Chambers Anthony, Routledge Tom, Dunning Joel, Scarci Marco
Brighton and Sussex Medical School, University of Sussex, Brighton, UK.
Interact Cardiovasc Thorac Surg. 2010 Aug;11(2):171-7. doi: 10.1510/icvts.2010.240408. Epub 2010 May 3.
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracoscopic surgical decortication (VATSD) might be superior to open decortication (OD) (or chest tube drainage) for the management of adults with primary empyema? Altogether 68 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATSD has superior outcomes for the treatment of persistent pleural collections in terms of postoperative morbidity, complications and length of hospital stay, and gives equivalent resolution when compared with OD. One study comparing VATSD and chest tube drainage of fibrinopurulent empyema found video-assisted thoracoscopic surgery (VATS) had higher treatment success (91% vs. 44%; P<0.05), lower chest tube duration (5.8+/-1.1 vs. 9.8+/-1.3 days; P=0.03), and lower number of total hospital days (8.7+/-0.9 vs. 12.8+/-1.1 days; P=0.009). Eight studies comparing early and late empyema report conversion rates to OD of 0-3.5% in early, 7.1-46% in late stage and significant reductions in length of stay with VATSD compared with OD both postoperatively (5 vs. 8 days; P=0.001) and in total stay (15 vs. 21; P=0.03). Additionally VATS resulted in reduced postoperative pain (P<0.0001) and complications including atelectasis (P=0.006), prolonged air-leak (P=0.0003), sepsis (P=0.03) and 30-day mortality (P=0.02). Five studies considered only chronic persistent empyema of which two directly compared VATSD to tube thoracostomy (TT). VATS resolved 88% of cases and had mortality rates of 1.3% compared with 62% and 11%, respectively, for TT. Moreover, conversion to OD was 10.5-17.1% with VATS and 18-37% with TT (P<0.05). In agreement with mixed stage empyema, hospital stay was reduced both postoperatively (8.3 vs. 12.8 days; P<0.05) and in total (14+/-1 vs. 17+/-1 days; P<0.05), and when compared with OD (one study), pain (P<0.0001), postoperative air-leak (P=0.004), hospital stay (P=0.020) and time to return to work (P<0.0001) were all reduced with VATS. Additionally, re-operation (4.8% vs. 1%; P=0.09) and mortality (4/123% vs. 0%) were lower in VATS vs. OD.
根据结构化方案撰写了一篇胸外科最佳证据主题文章。探讨的问题是，对于成人原发性脓胸的治疗，电视辅助胸腔镜手术剥脱术（VATSD）是否可能优于开放剥脱术（OD）（或胸腔闭式引流）？通过报告的检索共找到68篇论文，其中14篇代表回答该临床问题的最佳证据。现将这些论文的作者、期刊、出版日期和国家、研究的患者组、研究类型、相关结局及结果制成表格。我们得出结论，就术后发病率、并发症及住院时间而言，VATSD在治疗持续性胸腔积液方面具有更好的结局，且与OD相比，积液清除效果相当。一项比较VATSD与纤维脓性脓胸胸腔闭式引流的研究发现，电视辅助胸腔镜手术（VATS）治疗成功率更高（91%对44%；P<0.05），胸腔闭式引流时间更短（5.8±1.1天对9.8±1.3天；P=0.03），总住院天数更少（8.7±0.9天对12.8±1.1天；P=0.009）。八项比较早期和晚期脓胸的研究报告显示，早期转为OD的比例为0 - 3.5%，晚期为7.1 - 46%，与OD相比，VATSD术后住院时间（5天对8天；P=0.001）和总住院时间（15天对21天；P=0.03）均显著缩短。此外，VATS还能减轻术后疼痛（P<0.0001），减少包括肺不张（P=0.006）、持续漏气（P=0.0003）、败血症（P=0.03）及30天死亡率（P=0.02）等并发症。五项研究仅考虑慢性持续性脓胸，其中两项直接比较了VATSD与胸腔闭式引流术（TT）。VATS使88%的病例得到解决，死亡率为1.3%，而TT分别为62%和11%。此外，VATS转为OD的比例为10.5 - 17.1%，TT为18 - 37%（P<0.05）。与混合期脓胸情况一致，术后住院时间（8.3天对12.8天；P<0.05）和总住院时间（14±1天对17±1天；P<0.05）均缩短，与OD相比（一项研究），VATS在疼痛（P<0.0001）、术后漏气（P=0.004）、住院时间（P=0.020）及恢复工作时间（P<0.0001）方面均有改善。此外，VATS再次手术率（4.8%对1%；P=0.09）和死亡率（4/123%对0%）低于OD。
