title: Delayed referral and gram-negative organisms increase the conversion thoracotomy rate in patients undergoing video-assisted thoracoscopic surgery for empyema.
abstract: BACKGROUND
  The role of video-assisted thoracoscopic surgery in the treatment of pleural empyema was assessed in a consecutive series of 328 patients between 1992 and 2002. An analysis of the predicting factors for conversion thoracotomy in presumed stage II empyema was performed.
  
  
  METHODS
  Empyema stage III with pleural thickening and signs of restriction on computer tomography imaging was treated by open decortication, whereas a thoracoscopic debridement was attempted in presumed stage II disease. Conversion thoracotomy was liberally used during thoracoscopy if stage III disease was found at surgery. Predictive factors for conversion thoracotomy were calculated in a multivariate analysis among several variables such as age, sex, time interval between onset of symptoms and surgery, involved microorganisms, and underlying cause of empyema.
  
  
  RESULTS
  Of the 328 patients surgically treated for stage II and III empyema, 150 underwent primary open decortication for presumed stage III disease. One hundred seventy-eight patients with presumed stage II empyema underwent a video-assisted thoracoscopic approach. Of these 178 patients, thoracoscopic debridement was successful in 99 of 178 patients (56%), and conversion thoracotomy and open decortication was judged necessary in 79 of 178 patients (44%). The conversion thoracotomy rate was higher in parapneumonic empyema (55%) as compared with posttraumatic (32%) or postoperative (29%) empyema; however, delayed referral (p < 0.0001) and gram-negative microorganisms (p < 0.01) were the only significant predictors for conversion thoracotomy in a multivariate analysis.
  
  
  CONCLUSIONS
  Video-assisted thoracoscopic debridement offers an elegant, minimally invasive approach in a number of patients with presumed stage II empyema. However, to achieve a high success rate with the video-assisted thoracoscopic approach, early referral of the patients to surgery is required. Conversion thoracotomy should be liberally used in case of chronicity, especially after delayed referral (> 2 weeks) and in the presence of gram-negative organisms.
authors.affiliation: Division of Thoracic Surgery, University Hospital, Zurich, Switzerland. didier.lardinois@usz.ch
authors.forename: Didier
authors.initials: D
authors.lastname: Lardinois
authors.forename: Michael
authors.initials: M
authors.lastname: Gock
authors.forename: Edgardo
authors.initials: E
authors.lastname: Pezzetta
authors.forename: Christian
authors.initials: C
authors.lastname: Buchli
authors.forename: Valentin
authors.initials: V
authors.lastname: Rousson
authors.forename: Markus
authors.initials: M
authors.lastname: Furrer
authors.forename: Hans-Beat
authors.initials: HB
authors.lastname: Ris
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003646:Debridement / Q000379:methods; D016724:Empyema, Pleural / Q000382:microbiology* / Q000601:surgery*; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000150:complications; D006801:Humans; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D020775:Thoracic Surgery, Video-Assisted; D013908:Thoracotomy; D013997:Time Factors