Thoracoscopic decortication (VATS) for Empyema of the chest.

Simple bacterial pneumonia is an infection in the lung itself. Treatment of bacterial pneumonia is with oral or intravenous antibiotics. In some patients, fluid can develop next to the lung. This is called a para-pneumonic effusion. If the fluid is clear and uninfected, placement of a small tube can be done to drain the fluid. If the fluid is infected or has loculated pockets within the chest, it is called an empyema and simple tube drainage will fail to adequately treat the infection.

Options include percutaneous chest tube placement with tPA, thoracoscopy and chest tube placement, or thoracoscopic decortication. Each has its advantages and disadvantages.

Percutaneous chest tube placement with infusion of tPA. This procedure may be done with sedation if the patient has no pulmonary symptoms, but typically requires general anesthesia in children due to breathing concerns related to the underlying pneumonia. A small tube is placed into the chest under ultrasound guidance using a needle and wire technique. After the procedure, tPA (a clot dissolving substance) is placed into the tube at regular intervals to break up the pockets of fluid. The tube is removed when all of the loculated fluid has been treated. Advantages include lower costs and shorter procedure times. The procedure is typically done by a radiologist with special training.

Thoracoscopy and chest tube placement:
Under general anesthesia, a 5mm (1/8th inch) incision is made and a long, thin thoracoscopic camera is placed into the chest. The camera is used to break up the pockets of fluid which are then suctioned from the same hole. When completed, a chest tube is placed to allow any new fluid to accumulate. The advantage is extensive removal of the fluid, short surgical time, and direct vision of the debris within the chest. It will also allow conversion to a more extensive clean out, if needed. The disadvantage is that long standing infection may be adherent to the lung and require a second 5mm port for complete cleanout. This procedure is also more expensive than percutaneous chest tube placement. The procedure is typically done by a pediatric surgeon.

Thoracoscopic decortication:
Is a complete cleanout of the chest space using 2 small (5mm) incisions. One is for a camera to view the chest and the other is for small surgical instruments to break up the pockets of fluid and peel the infected material off the lung and chest wall. After surgery, a small chest tube is placed through one of the incisions to allow new fluid to drain. The chest tube is typically removed the 3rd day after surgery. Advantages include complete cleanout of the chest wall. Avoidance of tPA treatment after the procedure, and multiple studies proving decreased length of stay. Disadvantages include higher cost, potential for blood loss.


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