Clinical history and surgical management of parapneumonic empyema what is the role of video-assisted thoracoscopic surgery (VATS)?

Pleural empyema represents a frequent disease, characterized sometimes by blurred and unspecific signs or symptoms but requiring timely diagnosis in order to plan the most appropriate therapeutic regimen. Several classifications have proposed and the most widely used is the American Thoracic Society (ATS) one, according to increasing severity depending of the extent of disease. Different therapeutic strategies such as conservative regimens (antibiotic therapy and chest tube placement) and surgical one (empyemectomy with pleural decortication) were applied. To this date, minimally invasive surgery is assuming an important role in the management of empyema and represents the gold standard in stage II disease and a valid alternative to the classical approach in stage III in absence of a complete obliteration of the pleural space. Aim of the work is to define, through a comprehensive review of literature, the role of video-assisted thoracoscopic surgery according to limits and advantages compared to conservative methods and the most invasive surgical approaches.