title: Does videothoracoscopy improve clinical outcomes when implemented as part of a pleural empyema treatment algorithm?
abstract: OBJECTIVE
  We aimed to evaluate whether the inclusion of videothoracoscopy in a pleural empyema treatment algorithm would change the clinical outcome of such patients.
  
  
  METHODS
  This study performed quality-improvement research. We conducted a retrospective review of patients who underwent pleural decortication for pleural empyema at our institution from 2002 to 2008. With the old algorithm (January 2002 to September 2005), open decortication was the procedure of choice, and videothoracoscopy was only performed in certain sporadic mid-stage cases. With the new algorithm (October 2005 to December 2008), videothoracoscopy became the first-line treatment option, whereas open decortication was only performed in patients with a thick pleural peel (>2 cm) observed by chest scan. The patients were divided into an old algorithm (n = 93) and new algorithm (n = 113) group and compared. The main outcome variables assessed included treatment failure (pleural space reintervention or death up to 60 days after medical discharge) and the occurrence of complications.
  
  
  RESULTS
  Videothoracoscopy and open decortication were performed in 13 and 80 patients from the old algorithm group and in 81 and 32 patients from the new algorithm group, respectively (p<0.01). The patients in the new algorithm group were older (41 +1 vs. 46.3+ 16.7 years, p = 0.014) and had higher Charlson Comorbidity Index scores [0(0-3) vs. 2(0-4), p = 0.032]. The occurrence of treatment failure was similar in both groups (19.35% vs. 24.77%, p = 0.35), although the complication rate was lower in the new algorithm group (48.3% vs. 33.6%, p = 0.04).
  
  
  CONCLUSIONS
  The wider use of videothoracoscopy in pleural empyema treatment was associated with fewer complications and unaltered rates of mortality and reoperation even though more severely ill patients were subjected to videothoracoscopic surgery.
authors: Hospital das Clfnicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil. rmterra@uol.com.br
authors: Ricardo Mingarini
authors: RM
authors: Terra
authors: Daniel Reis
authors: DR
authors: Waisberg
authors: José Luiz Jesus de
authors: JL
authors: Almeida
authors: Marcela Santana
authors: MS
authors: Devido
authors: Paulo Manuel
authors: PM
authors: Pêgo-Fernandes
authors: Fabio Biscegli
authors: FB
authors: Jatene
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D016724:Empyema, Pleural / Q000601:surgery*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D015203:Reproducibility of Results; D012189:Retrospective Studies; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome