Empyema Thoracis: can we predict which patients have better outcomes following Surgery?

Abstract

OBJECTIVE: In patients with empyema thoracis, traditional predictors of postoperative outcomes may help select those who will benefit from surgery. However, with modern surgical practices – including the increasing use of minimally invasive Video Assisted Thoracic Surgery (VATS) – the roles of such predictors require re-evaluation. METHODS: Clinical data for 51 consecutive patients receiving decortications surgery for empyema thoracis were reviewed. Indications for surgery included unsuccessful non-surgical pre-treatment, persistent sepsis and/or restrictive pulmonary dysfunction from chronic empyema. The use of thoracotomy or VATS was at the surgeon’s discretion. RESULTS The studied cohort had a mean age of 50 years (range 3–76), and included 22 patients (43.1%) with organized stage III disease and 16 (31.4%) with tuberculous (TB) empyema. There was no mortality and minor complications occurred in 12 patients (23.5%). Clinical resolution of the empyema was achieved following surgery in all patients, and none required re-operation. Traditional predictors of surgical outcome did not correlate with operation times, complications, or lengths of stay (LOS). These included stage III disease, TB empyema, pre-operative symptom duration for 28 days or more, and duration of non-surgical management for 14 days or more. However, prolonged pre-operative symptom duration was associated with slower radiological resolution of postinflammatory changes for up to 9 months after surgery (p = 0.04). The only predictor of increased incidence of postoperative complications was a serum leucocyte count of over 12 x 109/l at the time of surgery (12.5% vs. 42.1%, p = 0.02). Patients aged 55 years or more had higher risk for persistent respiratory symptoms at up to 9 months after surgery (0% vs. 18.2%, p = 0.01), and showed trends for higher complication rates and longer LOS. Although similar to patients receiving thoracotomy in all key demographic and clinical variables, those 21 patients (41.2%) receiving VATS had shorter operation times (150mins vs. 217 mins, p < 0.01), shorter LOS (10.9 days vs. 18.7 days, p = 0.04), and a strong trend for better radiological resolution at 6 months after surgery. CONCLUSIONS With advances in thoracic surgery, the pertinence of traditional outcome predictors focused on empyema characteristics appears diminished. Instead, better surgical outcomes may be predicted by lack of leucocytosis, younger age, and particularly the use of the VATS approach.