Early source control with non-intubated uniportal video-assisted thoracoscopic surgery for acute thoracic empyema: a retrospective pilot cohort study.

BACKGROUND: Acute thoracic empyema often develops in older and frail patients, in whom treatment selection can be challenging. This retrospective pilot cohort study evaluated the clinical outcomes of non-intubated uniportal video-assisted thoracoscopic surgery (NI-uVATS) as a potential early source-control strategy for selected patients with acute thoracic empyema. METHODS: We retrospectively reviewed 41 consecutive patients with acute thoracic empyema who underwent NI-uVATS between July 2019 and June 2025. NI-uVATS was performed as the initial procedure in 32 patients (initial group) and after prior chest drainage in 9 patients (post-drainage group). The procedure was performed through a 3-4 cm uniportal incision under local anesthesia with sedation and included thoracoscopic septal disruption, large-volume saline irrigation, and chest tube placement. Clinical characteristics, operative findings, postoperative outcomes, complications, and microbiological results were analyzed. RESULTS: The cohort consisted mainly of older patients, and poor performance status was present in 13/32 and 3/9 patients, respectively. The thoracoscopic procedure was completed through the uniportal approach in all patients; however, one patient required intraoperative conversion to general anesthesia with endotracheal intubation because of excessive sputum and oxygen desaturation. Operative time was significantly shorter in the initial group than in the post-drainage group [83 (interquartile range: 66.5-98.8) vs. 104 (100.0-111.0) min, P=0.02]. Postoperative drainage duration, total drainage duration, and postoperative hospital stay did not differ significantly between the groups. There were no in-hospital or 6-month deaths. In the initial group, two patients required additional surgery under general anesthesia, and one developed recurrent empyema 1 month after discharge. Pleural fluid cultures obtained on postoperative day 1 were negative in 29/32 patients (90.6%) in the initial group and 9/9 patients (100%) in the post-drainage group (P>0.99). CONCLUSIONS: NI-uVATS may be a feasible early source-control option for selected patients with acute thoracic empyema. However, because treatment escalation events occurred in some patients and this was a retrospective pilot cohort study, these findings should be interpreted as exploratory and require validation in larger comparative studies.