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Interact CardioVasc Thorac Surg 2009;9:74-78. doi:10.1510/icvts.2009.203190 © 2009 European Association of Cardio-Thoracic Surgery
Long-term functional results after surgical treatment of parapneumonic thoracic empyemaDivision of Thoracic Surgery, Department of Surgery and Surgical Specialties, University of Modena and Reggio Emilia, Policlinico di Modena, Largo del Pozzo 71, 41100 Modena, Italy Received 19 January 2009; received in revised form 19 March 2009; accepted 24 March 2009
*Corresponding author. Tel.: +39594222257; fax: +39594223096.
Retrospective evaluation of long-term functional results of surgical treatment of chronic pleural empyema. Two different surgical procedures (debridement vs. decortication) and approaches (VATS vs. thoracotomy) were analyzed. Three end-points were considered: short-term surgical results, short- and long-term radiological results, clinico-functional long-term results. Fifty-one debridement (52% VATS, 48% thoracotomy) and 68 decortication were performed. Postoperative mortality and morbidity were 1.5% and 24%, respectively. Older age (>70 years old) had worse postoperative morbidity (P=0.048). Video-assisted thoracic surgery (VATS) debridement had lower postoperative hospital stay (P=0.006) and shorter duration of chest drainage (P=0.006). The infectious process was resolved in all patients. All patients presented a postoperative radiological improvement, 63 patients (60%) with a complete pulmonary re-expansion. Sixty patients (58%) referred a complete respiratory recovery. VATS debridement had a greater improvement in subjective dyspnea degree (P=0.041). The long-term spirometric evaluation was normal in 58 patients (56%). Age >70 years old resulted the only variable associated to poor long-term results (FEV1% <60% and/or MRC grade  2) at multivariate analysis. Surgical treatment of pleural empyema achieves excellent long-term respiratory outcomes. VATS is associated to less postoperative mortality and shorter postoperative hospital stay. In elderly patients, postoperative morbidity could be higher and long-term functional improvement less warranted.
Key Words: Pleural empyema; VATS debridement; Pulmonary decortication
Parapneumonic pleural empyema still represents a significant cause of morbidity and prolonged hospitalization. Approximately 50% of all bacterial pneumonias develop a pleural effusion and in one-third of these patients the pleural effusion becomes organized [1]. In these patients surgical treatment is mandatory in order to solve the infection, allowing the lung to re-expand and to prevent subsequent chronic respiratory impairment. In the last decades the video-assisted thoracic surgery (VATS) has been demonstrated as an effective procedure in selected patients, allowing an optimal debridement of early organized pleural effusions [2–4]. In the late phase of the pleural infectious process, when a thick pleural peel encases the lung, a pulmonary decortication is required and open approach is often needed [5]. Although the role of surgery in solving the chronic infectious pleural disease is well demonstrated, the long-term respiratory functional outcomes have been poorly investigated. In particular, some authors evaluated the respiratory functional outcomes after pulmonary decortication for late phase thoracic empyema [6–8], whereas few evidences are present in literature comparing VATS and the traditional surgical approach in term of long-term respiratory outcomes [9]. The aim of our retrospective non-randomized study is to evaluate the short- and long-term results of the surgical treatment of chronic parapneumonic effusions comparing different surgical procedures and approaches.
We retrospectively reviewed the surgical registries of the Division of Thoracic Surgery of the University of Modena and Reggio Emilia to find out all the parapneumonic empyemas surgically treated between January 1990 and December 2007. The surgical indications were the following: persistent pleural empyema despite chest tube drainage and antibiotic therapy, persistent sepsis, entrapped lung due to pleural thickening with consequent lung restriction. Two different surgical procedures were considered: the pleural space debridement (lysis of fibrous pleuro-pulmonary adherences and removal of all the empyematic material) and the pleuro-pulmonary decortication (resection of pleural peel). The surgical approach for debridement has been double: through open thoracotomy in the first year of our series and VATS from 1997. All the decortications were performed by a lateral open thoracotomy. One hundred and nineteen patients presented the above inclusion criteria and were considered for the study. All patients were recalled and a standard chest radiography, a spirometric evaluation and an interview on general respiratory conditions were performed. A long-term follow-up was possible in 104 patients (87%) (Fig. 1). The mean follow-up of the 104 patients was 82 months (median 62, range 19–180).
