemothoraces managed in this
experience are listed in Table 3. All of these patients with
hemothorax had a previous attempt at tube thoracostomy drainage
of the intrathoracic clot prior to the VATS consultation (Fig 2). The
decision to perform the thoracoscopic management was based on
the need to evacuate significant retained hemothoraces to avoid
or empyema. In this
pulmonaryto restriction
delayed complicationsnoof occasion
use the VATS approach for the
experience, there was
short-term evaluation or treatment of ongoing chest tube bleeding
or to urgently explore the thoracic cavity for occult intrathoracic or
diaphragmatic injury.
Preoperative Preparation and VATS Technique
Careful study of the preoperative radiographic studies is impor¬
tant before initiating the thoracoscopic intervention so that the best
location for intercostal access can be determined. The patient is
Figure 2. Posteroanterior chest radiograph of a large clotted he¬
Figure 1. CT
pustulant pleural collec¬
mothorax persisting after attempted tube thoracostomy drainage
that was successfully managed with VATS debridement and evac¬
uation of the pleural cavity.
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Copyright © 1996 by American College of Chest Physicians
pus pockets
grasper through
biopsy channel of
thora scope
Figure 3. Illustration of the pathologic processes resulting in loc¬
ulated pleural processes requiring VATS intervention.
brought to the operating room where general anesthesia is
used to conduct the procedure. After induction of anesthesia, a fi¬
through the enberoptic bronchoscopic examinationa is performed
dotracheal tube on all patients with diagnosis of empyema to rule
out the presence of an obstructing endobronchial lesion that would
prevent full reexpansion of the lung. Bronchoscopic examination is
also performed in all cases of idiopathic hemothorax. Conversion to
a double-lumen endotracheal tube is then accomplished to achieve
selective lung ventilation of the contralateral lung and collapse ofthe
ipsilateral lung during the VATS intervention.20 Theispatient is then
hemithorax prepared and
placed infora full lateral position and the After
the general
draped possible open thoracotomy. we estimating
location of the pleural space problem, aspirate the fluid collec¬
tion at the site of the proposed primary intercostal access with a
spinal needle before performing the intercostal incision. Once the
appropriate initial site of intercostal access is determined, our
practice is to digitally explore this initial intercostal entry site before
introducing trocars for the thoracoscope or endosurgical instru¬
This VATS approach to empyema and hemothoraces usually re¬
quires two to four intercostal access sites for proper endoscopic vi¬
sualization and instrument manipulation. After entering the pleu¬
ral cavity with the thoracoscope, we remove a sample of the pleural
exudate or coagulum for culture, Gram stain, and fungal stains. The
use of an "operating" thoracoscope can greatly facilitate the initial
of the pleural space (Karl Storz, America; Culver City,
Calif). All subsequent intercostal access is achieved under direct
thoracoscopic vision to avoid injury to the underlying lung paren¬
chyma. Direct in-line suctioning of the cavity contents and limited
lysis of thin adhesions can be accomplished through the biopsy/
suction channel ofthis instrument. After lysis of these adhesions, the
limits of the pleural space can be defined more accurately so that
subsequent sites of pleural access are created without potential in¬
jury to the lung. Endoscopic forceps, scissors, and retractors are
introduced under direct video guidance in strategically located in¬
tercostal access sites to break down the remaining loculations and
remove loose fibrinous material within the pleural cavity (Fig 3, 4).
We routinely use a special, large-bore suctioning device (SnowdenPencer Inc; Tucker, Ga) to evacuate the pleural exudate and/or clots
that are within the chest. Alternatively, a standard 36F Silastic chest
tube can be connected to the suction tubing to provide a large-bore
Figure 4. Illustration depicting the importance of accurate inter¬
costal access for VATS intervention on loculated pleural effusions.
suctioning system. When necessary, a limited decortication of
fibrinous pleural peels can be accomplished using standard or en¬
dosurgical instrumentation. However, the thoracoscopic recogni¬
tion of a significant "organized" fibrotic pleural peel associated with
trapped lung should lead the surgeon to convert to an open thora¬
cotomy to adequately decorticate the lung.
We also try to avoid disturbing broad areas of dense pleural
symphysis when performing the lysis ofoffendingpleural adhesions.
Such areas are rarely the cause of pulmonary parenchymal entrap¬
ment. However, when it is necessary for adequate decortication of
the lung and obliteration of the pleural space, we use an extrapleural dissection to free the lung in these areas. This dissection can
often be accomplished using the VATS approach; however, one
must also be prepared in these circumstances to convert to open
thoracotomy when technical difficulty precludes an adequate
After lysing the adhesions causing the loculations and evacuating
the pleural space, we routinely obtain thoracoscopic biopsy speci¬
mens when the cause of the pleural process is in question. The large
samples of pleura that are obtained can facilitate the diagnosis of
occult infectious agents (ie, tuberculosis) or an underlying malig¬
nancy responsible for the primary pleural effusive process (Fig 5).
