Video thoracoscopy in the surgical treatment of pleural empyema

Pleural empyema in most cases is a complication of inflammatory and purulent-destructive lung diseases, injuries and surgical interventions on the chest organs and is the most complex section in thoracic surgery. At present, according to domestic and foreign researchers, there is no reduction in the incidence of acute purulent-destructive lung diseases (ADLD) complicated by pleural empyema. As is known, in 19.1%-73.0% of cases, non-specific pleural empyema is caused by acute purulent-destructive lung diseases. The mortality rate is 7.2% - 28.3%.

Posttraumatic genesis of pleural empyema is noted in 6%-20% of cases. Mortality in posttraumatic pleural empyema sometimes reaches 30%, and the outcomes largely depend on the nature of the injury and the timing of providing assistance to victims with chest trauma.

Due to the expansion of indications and volume of intrathoracic interventions and the intensive growth of antibiotic resistance of microorganisms, the high incidence of postoperative pleural empyema and bronchopleural fistulas remains.

Treatment of patients with pleural empyema is still a complex problem, as evidenced by relatively high mortality rates, chronicity of the process, disability of patients, most of whom are people of working age. In addition, changes in the species composition of microflora and its tolerance to many antibacterial drugs, an increase in the proportion of anaerobic and hospital infections, and an increase in allergization of the population create additional difficulties in the treatment of patients with pleural empyema. Surgical treatment methods are often accompanied by complications, are traumatic and not always feasible due to the serious condition of patients. Promising is the use of "minor" surgery methods in the complex treatment of patients with pleural empyema, including videothoracoscopy, which, depending on the severity of pulmonary pathology, leads to a cure in 20%-90% of cases.

Among patients treated with endoscopic pleural sanitation, 8.4% were operated on, while among those treated with punctures and drainage without examination, 47.6%.

The first thoracoscopy in the world for massive infected left-sided pleurisy with the development of a chronic fistula in an 11-year-old girl was performed by the Irish surgeon Dr. Cruise (1866), using a binocular endoscope he developed.

The advisability of using thoracoscopy for pleural empyema was first discussed at the 16th All-Russian Congress of Surgeons by G.A. Herzen (1925). At first, thoracoscopy was widely used in the treatment of pulmonary tuberculosis. However, the emergence of new effective anti-tuberculosis drugs slowed down the further development of thoracoscopy for many years. This method has only been more widely used in the diagnosis and treatment of inflammatory diseases of the lungs and pleura in the last two decades.

V.G. Geldt (1973), using thoracoscopy in children with pyopneumothorax, noted its decisive importance in the diagnosis of intrapleural lesions and the choice of treatment. G.I. Lukomsky (1976) used thoracoscopy according to the Friedel method for widespread and total empyema, and for limited empyemas with destruction of lung tissue. A shortened bronchoscopic tube from the Friedel set No. 11 or No. 12 was inserted into the pleural cavity, and pus and fibrin flakes were removed from the pleural cavity using an aspirator under visual control. Thoracoscopy ended with the introduction of silicone drainage into the pleural cavity. Based on the experience gained, the author concludes that it is advisable to use thoracoscopy in the treatment of pleural empyema.

D. Keiser (1989), who used a mediastinoscope as an endoscope, reported successful treatment of acute pleural empyema using operative thoracoscopy.

In the last two decades, the world has seen significant technical progress in the healthcare sector, which has been realized in the creation of endovideo equipment and the emergence of new endoscopic instruments, which has expanded the scope of thoracoscopic surgery - up to resections of the lungs, esophagus, removal of mediastinal tumors, treatment of spontaneous pneumothorax, hemothorax. Today, videothoracoscopic operations have become the "gold standard" in the diagnosis and treatment of many diseases of the chest organs, including purulent-inflammatory diseases.

P. Ridley (1991) used thoracoscopy in 12 patients with pleural empyema. In his opinion, removal of necrotic masses under endoscopic control and thorough lavage of the empyema cavity allows for favorable results in the treatment of these patients.

V.A. Porkhanov et al. (1999) summarized the experience of treating 609 patients with pleural empyema using videothoracoscopic technology. They used videothoracoscopic lung decortication and pleurectomy for chronic pleural empyema: this method cured 37 (78.7%) patients. Conversion to thoracotomy was required in 11 (1.8%) patients.