Three principal end-points were considered:
2.1. Statistical analysis Descriptive statistical analysis was expressed in terms of frequency, mean and standard deviation. The frequencies were compared with  2-test for categorical variables. The continuous variables were compared with the t-test and ANOVA. A logistic regression analysis was performed to independently analyze variables predicting long-term functional prognosis. Values <0.05 were considered significant.
The study included 119 patients (67 males and 52 females). In 51 patients a pleural space debridement was performed, of which 27 patients (52%) through VATS and 24 patients (48%) through thoracotomy. In 68 patients a pulmonary decortication through thoracotomy was required. The mean age for the whole surgical series was 59 years (range 16–91 years). The mean duration of the pleural infection at the moment of the surgical treatment was of 47 days (median 30, range 6–180). The duration of the infection was significantly inferior in patients who underwent VATS debridements (12±6 days) compared with debridement through open thoracotomy (32±22 days) and the decortications (53±39 days) (P=0.001). 3.1. Short-term surgical results In Table 3, data regarding the surgical treatment and the postoperative period are reported. In 10 patients (8%) initially treated with VATS a conversion to thoracotomy was needed in order to perform a decortication. The mortality for the whole surgical series was 2.5% (ARDS in two patients and septic shock in one patient, all of them treated with decortication). In the other patients the pleural infection was solved at the time of discharge. Postoperative complications were present in 25 patients (24%): 11 cases of persistent air leak (>5 days), 10 cases of postoperative bleeding, two pneumonias and two cardiac arrhythmias. No significant differences in postoperative morbidity were recorded regarding surgical procedures and approaches. Postoperative morbidity was significantly worse in elderly people (34% vs. 10% for patients >70 years old and patients <70 years old, respectively; P=0.048).
3.2. Radiological results All of the patients evaluated in the follow-up presented a radiological improvement and in 63 patients (60%) a complete re-expansion of the lung parenchyma was shown (Table 4). A trend toward better pulmonary re-expansion for VATS debridement in comparison with the open approach was recorded (P=0.057).
3.3. Clinico-functional long-term results Sixty patients (58%) referred a complete functional respiratory recovery without dyspnea, even for intense exercise (MRC degree 0). Forty-four patients (40%) referred any degree of dyspnea: 28 patients (29%) only during significant efforts (MRC 1), 16 patients (13%) during moderate and medium exercise (MRC 2 and 3) and none of them referred symptoms at rest. In Table 5, we report the subjective functional results regarding dyspnea. Videothoracoscopic approach is associated to a better dyspnea degree in comparison with the traditional open approach (P=0.041).
In 58 patients (56%) the long-term spirometric evaluation was normal. Obstructive and restrictive respiratory failure were found respectively in 27 patients (26%) and 13 patients (13%), mixed respiratory disorders were found in 6 patients (5%). Out of those 46 patients who presented any kind of respiratory failure, 21 patients (49%) presented low degree disorders, with values >60% of the predicted for each spirometric parameter analyzed. In Table 6, we report the postoperative spirometric values. The FEV1/FVC is significantly inferior in patients who underwent a thoracotomy debridement (P=0.033).
In order to identify prognostic variables independently related to the long-term functional results, we analyzed in a logistic regression the patients who had a FEV1% <60% and/or a MRC grade 2 at the follow-up examination (Table 7). Age resulted the only clinical variable related to poor long-term functional prognosis: patients >70 years old had a significantly higher risk of poor long-term functional outcomes in respect to younger patients (P=0.006). A trend toward worse poor long-term functional outcomes was recorded for patients who presented an incomplete pulmonary re-expansion (P=0.057).