Once we judge the VATS intervention to be complete, we rou¬
tinely ask the anesthesiologist to reexpand the lung so that we can
inspect the adequacy of the decortication and the completeness of
the obliteration of the pleural space problem. If we are satisfied with
the results of the VATS procedure, strategic placement of chest
drainage tubes follows through two of the intercostal access sites.
The procedure is terminated with standard closure of all other in¬
tercostal access sites and establishment of 20 cm of negative pres¬
sure suction to the underwater seal chest drainage system.
If significant pleural fibrosis/symphysis with pulmonary entrap¬
ment is identified at VATS exploration, conversion to an open pro¬
cedure is indicated. When the conversion to thoracotomy is
performed, we maintain the VATS equipment set up on the oper¬
ative field so that continued video assistance can be utilized during
the open intervention to facilitate the dissection of hard-to-visual-
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Copyright © 1996 by American College of Chest Physicians
drainage. Bronchopleural fistulas were associated with
the space problem in four of the five patients requir¬
ing delayed open drainage procedures. These residual
pleural spaces and peripheral bronchopleural
hospital discharge
patients (n=14) with these
postoperative VATS problems.
Procedural-related VATS complications were un¬
common; however, two patients did have inadvertent
diaphragmatic injury during the creation of intercostal
access. One of these patients experienced moderate
bleedingof that
required conversion to thoracotomy for
diaphragmatic injury and a peripheral
liver parenchymal injury. The other patient did not
require any specific management beyond standard
wound closure and establishing an alternative site for
intercostal access, as the small nonbleeding right-sided
injury was located posteriorly in the costophrenic sulcus.
Five patients (6.6%) with empyema died after their
Figure 5. Illustration of VATS pleural
after evacuation of the empyema space.
in the apex of the chest and the
biopsy being performed
costophrenic recesses.L'
Of the 76 patients with complex empyemas in this
series, 63 (83%) were treated solely with thoracoscopic
and decortication of fibrinous
drainage, adhesolysis,Thirteen
visceral pleural peel.
patients (17%) required
conversion to open procedures after the VATS proce¬
dure. This included 12 of the 26 (46%) patients with
chronic empyemas known to be present for greater
than 3 weeks. Immediate conversion to thoracotomy
for decortication was performed in seven patients with
obvious trapped lung and chronic fibrotic pleural peels.
Five patients with chronic space problems persisting
after the VATS intervention were treated with local rib
resection and empyema tube drainage in four patients
and the creation of an Eloesser flap for long-term open
A final patient with a postop¬
drainage in one patient.underwent
a delayed thoracot¬
erative space problem
omy accomplish
Sixty-seven patients had their chest tubes removed
at 3.3±2.9 days, and 9 patients (12%) were sent home
with empyema tubes. Persistent peripheral bronchopleural fistulas were present in seven of the nine pa¬
requiring long-term open-tube thoracostomy
Small residual space problems associated
with obvious purulent drainage were present in the
other two patients treated with long-term open-tube
intervention as a result of progressive
patients who remained ven¬
tilator dependent after surgery eventually died of pro¬
gressive respiratory failure. Two other patients with
significant COPD also died of postoperative pneumo¬
nia. A final patient with autoimmune deficiency syn¬
drome, chronic Pneumocystis, and pulmonary Asalso died of progressive pulmonary sepsis.
The average hospital stay for the 71 patients surviving
VATS treatment for empyemas was 7.4±7.2 days.
Resolution of the hemothorax was accomplished in
all of the 23 patients undergoing VATS management.
Chest tubes were removed 2.8±0.5 days postopera¬
tively and hospital stay averaged 4.3±1.9 days. Twen¬
ty-two ofthese 23 patients undergoing VATS survived.
One heart transplant patient undergoing VATS for an
iatrogenic central venous line placement-related he¬
mothorax died several weeks postoperatively of cardi¬
ac-related causes.
With the advent of effective antibiotic therapies,
empyema has become a much less common clinical
however, this complication remains an im¬
of morbidity and mortality following
pneumonia or lung resection.6'27 Delays in appropriate
referral for surgical drainage of the empyema continue
significant prolongation in recovery from
these infectious problems and frequently result in the
need for more aggressive surgical interventions to
correct the pleural process.1"12
management of newly identified significant
to eradicate the problem
pleuralextensive can help
is necessary. Our
empyemas and hemothopresent approach
to cause
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Copyright © 1996 by American College of Chest Physicians
1 resolution] increasing
NO resolution
Algorithm of management for jpleural effusions and
hemothorax (modified from Ashbaugh DG).
Figure 6.
is aimed at minimizing hospital stay
and surgical morbidity for these patients. As outlined,
we initially approach significant parapneumonic pleu¬
ral fluid collections with thoracentesis. This is followed
tube thoracostomy drainage if the process recurs or
if frankly purulent fluid is identified. Accurately posi¬
tioned tube thoracostomy drainage is usually success¬
ful in controlling early "free-flowing" empyemas.28"32
These data support the use of the VATS approach
in the management of the "fibrinopurulent" phase of
empyema. Indeed, 49 of the 50 patients with empye¬
mas in the fibrinopurulent phase were successfully
treated with the VATS intervention alone. This fibrin¬
of empyema is usually characterized
by disease chronicity of several days to a few weeks.
