Video-Assisted Thoracoscopic Surgery for Empyema Secondary to Upper Gastrointestinal Leakage After Surgical or Endoscopic Intervention: A Multicenter Comparative Study.

INTRODUCTION: Empyema secondary to upper gastrointestinal (GI) leakage after surgical or endoscopic intervention is a rare but severe complication for which the role of video-assisted thoracoscopic surgery (VATS) remains unclear. This study evaluated the short-term safety and procedural feasibility of VATS, using the outcomes of VATS for parapneumonic empyema as a clinical benchmark. METHODS: We retrospectively reviewed patients undergoing surgery for empyema at two affiliated institutions (2015-2026). Patients with empyema secondary to upper GI leakage after surgical or endoscopic intervention were compared with those with acute Stage II-III parapneumonic empyema. The primary endpoint was 30-day mortality. Perioperative outcomes, including VATS completion, re-operation, postoperative hospital stay, and microbiological findings, were also compared. RESULTS: Of 257 empyema surgical records, 142 patients were analyzed (GI leakage group, n = 11; parapneumonic group, n = 131). The recorded interval from symptom onset to VATS was shorter in the GI leakage group (median 3 vs. 18 days, p < 0.001), and the incidence of multiloculated empyema on preoperative CT was lower (9.1% vs. 48.9%, p = 0.012). Re-operation was more frequent in the GI leakage group (36.4% vs. 5.3%, p = 0.005), and postoperative hospital stay was longer (median 34 vs. 16 days, p = 0.003). No 30-day deaths occurred in the GI leakage group, compared with 6 deaths (4.6%) in the parapneumonic group (p = 1.000). CONCLUSION: Empyema secondary to upper GI leakage after surgical or endoscopic intervention followed a refractory clinical course despite intervention before advanced pleural organization. VATS may be a feasible component of multidisciplinary source-control management, although frequent re-intervention may be required.