Pleuroscopy in empyema: is it ever necessary?

The use of pleuroscopy in empyema has not been reported before. I performed this procedure in 19 empyema patients. In 7, empyema was found incidentally, while pleuroscopy was done for a variety of other indications. Twelve others had known empyema that did not respond to treatment with drainage and antibiotics. In these patients pleuroscopy was carried out in order to determine lung expansibility, to search for factors possibly responsible for therapy failure, and to aid treatment. Useful information was obtained in every patient. Some findings were totally unexpected and revealing, e.g. a surgical sponge forgotten at an earlier heart operation, undigested food particles traced to an unrecognised perforation of an esophageal tumor, or an unsuspected broncho-pleural fistula. Treatment was modified accordingly. In addition to its diagnostic value, pleuroscopy is an important aid in treatment of empyema. All pus and debris can be aspirated under vision and tube drains can be placed in the most dependent position. In selected patients talc can be insufflated in order to cause pleurodesis. Although the use of talc in empyema has not been described before, our early experience is encouraging. I used it on three occasions, achieving each time complete pleurodesis and prompt cure of empyema. It is concluded that pleuroscopy is a useful diagnostic and therapeutic procedure, applicable in patients with empyema in whom conventional therapy failed. It provides the best way for talc insufflation when pleurodesis is difficult to achieve. Pleuroscopy should have an established place in the management of empyema.