Our study confirms the effectiveness of surgical treatment of parapneumonic pleural empyema: regardless of the type of approach and procedure required, the surgical treatment can solve the pleural infection in almost all the patients and in more than two-thirds of them it can restore a respiratory function that does not preclude their every-day activities. Many studies in literature show that VATS approach is effective in the fibro-purulent phase of the disease [2–4, 11, 12]. Our study confirms that VATS is associated with a significant reduction of the operative time, an early removal of chest drainages and a shorter postoperative hospital stay. Even if postoperative morbidity did not significantly change between surgical approaches and procedures, the only two postoperative deaths occurred after an open decortication. A key point for the effectiveness of VATS debridement is the early surgical referral. As demonstrated in our series, the introduction of VATS procedure is associated to a significant reduction of period of time elapsed from the onset of infectious disease to surgical referral. The ideal surgical timing during the natural history of a pleural empyema is still a debated argument [13]. In our experience, VATS debridement has been carried out safely and efficiently after a mean duration of 12 days of unresolved pleural infections. The early surgical referral that we have adopted in recent years has significantly reduced the number of pulmonary decortications at our institute. VATS is also associated to better radiological results than thoracotomy. This result, also if not statistically significant, can be correlated with the VATS capacity to explore the whole pleural space and to reach areas, such as the posterior costo-phrenic angles, which are difficult to be managed with the traditional approach. The evaluation of long-term functional results after surgical treatment has several methodological limitations: lung re-expansion's radiological evaluation or dyspnea quantification are purely subjective while the spirometric values are affected by the presence of respiratory co-morbidities. Given these unavoidable limitations, our study demonstrates that in almost 80% of the patients, the surgical treatment is associated with an adequate respiratory recovery. In particular, we found a perfect concordance between the radiological and the functional results, underlining the lung re-expansion's importance as a target of surgical treatment. This issue is also confirmed at multivariate analysis: even if the result approached significance, in our surgical series postoperative pulmonary re-expansion predicts long-term functional prognosis. In our experience almost all patients reported a significant recovery in terms of respiratory function. In particular, 58% of them did not present any kind of respiratory impairment and had a complete return to their every-day activities. Among the patients that referred a persistent dyspnea, the largest majority had low degrees of dyspnea that did not compromise their routine activities. Even if not confirmed at multivariate analysis, the long-term functional results could be influenced by the surgical approach: in our experience the traditional open approach seems to be related to a higher degree of persistent dyspnea and a more frequent obstructive respiratory impairment. This result can be partially explained by the better ability of VATS to obtain a pulmonary re-expansion in an early loculated pleural empyema. These excellent results cannot be guaranteed in older people. Some authors have reported that surgical treatment of thoracic empyema is effective in elderly people but with a significant mortality rate (11%) [14, 15]. These authors did not investigate the respiratory outcomes after surgical treatment. Our study confirmed that older people (>70 years old) were associated to an increased postoperative morbidity and presented more significant degrees of respiratory dysfunction either in terms of persistent subjective dyspnea and impaired spirometric parameters in respect to younger people. This latter result has been confirmed at multivariate analysis. The preoperative selection of this kind of patient should be particularly accurate and, when surgery is indicated, every effort should be made to perform a mini-invasive procedure. The main limitations of our study are related to its retrospective design and to the long period analyzed. Selection bias are unavoidable, in particular regarding the relation between the phase of the pleural infection, the surgical procedure performed and the surgical approach adopted. Even if definitive conclusions cannot be drawn given the retrospective nature of study, our data suggest that surgical therapy of chronic parapneumonic pleural empyemas is safe and affective for the large majority of patients. Mini-invasive surgical procedure with VATS should always be preferred, when technically feasible, because it guarantees a minor postoperative mortality and a shorter postoperative hospital stay. When VATS cannot be performed because of an obliterated pleural space, decortication through a traditional thoracotomy still remains an effective procedure that allows acceptable long-term functional results in young and adult population. More selective surgical criteria should be used in elderly patients who present higher risks of increased postoperative morbidity and reduced long-term functional improvement.
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Abstract
1. Introduction
