Successful Clinical and Radiological Outcomes Following Thoracoscopic Decortication in Critically Ill Patients
Prasad Adusumilli, Julie M. Schrader, Peter F. Ferson, Sebastien Gilbert.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
OBJECTIVE:
OBJECTIVE: Entrapped lung in otherwise compromised patients is clinically challenging. Thoracoscopic decortication in these patients is controversial because of concerns regarding tissue handling, visualization, and instrumentation necessary to achieve lung re-expansion.
METHODS: Review of clinical and radiological outcomes following thoracoscopic drainage and decortication in consecutive patients with pleural effusion or empyema resulting in a trapped lung (as evidence by CT scan and/or absence of lung expansion following percutaneous catheter or chest tube drainage). Patients with a bronchopleural fistula or calcified pleura were excluded.
RESULTS: Thirthy-seven patients [mean age 53 (22-83)] underwent 38 thoracoscopic decortications (right 66%; left 34%). Etiologies included: trauma (30%), pneumonia (27%), post-cardiac surgery effusion (16%), and other (27%). Twenty-five patients (68%) were hospitalized for more than 7 days before surgery and 12 (32%) were in intensive care. The mean operative time was 133 ± 9 minutes and blood loss averaged 130 ± 33 mL (range=50-1000 mL). Mean follow-up was 177 ± 32 days. Complete lung expansion was documented radiologically after 35 procedures (92%). In 2 cases, lung expansion was partial but did not require additional intervention. Ventilator wean was achieved in 89% of ventilator-dependent patients. One immunosuppressed patient with a pulmonary infarct, pneumonia and empyema developed a bronchopleural fistula after thoracoscopy which required a separate open procedure for definitive management. One patient (3%) died within 30 days from sepsis despite complete lung expansion.
CONCLUSIONS: Lung entrapment in clinically compromised patients may be safely and successfully managed by thoracoscopic decortication while avoiding morbidity associated with thoracotomy.
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