Thoracoscopic approach to the management of empyema thoracis. Indications and results.

The optimal management of empyema thoracis demands a fundamental knowledge of the pace and timing of the illness. Early free-flowing empyema should be drained by as dependent a drain as possible, while antibiotics directed against the underlying pneumonia are delivered. Late chronic empyema characterized by a constrictive rind intimately fused with the visceral pleura is best managed with an open decortication. Controversy exists when addressing the needs of the patient with a multiloculated acute empyema. Lengthy hospitalizations with prolonged chest tube drainage and administration of antibiotics likely will prove fruitless and culminate in open thoracotomy. The key to successful therapy lies in effective pleural evacuation and re-expansion of the lung. Intrapleural fibrinolytic therapy has been reported to produce excellent results in some centers and is a therapeutic option. Patients undergoing fibrinolytic therapy should be subjected to surgical drainage and debridement if significant improvement is not appreciated within 3 to 5 days. Early limited thoracotomy and thoracoscopic debridement theoretically accomplish the same end result. The advantages of thoracoscopy over limited thoracotomy are enhanced visualization of the pleural cavity and less postoperative pain and dysfunction.