PC Cassina, M. Hauser et al. (1999) assessed the feasibility and effectiveness of video-assisted thoracoscopic surgery in the treatment of non-tuberculous fibrinous-purulent pleural empyema in 45 patients after ineffective drainage. The average duration of conservative treatment was 37 days (from 8 to 82 days), with a treatment effectiveness of 82%. Decortication by standard thoracotomy was required in 8 cases. Dynamic observation with an examination of the external respiratory function in 86% of patients after video-assisted thoracoscopic operations showed normal values, in 14% - moderate obstruction and restriction. The authors did not note recurrence of empyema. The researchers conclude that video-assisted thoracoscopic sanitation of the empyema cavity is effective in the treatment of purulent-fibrinous empyema, when drainage and fibrinolytic therapy have not been successful. At a later stage of the organization of pleural empyema, the method of choice is considered to be thoracotomy and decortication.

In 2001, V.N. Egiev described a case of successful video-assisted thoracoscopic radical sanitation of chronic non-specific pleural empyema.

To improve the efficiency of endovideothoracoscopic surgery, some thoracic surgeons began to use ultrasound, laser radiation, and argon plasma. A. N. Kabanov, L. A. Sitko et al. (1985) used closed ultrasound decortication of the lung through a thoracoscope with a special waveguide-curette, followed by insonification of the empyema cavity in an antiseptic solution in order to enhance the rejection of pathological substrates and the bactericidal properties of antiseptics. I. I. Kotov (2000) developed and implemented a method of laser thoracoscopy with evaporation of the pyogenic-necrotic layer of opened pulmonary destructions and welding of bronchopleural fistulas with a carbon dioxide laser beam. V. N. Bodnya (2001) developed a surgical technology of video-assisted thoracoscopic pleural empyemaectomy, decortication of the lungs in the 3rd stage of pleural empyema using an ultrasonic scalpel and treatment of lung tissue with an argon torch based on the experience of treating 214 patients. The number of postoperative complications decreased by 2.5 times, the hospitalization time was reduced by 50%, the effectiveness of the developed technique was 91%.

V.P. Savelyev (2003) analyzed the treatment of 542 patients with pleural empyema. In 152 patients, thoracoscopy was performed with drainage of the empyema cavity with two or more drains for continuous flow washing. In 88.7% of them, thoracoscopy was the final method of treatment.

There are different views on the timing of videothoracoscopy, some authors justify the need for more active diagnostic and therapeutic tactics, and perform videothoracoscopy for emergency indications on the day of admission, taking into account general contraindications. The authors recommend performing thoracoscopy for diagnostic and therapeutic purposes immediately after the diagnosis of pleural empyema. By expanding the indications for videothoracoscopy for pleural empyema, it is possible to reduce the need for thoracotomy and traditional surgeries from 47.6% to 8.43%, reduce postoperative mortality from 27.3% to 4.76% with a reduction in the duration of hospitalization by 33%.

Other surgeons believe that thoracoscopy should be used at a later stage after a set of diagnostic measures and when conservative therapy with punctures and drainage is unsuccessful. There is still a widespread opinion that one should not rush with thoracoscopy and reliable correction of homeostatic and volemic disorders is added to the listed conditions. Probably, the latter is true only in the case of an advanced pathological process in the pleura.

Indications and contraindications for the use of videothoracoscopy

Based on many years of experience in the use of videothoracoscopy in the treatment of acute and chronic pleural empyema, the following indications for its use have been developed:

• Ineffectiveness of traditional treatment methods, including closed drainage of the pleural cavity;
• Fragmented pleural empyema (pleural empyema with multiple encapsulations);
• Empyema of the pleura with signs of destruction of lung tissue, including bronchopleural communications.

Contraindications to the use of videothoracoscopy are:

• The presence of general somatic diseases in the stage of decompensation;
• Intolerance to mechanical ventilation in single-lung ventilation mode;
• Mental illness;
• Violation of the hemostasis system;
• Bilateral lung damage, accompanied by severe respiratory failure.

How is videothoracoscopy performed?

