Reply to Divisi et al.

I would like to thank Dr Divisi, Professor Roberto Crisci et al. from G. Mazzini Hospital in Teramo for the kind words and for the chance to stress some issues of videothoracoscopic treatment of pleural empyema [1]. First, a word of clarity in the classification of empyema [2].

Light has classified para pneumonic effusions according to radiological, physical and biochemical characteristics in seven classes, whereas a true empyema is only in class 6 (simple empyema) and 7 (complex empyema), class 5 being defined as complex complicated pleural effusion (and not complex complicated empyema as reported in the Divisi's letter). The American College of Chest Physicians (ACCP) has staged patients with pleural empyema according to the risk of a poor outcome into four categories (I–IV) and the American Thoracic Society (ATS) has staged empyema in three steps (I, exudative; II, fibrinopurulent; and III, chronic organization) according to the natural course of the disease: ATS stage III, ACCP category IV, and Light class VII are equivalent, as well as ATS II, ACCP III, and Light IV–VI.

According to our experience and as presented in a recently published best-evidence topic, which evaluated 68 articles during the period March 1950–February 2010, the videothoracoscopic approach offers equivalent outcomes compared with open approach in terms of resolution of disease [3–5]. The most recent articles also highlighted superior outcome for video-assisted thoracoscopic surgery (VATS) in terms of hospital stay, postoperative pain, and postoperative complications.

The issue of the stage of empyema should never discourage surgeons from the thoracoscopic approach. The 5.9% overall conversion rate of our series becomes as high as 16.4% when referred to 67 patients in stage III empyema, which signifies advanced stage. Nevertheless, this value that takes into account the overall learning curve of our Institution becomes acceptable to avoid a policy of thoracotomy in all advanced stages. VATS should represent the beginning of every empyema procedure, no matter what the stage, with thoracotomy being the alternative when the minimally invasive approach fails. Furthermore, there is absolutely no greater risk of iatrogenic lung injury during VATS decortication than during thoracotomy. As regards the proposed use of carbon dioxide (CO₂) insufflation during thoracoscopy to facilitate decortications, we have no experience even if it can be interesting from a theoretical point of view. Low-flow CO₂ insufflation with an intrapleural pressure of 8–10mmHg should be safe even if some catastrophic complications have been reported.

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