The uniportal VATS in the treatment of stage II pleural empyema: a safe and effective approach for adults and elderly patients—a single-center experience and literature review

We retrospectively reviewed our prospectively collected database of u-VATS procedures from the institution of a dedicated thoracic surgical team on November 2018 to February 2022, according to Strengthening the Reporting of Observational studies in Epidemiology (STROBE) [13], in our regional referral center for Thoracic Surgery of Regione Molise General Surgery Unit of “A. Cardarelli” Hospital, in Campobasso, Molise, Italy (Fig. 1).

Fig. 1figure 1

STROBEline flowchart. u-VATS, uniportal-video-assisted thoracoscopy; COPD, chronic obstructive pulmonary disease

Grade of eligibility was defined by the presence of a stage II PE fitting for surgery, according to the American Association of Thoracic Surgery (AATS) classification, evaluated through biochemical investigations, such as the alterations of flogosis indices, and instrumental investigations, like ultrasound (US), chest-XR and computed tomography (CT) scan [1] (Fig. 2).

Fig. 2figure 2

Computed tomography scan of the chest showing a right pleural effusion

Surgical exclusion criteria were: lack of patient compliance, the presence of lung cancer, chest trauma, non-pulmonary surgery and stage III PE.

Anesthesiological exclusion criteria were: lack of patient compliance, right ventricular dysfunction, hemodynamic instability, severe chronic obstructive pulmonary disease (COPD), severe pulmonary hypertension and other comorbidities which make it impossible to perform a single lung ventilation (Fig. 1).

Study exclusion criteria were: patients managed by general surgeons not involved in thoracic team before its institution, any data not prospectively collected.

A team composed of thoracic surgeons, anesthesiologist, infectious disease specialist and internist/pulmonologist discussed all cases, placing surgical indication, according to the EACTS guidelines [3]. American Society of Anesthesiologist (ASA) score was used to evaluate intraoperative risk [14].

Before surgery, all patients performed routine blood samples, electrocardiogram (ECG), and start a broad-spectrum antibiotic therapy including metronidazole with parental second or third cephalosporin generation (more frequent ceftriaxone) or parental aminopenicillin with ß-lactamase inhibitor (more frequent ampicillin/sulbactam) according to AATS guideline [1].

Due to the high incidence of the severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) over the years of this study, all patients performed a rhino-pharyngeal molecular swab before the admission in the general surgery ward.

After surgery, all patients performed a chest-XR or CT scan to visualize lung re-expansion.

To achieve a rapid recovery of patient’s conditions, the enhanced recovery after surgery (ERAS) program was used [15].

Postoperative complications were assessed according to the Clavien–Dindo classification [16].

Treatment of postoperative anemia, a frequent complication during thoracic surgery, was performed according to our general surgery unit protocol (Additional file 1).

Postoperative pain was evaluated, every morning, through Visual Analogue Scale (VAS) [17].

Follow-up was planned at 1 week after discharge, using lung US, and 30 days, using chest-XR, after discharge. In either adult and elderly patients, Instrumental Activities of Daily Living (IADL) scale was administered in order to understand the return to normal activities of daily living [18].

All individuals included in this study signed an informed consent for the scientific anonymous use of clinical data. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of the University of Molise (protocol number 10/21, approved date: May 12, 2021).

Technical Notesu-VATS Technique

All procedures were performed under general anesthesia and single lung ventilation, using a double-lumen endotracheal tube. The patient was put in lateral decubitus position with the arms flexed toward the head. To allow a better intercostal space extension, the operating table was flexed into a wedge position with the patient’s head and lower limbs slightly inclined.

After careful skin disinfection with iodopovidone 10%, an ultrasound-guided block of the serratus anterior plane (SAP block with ropivacaine 0.25%, 30 ml) was performed to achieve a better postoperative pain management (Fig. 3).

Fig. 3figure 3

Ultrasonographic evaluation in serratus plane block (SAP block) during uniportal video-assisted thoracoscopy (u-VATS) surgery

The operating surgeon and the assistant stand in front of the patient and the video-monitor.

At the level of the fifth intercostal space, in the correspondence of the mid axillary line, a single incision of 2–3 cm, preserving the muscular structure, was made. Subsequently, to ensure incision enlargement and protection of the structure, a wound protector was inserted. At this point, a 5 mm or 10 mm 30° thoracoscope and endoscopic instruments were introduced (Fig. 4).

Fig. 4figure 4

A, B Stage II of pleural empyema at uniportal video-assisted thoracoscopy (u-VATS) approach characterized by a exudative thickening and dense fibrin depositions in pleural space

To achieve a complete lung re-expansion, the operation continued with debridement and removal of all adhesions, septa, and inflammatory effusion from both the visceral and the parietal pleura (Fig. 5).

Fig. 5figure 5

A, B Visceral and parietal decortication in patient affected by stage II pleural empyema

In case of difficulty in operating management through thoracoscopy, an anterolateral thoracotomy was performed.

Multiple washings with warm physiological solution (NaCl 0.9% solution) were performed to eliminate the residual effusion and organized pus from the visceral pleura. The operation proceeded with decortication with an electrocautery device.

Parenchymal re-expansion was evaluated with lung inflation, and at the same time an accurate aerostasis’ control was carried out.

At the end of surgery, one or two chest tube drainages (28–32 French) were placed.

The timing of chest tube removal was inspired by post-surgical factors (no air leak, drained fluid of clear appearance, whose quantity in 24 h was less than 450 ml) [15], clinical aspects (quantitative decrease of inflammatory indices, fever) and radiological evidence of complete lung re-expansion.

Postoperatively, patients continued with the antibiotic regimen instituted preoperatively and analgesics, such as paracetamol (1000 mg/100 ml) or ketorolac (30 mg/ml), as needed for pain control. Gradually then, patients were referred to respiratory physiotherapy.

Statistical analysis

Statistical analysis was designed to better define the safety and effectiveness of u-VATS in both adults (age < 70 years) and elderly (age ≥ 70 years).

A two-tailed p value < 0.05 was accepted as statistically significant.

First, we applied the Shapiro–Wilk test, to test the normal distribution of quantitative elements. Later, independent samples, whose distribution was normal, were tested using the unpaired t-test. The Mann–Whitney test was used in case of non-normal distributions of values.

Quantitative data were expressed like mean ± standard deviation (SD). We used the random-effects model to calculate summary 95% confidence interval (C.I.).

Chi-square test (χ2) or Fisher’s exact test was used for qualitative data.

Data analysis was carried out with IBM Statistical Package for the Social Sciences (IBM SPSS®).

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