PURPOSE: The management of empyema is controversial. Therapies include video-assisted thoracic surgery (VATS) and tube thoracostomy with intrapleural thrombolysis (IPT). Our experience in an inner-city hospital was reviewed.
METHODS: Retrospective review of 22 patients (13 male, 9 female) treated for empyema over a period of 15months with either VATS or IPT with tPA. The median duration of symptoms before referral was 15 days (7-28); all patients received antibiotics (mean 7.5 days) before referral. Prior tube thoracostomy had been performed in 15 patients (68.2%). Chest XRay (CXR) and CT were performed pre-and post intervention and scored by a chest radiologist. Statistical analysis was performed on SPSS version 11 and included t-test and Chi-square analyses to compare groups.
RESULTS: 16 of the 22 patients were managed with VATS. These patients were significantly older (54.6 versus 38 years, p=0.01). All patients managed with IPT had at least one risk factor for immunosupression, compared to 50% in the VATS group (p=0.03). IPT patients received a median of 3 doses of t-PA and the median interval between first and last dose was 50hrs (24-100hr). Surgery was recommended in only 1 patient following t-PA. In the VATS group median operative time was 81 minutes (27-184) and no patient required further intervention. There were no deaths in either group. Median length of stay was not significantly different (12.25 versus 11 days, p=0.4), the percentage improvement in the CXR was not significantly different, and the residual pleural thickness on follow-up CT was similar (4 versus 3mm, p=0.69). Fever resolved more rapidly following VATS (2.8 versus 5 days, p=0.021).
CONCLUSION: In our series we found that management of empyema with VATS was associated with faster resolution of clinical parameters including fever and a trend towards shorter length of stay. However, long-term radiological and clinical outcomes were similar between groups.
CLINICAL IMPLICATIONS: In the treatment of empyema in immunocompromised patients in whom surgery was either declined or considered high risk, Intrapleural thrombolysis with tPA gave similar long-term outcomes to VATS.
DISCLOSURE: Ross Morgan, None.