title: Mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema.
abstract: OBJECTIVE
  This prospective study is an evaluation of the mini-open vacuum-assisted closure with instillation (Mini-VAC-Instill) therapy for the treatment of complicated pleural empyema.
  
  
  METHODS
  We investigated septic patients in poor general physical condition (Karnofsky index ≤50%) with multimorbidity and/or immunosuppression who were treated by minimally invasive intrathoracic VAC-Instill therapy without the insertion of an open-window thoracostomy (OWT) between December 2012 and November 2014. All patients underwent mini-thoracotomy with position of a tissue retractor, surgical debridement and local decortication. Surgery was followed by intrathoracic vacuum therapy including periodic instillation using antiseptics. The VAC dressings were changed under general anaesthesia and the chest wall was closed during the same hospital stay. All patients received systemic antibiotic therapy.
  
  
  RESULTS
  Fifteen patients (13 males, median age: 71 years) underwent intrathoracic Mini-VAC-Instill dressings for the management of pleural empyema without bronchopleural fistula. The median length of vacuum therapy was 9 days (5-25 days) and the median number of VAC changes per patient was 1 (1-5). In-hospital mortality was 6.7% (n = 1) and was not related to Mini-VAC-Instill therapy or intrathoracic infection. Control of intrathoracic infection and closure of the chest cavity was achieved in 85.7% of surviving patients (12 of 14). After the follow-up at an average of 13.2 months (range, 3-25 months), we observed recurrence once, 21 days after discharge. Two patients died in the late postoperative period (Day 43 and Day 100 after discharge) of fulminant urosepsis and carcinoma-related multiorgan failure, respectively. Analysis of the follow-up interviews in the outpatient clinic showed a good quality of life and a subjectively good long-term aesthetic result.
  
  
  CONCLUSIONS
  Mini-VAC-Instill therapy is an upgrade of Mini-VAC, which guarantees the advantage of an open treatment, including flushing but without OWT. This procedure is minimally invasive, highly compatible especially with patients in poor general condition and may be an alternative to the OWT in selected patients. Consequently, a very short course of therapy results in good patient acceptance.
authors.affiliation: Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany zsolt.sziklavari@barmherzige-regensburg.de.
authors.forename: Zsolt
authors.initials: Z
authors.lastname: Sziklavari
authors.affiliation: Department of Thoracic Surgery, University Regensburg, Regensburg, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Ried
authors.affiliation: Department of Thoracic Surgery, University Regensburg, Regensburg, Germany.
authors.forename: Reiner
authors.initials: R
authors.lastname: Neu
authors.affiliation: Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany.
authors.forename: Rudolf
authors.initials: R
authors.lastname: Schemm
authors.affiliation: Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Grosser
authors.affiliation: Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany.
authors.forename: Tamas
authors.initials: T
authors.lastname: Szöke
authors.affiliation: Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany Department of Thoracic Surgery, University Regensburg, Regensburg, Germany.
authors.forename: Hans-Stefan
authors.initials: HS
authors.lastname: Hofmann
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D003131:Combined Modality Therapy; D003646:Debridement / Q000379:methods; D016724:Empyema, Pleural / Q000188:drug therapy / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D054843:Negative-Pressure Wound Therapy / Q000379:methods*; D011446:Prospective Studies; D018805:Sepsis / Q000188:drug therapy / Q000601:surgery*; D013908:Thoracotomy / Q000379:methods; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents
keywords: Empyema; Instillation; Minimally invasive; Negative pressure wound therapy; Vacuum-assisted closure