Efficacy of medical thoracoscopy in thoracic empyema treatment

For a long time, Medical Thoracoscopy (MT) has played a marginal role in the management of pleural infection but in recent years his role has become more established. Pleural empyema defined as pus in the pleural cavity has been subdivided on the basis of ultrasonography and endoscopic appearance into 3 stages: free-flowing effusion (stage 1), multiloculated with a tendency toward loculations (stage 2) and chronic fibrous thickening involving also visceral pleural (stage 3). (Fig.1) Aim: The aim of this study was to evaluate efficacy and safety of medical thoracoscopy in patients with all stages of infectious pleural effusion Methods: We performed a retrospective study of patients referred for empyema and treated by medical thoracoscopy at Brescia and Sarzana pleural disease departments from December 2016 to December 2019. All patients underwent ultrasonography to localize and to stage pleural fluid collection and received MT with rigid thoracoscope to identify and break down fibrous pleural adhesions. Results: A total of 83 patients with empyema were treated by medical thoracoscopy; empyema was stage 1 in 6 patients ( 7,2%), stage 2 in 44 patients (53 %), and stage 3 in 33 patients ( 39,8%). MT was successful without further intervention in 79 patients (95,2%): all patients with stage 1 and 2 and 29 patients with stage 3 organizing effusion. Only 4 (12%) of the 33 patients with stage 3 required surgical intervention. Conclusion: pleural empyema, as stratified by ultrasonography, can safely and successfully be treated by MT in particular if performed in early stages of infection.