Loculated fibrinopurulent empyema is a major problem, and often requires VATS or decortication, with considerable morbidity and cost. A few reports mention medical thoracoscopy as an option. We describe our experience with therapeutic medical thoracoscopy for treatment of loculated empyema.
Thoracoscopy was done with conscious sedation ( Midazolam + fentanyl) and local anaesthesia, in the endoscopy suite or the ICU. Using a single port technique, the Olympus semirigid pleuroscope and Storz rigid telescopic forceps were used to debride visible loculations and adhesions, aspirate fluid and take biopsies. The procedure end-point was adequate pleural drainage, and loculation and adhesion breakdown with good lung expansion. All patients received 4 weeks of appropriate antibiotics. Immediate and long term success (defined as resolution of infection with good lung expansion), complications, drainage duration, and length of stay were studied.
The study included 21 patients, 17 males and 4 females, ages 17–75 years (Table 1). 48% (10) patients were diabetic. 29% (6) patients were admitted into the ICU with sepsis. 62% (13) were poor candidates for general anesthesia (GA) due to age and co-morbidities. The latency between admission and procedure was 2 days (range 1–4). Short term success was 95% (20) patients. Complications were few - 1 patient had an air leak for 48 hrs and another had inadequate lung expansion with persistent fever, and underwent decortication. The average drainage time was 2.8 days, and length of stay was 5 days. Long term success (4 months) was the same at 95%. A definitive diagnosis could be established in all cases (13 pyogenic and 8 tuberculous empyema).
Therapeutic medical thoracoscopy, with conscious sedation for loculated empyema is safe and effective, when done early in the disease. The advantages include reduced hospital stay, morbidity and cost. It is also an effective option in patients with significant medical comorbidities, who are at high risk for GA.
This procedure is another useful modality to treat empyema. Its precise role in empyema management needs further studies.
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