Videothoracoscopic surgeries are often performed under general anesthesia with separate intubation of the bronchi with a double-lumen tube. Such single-lung ventilation is necessary for complete lung collapse and creation of free space, which allows for a thorough and complete examination of the chest cavity. But depending on the tasks set by the surgeon, videothoracoscopy can be performed under local or regional anesthesia.

The patient's position on the operating table. The most common position is the patient's position on the healthy side on a bolster placed in the middle of the chest, which maximally promotes the separation of the intercostal spaces. This position, although it gives the surgeon freedom of action, has its drawbacks. Compression of the healthy lung has an adverse effect on ventilation when the diseased lung is disconnected from the act of breathing, and there is also a risk of purulent fluid flowing into its bronchial tree. A more gentle position for the patient is the semi-lateral position on a high wedge-shaped bolster. In this case, the healthy lung is subjected to less compression. The patient must be securely fixed, since depending on the surgical situation, it may be necessary to change the patient's position in one direction or another.

Surgical technique. The place of choice for insertion of the first thoracoport is selected individually, depending on the shape, size and localization of the empyema cavity. Optimization of the localization of the insertion of the first port is facilitated by a close study of radiographs in 2 projections, computed tomography and ultrasound scanning of the chest before surgery. The number of thoracoports depends on the tasks set before the operation. Usually 2-3 thoracoports are sufficient. In case of an adhesive process in the pleural cavity, the first thoracoport is inserted in an open manner, penetrating the pleural cavity with a finger. An artificial pleural cavity is created in a blunt manner, sufficient for insertion of additional ports and performing the necessary surgical manipulations. During videothoracoscopy, various techniques are used: evacuation of purulent exudate, dissection of pleural adhesions to defragment the empyema cavity, removal of purulent detritus and sequesters, resection of destructive pulmonitis zones, lavage of the empyema cavity with antiseptic solutions, partial or complete pleurectomy and decortication of the lung. All authors complete thoracoscopy by draining the empyema cavity. Some surgeons use passive aspiration when treating pleural empyema with bronchial fistula. Most prefer active aspiration of the contents from the pleural cavity. In acute empyema without destruction of lung tissue and bronchial fistula, active aspiration is indicated, which allows eliminating the cavity and curing empyema in 87.8-93.8%. Active aspiration creates conditions for active expansion of the collapsed lung, helps reduce intoxication and is a measure for preventing bronchogenic dissemination of purulent infection. The degree of rarefaction required for lung expansion largely depends on the duration of pyopneumothorax, the size of the bronchopleural communications and the degree of lung collapse. Many authors suggest supplementing active aspiration with flow, fractional, flow-fractional lavage of the empyema cavity, even using automated control systems for this process.

Application of videothoracoscopy in treatment of pleural empyema with bronchopleural communications (BPC). The main reason for the insufficient efficiency of drainage methods is the presence of bronchopleural fistulas, which not only prevent the lung from straightening and support the purulent process, but also limit the possibility of pleural cavity lavage. This drawback is eliminated by combining videothoracoscopy with temporary bronchial occlusion (TOB). Despite the numerous methods of eliminating bronchopleural communications during videothoracoscopy, such as electrocoagulation of the mouths of bronchopleural communications, the use of medical glues, suturing devices, welding of bronchopleural communications with high-energy laser radiation, the problem of their elimination remains relevant today. Their low efficiency is primarily due to the fact that all these manipulations are carried out in conditions of a purulent-necrotic process, which contribute to the failure of the “welded” tissues, the cutting through of the inflamed lung tissue and the rejection of the adhesive filling.

In the literature, reports on the combination of videothoracoscopy with temporary bronchial occlusion are rare. Thus, I. I. Kotov (2000) recommends combining videothoracoscopy with temporary bronchial occlusion in cases of pleural empyema with medium and large-caliber bronchopleural communications with a pliable lung. The use of temporary bronchial occlusion, according to V. P. Bykov (1990), made it possible to reduce mortality in patients with pyopneumothorax by 3.5 times.

Early use of videothoracoscopy with subsequent occlusion of the fistula-bearing bronchus allowed recovery in 98.59% of patients, and in the group of patients with pleural empyema without fistula, recovery was achieved in 100%.

