The Atrium: Pleural Sepsis

After a 33-year humbling experience treating empyema thoracis at a county hospital, I thought I had witnessed almost all there was to see about empyema diagnosis & treatment. Ours was one of the first randomized trials of VATS vs. fibrinolytic therapy, published in 1997 [Wait MA, Sharma S, Hohn J, Dal-Nogare A. A randomized trial of empyema therapy. Chest 1997;111(6):1548-1551.] and set the stage for empyema management until the MIST trials started. MIST-1 showed no benefit of SK added to simple chest tube in 2005; MIST-2 treated "pleural infection" with remarkable success and a surprisingly low need for surgical referral, including in the drainage plus placebo group, in 2011. MIST-3 trial showed "equivalent" hospital LOS between VATS and fibrinolytic therapy, even though VATS wasn't undertaken for an average of 3 days from referral; QUALY was used as another primary endpoint, highlighting the inadequacies of MIST-3: acute care general thoracic surgery had apparently fallen out of favor, and QUALY became a substitute therapeutic endpoint, supplanting radiographic & functional endpoints of empyema cure. MIST-4 will evaluate single-port VATS debridement & drainage with decortication avoidance as a plausible therapy for empyema. Anyone well-versed with major decortications of fungal or TB empyema, chronically entrapped lung, failed robotic empyema surgery, or who ever had to resort to rib resection/empyema tube or Eloesser flap or any other thoracoplasty technique will rapidly realize that the outcome hinges on the selection bias and on how clinically relevant the endpoints which are being studied have been defined. My prediction is MIST-4 will demonstrate what we did in '97: the superiority of early VATS debridement/decortication/drainage...so long as the general thoracic surgeons embrace the urgency of acute care general thoracic surgery and treat empyema thoracis with the same sense of urgency that a general surgeon would an empyema of the gallbladder, a neurosurgeon a subdural empyema, or a urologist an empyema of the bladder. I hope MIST-4 will embrace some robust metrics of success, especially those focused on complete lung expansion without significant compromise of lung volume.