Computed tomography-guided thoracoscopic debridement for multiple loculated organizing empyema: a case report
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Video-assisted thoracoscopic surgery (VATS) for organizing empyema is challenging because fibrous septa and peel within the cavity are thickened and hardened. Some patients have multiple isolated empyema cavities that require debridement individually because firm intrathoracic adhesion was developed during this phase. If the debridement was incomplete as a result of worrying about an accidental injury of the surrounding organ, additional interventions may be required due to the persistent empyema cavity or insufficient expansion of the ipsilateral lung. We here describe a representative case with multiple loculated organizing empyema that could safely and reliably perform VATS debridement under C-arm cone-beam computed tomography (CBCT).
A 67-year-old woman was admitted to our department for the treatment of right empyema. Chest computed tomography showed fluid collection in three independent spaces within the right thoracic cavity. It was assumed that a firm adhesion between the lung and chest wall was developed because about 7 weeks passed since the onset. Therefore, we decided to use CBCT to completely debride three empyema cavities separately by VATS. One cavity was only in a narrow range with the chest wall, and it was located on the back of cost rib cartilage. By clicking any intended anatomical structures on CBCT images, the position was readily depicted by lase projection on the body surface, which helped to place the best skin incision. Moreover, in other cavities, CBCT after initial debridement showed insufficiently dissected cavity. Additional debridement resulted in a successful shrinkage of the empyema cavity.
We believe that VATS debridement under CBCT guidance is one of the useful treatment options for multiple loculated organizing empyema.
KeywordsMultiple loculated organizing empyema Debridement Video-assisted thoracoscopic surgery C-arm cone-beam computed tomography
C-arm cone-beam computed tomography
Multidetector computed tomography
Video-assisted thoracoscopic surgery
Over 50 years ago, the American Thoracic Society described three stages in the natural course of pleural empyema, namely the exudative, fibrinopurulent, and organizing phases . In the fibrinopurulent phase, the empyema cavity is multi-chambered with fibrous septa. The septa at this phase are soft and it becomes a good indication for surgical debridement by video-assisted thoracoscopic surgery (VATS) [2, 3]. However, VATS for organizing phase empyema is challenging because fibrous septa and peel within the cavity are thickened and hardened. It sometimes is difficult to confirm the accurate extent that should be dissected, which can result in incomplete debridement or injury of vital organs [4, 5]. We here describe a representative case with multiple loculated organizing empyema who underwent VATS debridement under C-arm cone-beam computed tomography (CBCT; Artis zeego; Siemens Health GmbH, Erlangen, Germany) in a hybrid operating room.
CBCT in the hybrid operating room is currently used in various fields, such as cardiology, neurosurgery, and vascular surgery. With regard to respiratory surgery, although some reports describe the usefulness in identifying the intrapulmonary small lesions , it remains controversial if CBCT is useful in surgical treatment of empyema. Decortication via open thoracotomy requires wide adehesiolysis in order to peel the fibrous capsule of each cavity via single thoracotomy incision, which can often result in lung injury, thereby development of bronchopleural fistulae. Therefore, for some patients who have multiple isolated empyema cavities by developing firm intrathoracic adhesion, it is better performing debridement and drainage, individually. For these cases, VATS is advantageous because it does not necessarily require adhesiolysis and wide skin incision. However, concern remains whether the debridement without intrathoracic adhesiolysis is adequate or not because of the possibility of residual or overlooked contaminated cavities. Although transthoracic echo may also be useful to identify the location of the empyema cavity, this modality is not helpful to know whether the debridement is adequately accomplished or not. If the debridement was incomplete as a result of worrying about an accidental injury of the surrounding organ, additional interventions may be required due to the persistent empyema cavity or insufficient expansion of the ipsilateral lung [4, 5]. In the present case, accurate and effective VATS debridement and drainage with small skin incision was accomplished by using CBCT.
With respect to the radiation exposure, Chao et al. reported based on their experience with preoperative or intraoperative localization of small intrapulmonary nodules. They reported that the amount of radiation exposure by intraoperative localization with CBCT was comparable to that by preoperative localization with MDCT . Because the amount of exposure by CBCT may depend on the times of C-arm rotation, we must attempt to restrict the times and extent of radiation exposure by CBCT.
The best treatment strategy for multiple loculated organizing empyema remains controversial. We believe that thoracoscopic debridement under CBCT guidance is one of the useful treatment options for multiple loculated organizing empyema.
MA is the first and KU is the corresponding author of this manuscript. MA, TU, SM, TT, and KU participated in the operation of this case. MA, TU, YT, GK, AHT, KM, TN, NY, and KK treated the patient after the operation. MS supervised the operation and the editing of the manuscript. MA and KU drafted the manuscript, and all authors read and approved the final manuscript.
None of the authors have anything to disclose.
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Written informed consent was obtained from the patient for publication of this case.
The authors declare that they have no competing interests.
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