The mechanism of the positive effect of temporary bronchial occlusion on the course of the purulent-destructive process in the lung during pyopneumothorax is as follows:

• A stable vacuum is created in the pleural cavity as a result of its separation from the bronchial tree by the obturator.
• The residual pleural cavity is eliminated by straightening and increasing the volume of the healthy part of the lung, shifting the mediastinum, reducing the intercostal spaces and raising the diaphragm.
• Promotes emptying and obliteration of foci of destruction in lung tissue in conditions of temporary atelectasis of the affected parts of the lung with constant active aspiration of contents from the pleural cavity.
• Bronchogenic dissemination of purulent infection is prevented by isolating healthy parts of the lungs.
• Favorable conditions are created for the closure of bronchopleural communications as a result of the formation of adhesions between the visceral and parietal pleura, and the formation of limited fibrothorax.

The expediency of using temporary bronchial occlusion after videothoracoscopic sanitation of the pleural cavity in combination with active aspiration through installed drains in the pleural cavity is recognized by all authors, since these treatment methods complement each other and in combination minimize their disadvantages. In this situation, the use of videothoracoscopy in combination with temporary bronchial occlusion is pathogenetically justified, appropriate and promising.

Programmed videothoracoscopy

During the suppurative process in acute pleural empyema, after videothoracoscopy and drainage of the pleural cavity, periods of clinical regression occur in approximately half of the cases. The reasons for this are the formation of purulent-necrotic sequesters, non-drainable purulent encapsulations (fragmentation of the empyema cavity), the inability of the rigid lung to completely fill the pleural cavity. As a result, in 45-50% of cases, treatment cannot be limited to one primary thoracoscopy; additional manipulations and multiple sanitation are necessary.

V.N. Perepelitsyn (1996) used therapeutic thoracoscopy in 182 patients with non-specific acute and chronic pleural empyema, of which 123 patients had acute para- and metapneumonic pleural empyema. Some patients underwent staged sanitation thoracoscopy. On average, repeat thoracoscopy was performed four times (in 8 patients). In patients admitted in the first 1-30 days from the onset of the disease, it was possible to reduce the average duration of inpatient treatment from 36 to 22 days.

Since 1996, V.K. Gostishchev and V.P. Sazhin have used dynamic thorascopic sanation in the treatment of pleural empyema. Using endoscopic manipulators, they destroyed pulmonary-pleural adhesions, removed fibrinous deposits from the visceral and parietal pleura, and performed necrectomy of melted areas of lung tissue. After sanation, drainage tubes were installed under the control of a thoracoscope to form a flow-aspiration system, and the lung abscess cavity was drained by puncture. Subsequent thoracoscopic sanations were performed at intervals of 2-3 days. In this case, loose adhesions of the lung with the pleura were separated, and staged necrectomy was performed. In the period between sanations, the pleural cavity was washed with antiseptics through the drainage system, and the lung abscess cavity was sanitized. The presence of a normal thoracoscopic picture and normalization of temperature served as an indication for stopping thorascopic sanation and switching to only drainage sanation of the pleural cavity. The ineffectiveness of dynamic thoracoscopic sanation, as a rule, was associated with the presence of difficult-to-remove fibrinous deposits in the pleural cavity and extensive foci of destruction in the lung tissue, which served as an indication for open sanation of the pleural cavity. For this purpose, thoracotomy was performed and necrectomy and lavage of the pleural cavity with antiseptics were performed under visual control. After sanation, the pleural cavity was loosely filled with tampons with water-soluble ointments. The operation was completed by forming a controlled thoracostomy using a zipper for subsequent planned sanation of the pleural cavity. The authors used dynamic thorascopic sanation in the treatment of 36 patients with pleural empyema. The number of sanitation procedures per patient varied from 3 to 5. The transition to open sanitation of the pleural cavity was performed in 3 patients, which amounted to 8.3%. 2 patients died (5.6%).

A special feature of the treatment of pleural empyema is the need to straighten and maintain the lung in a straightened state. Any repeated invasion can lead to lung collapse. Therefore, when treating empyema, it is important to perform not the greatest number of sanations of the purulent focus, but the optimal number.

