Indications for VATS or open decortication in the surgical treatment of fibrino-purulent stage of parapneumonic pleural empyema.

Open and Video-Assisted Thoracoscopycal pleural decortications are proved and effective surgical procedure in the surgical treatment of pleural empyema in the fibrinopurulent stage. Early referral to surgery gives a better chance of success in VATS pleural decortications than open decortications. Pleural morphology, biochemistry and biology can also affect the outcome of the surgical treatment of pleural empyema. The aim of this paper is to compare the results of VATS and open decortications of the pleura according to the preoperative morphological and biochemical conditions of the pleura and the pleural cavity as well as postoperative morphological and functional improvement in patients with parapneumonic, fibrinopurulent pleural empyema. Two different approaches (VATS and open pleural decortications) were analyzed in 37 patients divided into two groups. The biochemical analysis of pleural fluid (LDH, glucose, pH and albumins) and the pleural thickness of the chest CT scan were measured. The success of the operations was measured by plain chest X-ray and functional tests after 3 months postoperatively. The group with VATS pleural decortications showed a significantly (p<0.001) lower pleural LDH level and pleural thickness and significantly higher levels (p<0.001) of glucose and albumins than the group with opened pleural decortications. The differrences in the pleural pH were not significant. Postoperative chest X-rays at discharge were significantly better in VATS pleural decortications. FEV1 and FVC, predicted and 3 months after operation, were not significantly different between the two groups. VATS and open decortications are safe and effective for the majority of patients. When VATS pleural decortications cannot be performed due to an obliterated pleural space, open pleural decortication still remains an effective procedure that allows acceptable functional and morphological results. Preoperative determination of pleural LDH, glucose, and albumins, as well as the thickness of pleural peel on CT scan, enables better evaluation of the pleural condition and a more exact indication of the right procedure.