Bongiolatti Stefano, Voltolini Luca, Borgianni Sara, Borrelli Roberto, Tancredi Giorgia, Viggiano Domenico, Gonfiotti Alessandro
Thoracic Surgery Unit, University Hospital Careggi, Florence, Italy.
Interact Cardiovasc Thorac Surg. 2017 Apr 1;24(4):560-566. doi: 10.1093/icvts/ivw423.
The surgical approach to chronic pleural empyema is still controversial. Video-assisted thoracic surgery (VATS) debridement and decortication has shown favourable outcomes, while the uniportal VATS (U-VATS) approach is still anecdotal. We report our experience with ultrasonographic (US) preoperative staging followed by U-VATS decortication for pleural empyema.
We performed a retrospective analysis of patients who underwent surgical treatment of stage II and stage III pleural empyema from 2012 to 2015. Pre-, intra- and postoperative data were investigated to evaluate outcomes including postoperative complications and disease recurrence. Results were analysed according to preoperative US appearance of pleural space (stages A-E) and surgical approach (thoracotomy vs U-VATS).
We performed 30 (47%) uniportal thoracoscopic pleural decortication and 34 (53%) open decortication for empyema in stage II (40%) or III (60%) obtaining a complete debridement and decortication in all patients. In-hospital mortality was zero and overall morbidity was 29%. U-VATS was associated with lower blood loss (118 ± 80 ml vs 247 ± 140 ml P < 0.001), lower chest tubes duration (5.6 ± 1.4 vs 10.6 ± 4.4 days P < 0.001), shorter hospital stay (6.7 ± 1.9 vs 12.2 ± 4.7 days, P < 0.001) and lower complications (10% vs 16%, P < 0.001). Elevated US patterns (D-E) are associated with thoracotomy, higher blood loss, operative time and a significant incidence of complications.
Uniportal thoracoscopic decortication for pleural empyema is a safe and effective approach for selected patients based on a combination of clinical and imaging staging. US patterns well corresponded with intraoperative pleural findings and showed a prognostic value.
慢性脓胸的手术治疗方法仍存在争议。电视辅助胸腔镜手术（VATS）清创剥脱术已显示出良好的效果，而单孔VATS（U-VATS）方法仍缺乏大量病例报道。我们报告了我们对脓胸患者进行术前超声（US）分期，随后采用U-VATS剥脱术的经验。
我们对2012年至2015年接受II期和III期脓胸手术治疗的患者进行了回顾性分析。研究术前、术中和术后数据，以评估包括术后并发症和疾病复发在内的结果。根据术前胸膜腔超声表现（A-E期）和手术方式（开胸手术与U-VATS）分析结果。
我们对II期（40%）或III期（60%）脓胸患者进行了30例（47%）单孔胸腔镜胸膜剥脱术和34例（53%）开放剥脱术，所有患者均实现了完全清创和剥脱。住院死亡率为零，总体发病率为29%。U-VATS与较低的失血量（118±80ml对247±140ml，P<0.001）、较短的胸管留置时间（5.6±1.4天对10.6±4.4天，P<0.001）、较短的住院时间（6.7±1.9天对12.2±4.7天，P<0.001）和较低的并发症发生率（10%对16%，P<0.001）相关。超声表现升高（D-E期）与开胸手术、更高的失血量、手术时间和显著的并发症发生率相关。
基于临床和影像学分期的综合评估，单孔胸腔镜剥脱术治疗脓胸对选定患者是一种安全有效的方法。超声表现与术中胸膜发现良好对应，并显示出预后价值。