Amarantov D.G. (2009) recommends performing emergency surgical thoracoscopy in patients with acute para- and metapneumonic pleural empyema in order to determine the characteristics of intrapleural changes and the degree of reversibility of the chronic component of the purulent process upon admission. Based on the characteristics of intrapleural changes revealed during the first thoracoscopy and the duration of the disease, a thoracoscopic treatment program and tactics of antibacterial, detoxification therapy and physiotherapy are developed. After each thoracoscopy, the next one is recommended to be performed only if signs of "clinical regression" appear within the time frame depending on the characteristics of intrapleural changes during the first thoracoscopy. To create a stable trend towards recovery or to identify irreversible signs of the formation of chronic empyema, 1-4 thoracoscopies are sufficient. The tactics of surgical techniques should depend on the thoracoscopic characteristics of the empyema cavity. Depending on the characteristics of intrapleural changes, the optimal time for performing staged thoracoscopy when signs of clinical regression occur in patients with a primary thoracoscopic picture of the serous-purulent stage are the 3rd, 9th, 18th days, with a picture of the purulent-fibrinous stage - the 6th, 12th, 20th days, with a picture of the proliferative stage - the 6th, 12th, 18th days. The proposed algorithms for performing programmed staged thoracoscopy in combination with surgical techniques for influencing the empyema cavity depending on the type of inflammation during primary thoracoscopy allow to standardize the approach to treating patients with acute para- and metapneumonic pleural empyema. According to the author, the use of programmed staged thoracoscopy increases good immediate results of treating patients with acute para- and metapneumonic pleural empyema by 1.29 times; reduces the time of labor rehabilitation by 23%; reduces disability by 85%; increases good long-term results by 1.22 times; reduces mortality by 2 times.

In recent years, video-assisted thoracic surgery has become more widely used, which has become an alternative to thoracotomy in many diseases, including the treatment of pleural empyema. Izmailov E.P. et al. (2011) believe that video-assisted lateral mini-thoracotomy performed in the period from 1-1.5 months after the onset of pleural empyema is the most justified in the treatment of acute pleural empyema. The use of such tactics allowed 185 (91.1%) patients to achieve clinical recovery and eliminate the pleural empyema cavity.

Yasnogorodsky O.O., using a mini-access with video support, determines the indications for intervention, focusing on the results of sanitization of the empyema cavity, radiological characteristics of the state of the lung tissue, the ability of the lung to re-expansion taking into account the somatic background, concomitant diseases, age of the patient, etc. The main advantage of such access, the author emphasizes, is the possibility of a double view of the operated area, sufficient lighting, the ability to use both traditional and endoscopic instruments. Of 82 patients with pleural empyema, only 10 needed to expand the mini-access to a standard thoracotomy, and in most patients, the empyema cavity was adequately sanitized.

To summarize, the following conclusions can be made:

1. Videothoracoscopy for pleural empyema has not yet received sufficient recognition and widespread practical application, especially in the treatment of chronic pleural empyema. The place of videothoracoscopy in the algorithm of complex treatment of pleural empyema is constantly being sought, and indications for its use are being worked out.
2. Videothoracoscopy for pleural empyema allows in most cases to cure acute pleural empyema and avoid its transition to chronic.
3. The use of programmed video-assisted thoracoscopic sanation of the pleural cavity is a promising direction in the complex treatment of pleural empyema, however, the number, optimal timing and direction of each stage of thoracoscopic sanation remain an unresolved issue to date and require further study.
4. The complex use of videothoracoscopy in combination with bronchial occlusion of the fistula-bearing bronchus in patients with pleural empyema with bronchopleural communications allows the majority of patients to be cured of the disease, eliminate the need for traumatic surgery, and otherwise, prepare for traditional surgical treatment in a shorter time.
5. The place of video-assisted mini-thoracotomies in the algorithm of surgical treatment of pleural empyema is not clearly defined, and the advantages that it has give reason to believe about the prospects of its use in the treatment of pleural empyema.

Candidate of Medical Sciences, Thoracic Surgeon of the Thoracic Surgery Department Matveev Valery Yuryevich. Videothoracoscopy in the surgical treatment of pleural empyema // Practical Medicine. 8 (64) December 2012 / Volume 1