Exudative pleural fluid and numerous adhesions re¬
sulting in loculation of the effusive process are seen.
The VATS approach is well suited for the evaluation of
these problems, breaking down the areas of loculation,
and completely evacuating the gelatinous exudate from
the pleural space. Fibrinous peels can usually be
removed from the visceral pleural surface to free any
early lung entrapment. A unilocular process is ulti¬
that can be obliterated with strategi¬
mately obtained
chest tubes and subsequent full expansion
of the lung at the termination of the procedure.
Empyemas that have reached the "organized" phase
are characterized by the presence of a thick pleural
peel causing varying degrees of pulmonary parenchymal entrapment. These processes are usually found to
be several weeks old when the patient's clinical history
is carefully reviewed. Customarily, rib resection and
empyema tube drainage, long-term open drainage, or
is summarized by the algorithm
6.7 This flexible management scheme
formal thoracotomy and decortication have been re¬
these organized empyemas. Limited
quired to manage
muscle flap rotation are also needed
in some instances to obliterate the pleural space
The decision to choose one or the other
of these approaches has largely depended on the pa¬
tient's physiologic reserve and the extent of the
parenchymal entrapment present.
Once the empyema has progressed to this chronic,
organizing phase, VATS is often unsuccessful as the
primary management because the thick visceral pleu¬
ral peel makes decortication difficult. Although thora¬
cotomy is usually needed to accomplish this procedure,
is lost by beginning the intervention with an
initial VATS exploration. Many of these more estab¬
lished empyemas will not have yet progressed to the
fibrotic phase, as evidenced by the fact that 14 of 26 of
chronic empyemas (54%) were successfully managed
with VATS alone. The need for open decortication of
the lung can be determined by the experienced
surgeon at the time of this initial VATS exploration of
the empyema. The VATS exploration can also help in
the most appropriate site for the thoracot¬
to approach the empyema and lung en¬
VATS is also a reasonable first step, or ancillary
maneuver, when limited open drainage procedures are
chosen for the physiologically impaired patient with
empyema. Visualization and breakdown of the deeper
within the organized pleural process can lead
to more accurate placement of the "open" drainage
catheters. Additionally, postoperative irrigation of the
empyema can be facilitated with VATS-directed place¬
ment of the chest drainage catheters.15"17
The division of pleural adhesions and the attempted
removal of the visceral pleural rind encountered dur¬
ing the VATS intervention can lead to pulmonary pa¬
injury and significant peripheral postoper¬
ative bronchopleural fistulas. Chronic air leak and
prolonged space problems
may result if obliteration of
the pleural space is not achieved at the end of the
Such pleural space problems occurred in
14 of our patients, which caused the need for long-term
tube thoracostomy drainage or for delayed "open"
drainage procedures. Although this frequency of post¬
operative air leak and pleural space problems is simi¬
lar to that seen following open procedures, mature
surgical judgment must be exercised when solely rely¬
ing on the VATS approach so that unnecessary mor¬
bidity and delays in the patient's recovery from the
empyema can be avoided.
The VATS approach is also an effective minimally
invasive means of definitively addressing significant
hemothoraces persisting after attempted tube thora¬
costomy drainage. Although others have described the
use ofthe VATS approach in the short-term evaluation
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Copyright © 1996 by American College of Chest Physicians
Clinical Investigations
and treatment of selected cases of blunt and penetrat¬
ing thoracic trauma,35"40 we do not report any experi¬
ence with such VATS applications. We do believe that
the use of VATS should be considered early in the
management of significant retained hemothoraces to
avoid the problems of late fibrothorax or secondary
infection within the intrathoracic clot.
In summary, VATS appears to be an effective initial
management for most complex pleural empyemas and
hemothoraces. Excellent visualization of the pleural
cavity permits drainage of loculated fluid, removal of
fibrinous material, and the ability to perform limited
decortication of the lung. Early referral for this mini¬
mally invasive surgical intervention can assist in con¬
the fibrinopurulent phase of empyema before
it progresses to the chronic fibrotic phase. However,
the surgical team performing VATS must be prepared
to convert to open surgical management of the empy¬
ema when it is necessary to achieve the desired ther¬
apeutic end points.41,42 Finally, VATS appears to be an
effective alternative to thoracotomy for the manage¬
ment of significant retained hemothoraces after un¬
successful tube thoracostomy drainage.
ACKNOWLEDGMENT: We thank Ron Filer for his illustrative
assistance in
preparing this manuscript.
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I ¦National ACCP
^Puirpioriary Board
6-10, 1996
Phoenix, Arizona
6-10, 1996
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Copyright © 1996 by American College of Chest Physicians
Clinical Investigations
Thoracoscopy for Empyema and Hemothorax
Rodney J. Landreneau, Robert J. Keenan, Stephen R. Hazelrigg,
Michael J. Mack and Keith S. Naunheim
Chest 1996;109;18-24
DOI 10.1378/chest.109.1.18
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