The role of video-assisted thoracoscopic surgery in the treatment of parapneumonic empyema after the failure of fibrinolytics

Background: Approximately 10% of patients treated with intrapleural instillation of fibrinolytics fail to respond and therefore need more invasive techniques, such as video-assisted thoracoscopic surgery (VATS). Methods: During the period 1994-99, we treated 20 consecutive patients with complicated parapneumonic effusion (CPE) and pleural empyema (PE) that did not resolve with urokinase instillation given through the chest tube in a dose of 100,000 IU diluted in 100 ml of normal saline/daily for 3-5 days. The patients' ages ranged from 21 to 68 years (median, 46); 14 were male and six female. All patients had pleural fluid pH <7.1, lactate dehydragenase (LDH) > 1000, glucose <40 mg/dl and were submitted to VATS. Results: Complete drainage was observed in 17 patients (85%), in the other three (15%), the procedure had to be converted to open thoracotomy due to a thickened visceral pleural peel. The mean operative time was 80.3 min (range, 55-140), and the mean duration of postoperative hospital stay was 7.5 days (range, 4-19). Conclusion: We found that VATS is a safe, effective, and well-tolerated surgical procedure in CPE and PE patients who have failed to resolve with initial treatment with fibrinolytics.