Awake video-assisted pleural decortication for empyema thoracis

OBJECTIVE: To evaluate feasibility, technical features and results of video-assisted pleural decortication for empyema thoracis performed in awake patients. METHODS: This retrospective analysis involved a cohort of 19 patients (median age: 58 years) undergoing awake video-assisted thoracoscopic pleural decortication under epidural anaesthesia (N=15) or paravertebral blocks (N=4) between March 2004 and September 2008. Baseline and perioperative data including degree of postoperative lung re-expansion at 48 h, hospital stay, morbidity rate and daily fluid loss were recorded. In addition, intra- and perioperative changes in main pathophysiological variables PaO(2)/FiO(2) ratio, PaCO(2), mean arterial pressure and heart rate were analysed. RESULTS: Origin of the empyema was parapneumonic (N=14), post-traumatic (N=3) and cancer related (N=2). All patients underwent previous conservative management. The duration of the symptoms averaged 35 days (quartile range (QR): 28-40). Co-morbidities included chronic obstructive pulmonary disease (COPD) (N=4), HIV infection (N=1), diabetes mellitus (N=2) and cirrhosis (N=1). Operation was performed videothoracospically in 15 patients whereas four patients with major pleural thickening underwent awake lateral thoracotomy. Operative time averaged 50 min (QR: 40-70). Perioperative data analysis showed no intra-operative deterioration in arterial oxygenation (median-Delta: 0 mm Hg, QR: -5/+9, P=0.6). Transient permissive hypercapnia (<55 mm Hg) developed in three patients with no need of conversion to general anaesthesia. Median pain level assessed by a visual analogue score (VAS) 1h postoperatively was 4 (QR: 2-5), and it was significantly reduced on postoperative day 1 (median 3, QR: 2-4, P=0.03). There was neither mortality nor major morbidity. Hospitalisation averaged 6 days (QR: 5-7). At postoperative chest X-ray, lung re-expansion was rated as complete in 16 patients, satisfactory in (>80%) two patients and unsatisfactory in a 86-year-old patient with pleural mesothelioma who has the chest drain still in place 5 months after surgery. No patient had recurrence of the empyema at subsequent follow-ups. CONCLUSIONS: In our study, awake video-assisted pleural decortication proved feasible and resulted in satisfactory lung re-expansion in 95% of the patients. We hypothesise that spontaneous ventilation facilitated both identification of the correct plane and dissection, thus resulting in lesser surgical injury on the underlying lung.