THORACOSCOPY FOR EMPYEMA, BRONCHOPLEURAL FISTULA, AND CHYLOTHORAX

The management of complications affecting the pleural space is sometim es technically demanding, but has been enhanced by the recent introduc tion of thoracoscopic techniques. An empyema in the fibrinopurulent ph ase is best managed by disruption of the loculations and complete drai nage of the infected space. This is easily accomplished with the use o f thoracoscopy, which also permits inspection of the pleural space to determine whether additional surgical intervention is required. In con trast, thoracoscopy is not indicated in the management of a free-flowi ng empyema or a chronic empyema associated with a fibrous capsule. Bro nchopleural fistulas are occasionally treated by thoracostomy tube dra inage alone, but, in most situations, surgical intervention is necessa ry to permit reclosure of the bronchus, coverage of the stump with vas cularized tissue, and decortication or tissue flap rotation to fill th e pleural space. These maneuvers are beyond the capabilities of curren t thoracoscopic techniques. Chylothorax is best treated initially by i ntercostal tube drainage and supportive measures. When surgical interv ention is necessary to directly close a lymph vessel leak, thoracoscop ic techniques have been successful in effecting closure, according to anecdotal reports.