In the period studied, 33 patients received VATS-D for TE /PPE (Table 1). Twenty-six cases (79%) was ACCP category 3 and 7cases were 4 (21%). Thirty cases (91%) were primary TE/PPEs and 3 (9%) were secondary. Among primary cases, chest computed tomography demonstrated pneumonia in 25 case and lung abscess in one case. They were considered to be the cause of TE/PPE. In rest 5 cases (15%), the cause was unknown. Three secondary cases followed lobectomy for lung cancer, percutaneous transhepatic gallbladder drainage for acute cholecystitis and traumatic hemopneumothorax.
Time from the onset or the diagnosis of TE/PPE to VATS-D was about two weeks (Table 2). Six mental disorder cases (5 schizophrenia and 1 severe depression) was included in this study (Table 1). Though, it is difficult to determine the onset of TE/PPE in these patients, the day complaint of fever, chest pain or dyspnea was noticed by the patient or a caregiver was set as the onset. Preoperative period in these cases tended to be longer than other cases mean 25 vs 14, median 30 vs 13 day, respectively.
The median Postoperative hospital stay was 14 days. Postoperative drainage duration was about a week. Major postoperative complication corresponding to Clavien-Dindo Classification gradeⅢ or higher occurred in 4 cases (Table 2). Postoperative acute respiratory failure requiring ventilator management in 3, cerebral infarction in one case. No death in hospital was observed within 30 days after surgery. Recurrence and progression to chronic empyema were seen in 3 cases and 1 case, respectively. The recurrent cases were treated by simple drainage and chronic empyema was treated by omentoplasty.
Bacterial culture from pleural effusion was positive in 12 cases (36%). Streptococcus in 7, anaerobic bacteria 3, staphylococcus, neisseria, prevotella in 1 case, respectively were identified. Fluoroquinolone resistance was observed in 2 cases of anaerobic bacteria, and CLDM resistance was observed in 1 case, but no problematic resistant bacteria were observed.
Preoperative and post-operative antibiotics choice are shown in Table 3. Carbapenem or tazobactam/piperacillin (TAZ/PIPC) was selected in more than 60% of cases as an initial agent. Of these cases, 8 had postoperative conversion into fluoroquinolone or cephalosporin. On the other hand, switching to carbapenem or TAZ/PIPC from another agent was performed in 5 cases. During the post-operated course, 3 cases had converted the antibiotics (from cephalosporin to fluoroquinolone or sulbactum/ampicilin). In four cases, oral administration of levofloxacin (LVFX) was added before discharge.
Postoperative inflammatory parameters required 7 days to return to the normal values (Table 4). Body temperature was measured at least 3 times per day. Laboratory examination was performed routinely on the day after surgery and added when deemed necessary. Mean 5, median 4 times of laboratory examination were performed post-operatively before discharge.
Table 1. Characteristics of the patients
|
|
n(%)
|
mean ± SD
|
median (range)
|
Epidemiological data
|
|
|
|
Gender
|
|
|
|
male
|
28(85)
|
|
|
female
|
5(15)
|
|
|
age (years)
|
|
62 ± 11
|
63 (28–88)
|
Comorbidity
|
21 (64)
|
|
|
diabetes
|
9 (27)
|
|
|
cardiovascular
|
7 (21)
|
|
|
cerebrovascular
|
3 (9)
|
|
|
mental disorder
|
6 (18)
|
|
|
cancer bearing
|
1 (3)
|
|
|
use of steroids
|
1 (3)
|
|
|
Ecog Performance Status
|
|
|
|
0–1
|
30 (91)
|
|
|
2
|
0
|
|
|
3
|
3 (9)
|
|
|
Laboratory examination
|
|
|
|
WBC (/µl)
|
|
16800 ± 9,300
|
13200 (4800-50,000)
|
seg (%)
|
|
83.1 ± 5.9
|
83.5 (70.4–94.4)
|
CRP (mg/dl)
|
|
20.4 ± 9.8
|
18.8 (3.4–42.4)
|
Table 2. Post operative course
|
|
n(%)
|
mean ± SD
|
median (range)
|
major complication
|
4 (12%)
|
|
|
respiratory failure
|
3 (9%)
|
|
|
cerebral infarction
|
1 (3%)
|
|
|
hospital stay (day)
|
|
16.3 ± 9.1
|
14 (7–51)
|
drainage duration (day)
|
|
7.4 ± 7.2
|
6 (2–43)
|
antibiotics duration (day)
|
|
7.2 ± 4.9
|
7 (1–18)
|
Failure of TE/PPE treatment
|
4 (12%)
|
|
|
recurrence
|
3 (9%)
|
|
|
progression to chronic empyema
|
1 (3%)
|
|
|
Table 3. Pre/Post -operative antibiotics
|
|
pre-operative
|
post-operative
|
|
n (%)
|
n (%)
|
Carbapenem
|
18 (55)
|
15 (45)
|
MEPN
|
15
|
12
|
IPM/CS
|
1
|
1
|
DRPM
|
2
|
2
|
Penicillin
|
12 (36)
|
6 (18)
|
TAZ/PIPC
|
3
|
3
|
SBT/ABPC
|
9
|
3
|
Fluoloquinolon
|
2 (6)
|
9 (27)
|
PZFS
|
2
|
3
|
CPFX
|
-
|
2
|
LVFX p.o.
|
-
|
4
|
Cepharosporin
|
1 (3)
|
10 (30)
|
CFPM
|
1
|
1
|
CMZ
|
-
|
2
|
CEZ
|
-
|
5
|
CTRX
|
-
|
2
|
Lincomycin
|
7 (21)
|
3 (9)
|
CLDM
|
7
|
3
|
MEPN meropenem, IPM/CS imipenem/cilastatin, DRPM doripenem,
TAZ/PIPC tazobactam/piperacilin, SBT/ABPC sulbactam/ampicillin,
PZFS pazofloxacin, CPFX ciprofloxacin, LVFX p.o. Levofloxacin per os
CFPM cefepime, CMZ cefmetazole, CEZ cefazolin, CTRX ceftoriaxone
CLDM clindamycin
|
Table 4. Post-operative inflammatory parameters
|
mean ± SD
|
median (range)
|
Body temperature
|
|
|
<37.5ºC
|
4.5 ± 4.4
|
3 (0–18)
|
<37.0ºC
|
7.4 ± 7.5
|
6 (0–18)
|
White blood Cell
|
|
|
<10,000/µl
|
6.1 ± 5.5
|
4 (1–22)
|
seg < 80%
|
7.1 ± 3.9
|
7 (0–17)
|