Successful two-port video-assisted thoracoscopic surgery for acute empyema in a high-risk patient with a high RAPID score: a case report

Introduction

The median 30-day mortality rate of empyema is approximately 4%, rising to around 20% in older adults aged >80 years (1). Acute empyema, a clinical manifestation of pleural infection, is typically classified into three stages: stage I (exudative stage), stage II (fibrinopurulent stage), and stage III (organizing stage) (2). Surgical intervention is considered when antibiotic therapy and pleural drainage prove ineffective, depending on the patient’s condition and imaging findings. The renal (urea), age, fluid purulence, infection source, dietary (albumin) (RAPID) score was developed to predict the prognosis of acute empyema (3). It is calculated based on age, urea level, albumin level, hospital-acquired infection, and the presence or absence of purulence, and it stratifies patients into low-, medium-, and high-risk groups. Recently, there have been efforts to use the RAPID score as a reference for determining surgical indications (4,5). Previous studies have reported that patients with low- or medium-risk RAPID scores are good candidates for surgical treatment of empyema. However, surgical indications for patients with high-risk RAPID scores remain controversial. Furthermore, the number of reported cases involving surgical intervention in high-risk patients is still limited. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-220/rc).

Case presentation

An 85-year-old man residing in a nursing home, with an Eastern Cooperative Oncology Group performance status of 3 (6), was admitted to a general hospital with a 6-day history of cough and fever. His medical history included type 2 diabetes, chronic kidney disease stage 3b (7), cerebral infarction, post-carotid artery stenting status, and post-coronary artery stenting status. He had been receiving aspirin (100 mg/day) as antiplatelet therapy. On admission, he required oxygen at 6 L/min and had a fever of 38.8 ℃. Blood tests revealed elevated inflammatory markers (C-reactive protein, 25.03 mg/dL; white blood cell count, 21,780/µL), malnutrition (albumin, 2.3 g/dL), and impaired renal function (serum creatinine, 1.41 mg/dL; blood urea nitrogen, 31 mg/dL). Computed tomography showed a capsulated fluid collection with multiloculation in the right thoracic cavity and consolidation in the right lower lobe of the lung. Acute empyema secondary to aspiration pneumonia was suspected, and ampicillin/sulbactam (3 g every 8 hours) was initiated. A thoracic drainage tube was placed; however, only a small amount of serosanguinous pleural effusion was drained. A second drainage tube was inserted, but drainage remained inadequate. On day 4 of admission, a chest X-ray showed no reduction in the fluid collection, and the patient continued to require oxygen at 4 L/min. The pleural fluid culture was negative. Because computed tomography revealed a multiloculated fluid collection and ineffective drainage, the condition was assessed as stage II empyema, requiring semi-elective surgery (Figure 1). Despite his advanced age, numerous comorbidities and high American Society of Anesthesiologists-physical status (classified as class IV) (8), the patient had no cognitive impairment and expressed a strong desire to undergo surgery to cure the empyema. Therefore, we decided to proceed with surgery. On day 5 of admission, two-port video-assisted thoracoscopic surgery (VATS) decortication was performed for empyema debridement (Figure 2). As part of perioperative management, aspirin was withheld and replaced with heparin. The first access port was placed at the right fifth intercostal space. Adhesions between the visceral and parietal pleura were initially dissected, followed by removal of fibrin clots forming multiloculated fluid collections. The second port was inserted at the right seventh intercostal space. Fibrous pleural tissue trapping the lung was carefully removed to improve lung re-expansion. After confirming sufficient lung re-expansion, two chest tubes were placed. The total operative time was 183 minutes, with an estimated blood loss of 1,740 mL (including pleural effusion). During the procedure, 560 mL of packed red blood cells and 240 mL of fresh frozen plasma were transfused. An additional 280 mL of packed red blood cells was administered later that day after surgery. Postoperatively, inflammatory markers improved markedly, and chest X-ray confirmed satisfactory re-expansion of the right lung (Figures 3,4). With ongoing rehabilitation, all chest tubes were removed by postoperative day 7, and aspirin was resumed. The patient was discharged on postoperative day 13 without complications. At 3 months postoperatively, chest X-ray showed good right lung expansion with no evidence of empyema recurrence (Figure 4).

Figure 1 Imaging findings on admission and the day before surgery. (A) Chest X-ray on admission showing reduced radiolucency throughout the entire right lung. (B) Chest X-ray on the day before surgery showing two chest drains placed in the right thoracic cavity. (C) Axial chest computed tomography scan at the level of the carina on the day before surgery, showing a capsulated fluid collection in the posterior right thoracic cavity. (D) Axial chest computed tomography scan at the lung base level on the day before surgery, showing a multiloculated fluid collection in the right thoracic cavity.

Figure 2 Port placement and intraoperative images. (A) Port placement. The first access port was created with a 35 mm incision at the right fifth intercostal space. The second port (13 mm in diameter) was inserted at the right seventh intercostal space. (B) Intraoperative image during VATS showing removal of multiloculated fluid (indicated by a star) in the right thoracic cavity using grasping forceps. The right lung is indicated by triangles. (C) Intraoperative image during VATS showing fibrous pleural tissue (triangles) attached to the right lung (star), being removed with grasping forceps. VATS, video-assisted thoracoscopic surgery.

Figure 3 Clinical course after admission. The clinical course following admission is illustrated, with the number of days from symptom onset shown along the x-axis and corresponding in-hospital events annotated below. The WBC count and C-reactive protein level are represented by crosses connected with a dotted line and dots connected with a solid line, respectively. The patient was admitted on the sixth day after symptom onset, and thoracic drainage was initiated. Surgery was performed on day 10, and chest tubes were removed on day 17. As shown at the top of the figure, ampicillin/sulbactam (3 g every 6 hours) was administered throughout hospitalization. Heparin (5,000 U/day) was used from days 11 to 16 as a substitute for aspirin (100 mg/day). The patient was discharged on day 23 (postoperative day 13). CRP, C-reactive protein; WBC, white blood cell.

Figure 4 Postoperative chest X-ray images. (A) Chest X-ray on postoperative day 1. Two chest drains were placed at the apex and base of the right lung. (B) Chest X-ray at 3 months postoperatively.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Discussion

In this case, early initiation of rehabilitation and the absence of postoperative complications were achieved through VATS, which is less invasive than thoracotomy. The indication for surgical intervention in acute empyema is generally determined based on imaging findings and the patient’s overall condition. In stage II acute empyema, where multiloculation is present, thoracic drainage is often insufficient, and surgical intervention is typically required. VATS is preferred over thoracotomy because of its lower risk of bleeding and comparable outcomes (9,10). It is also recommended by the British Thoracic Society Guideline for Pleural Disease (11). If necessary, VATS can be converted to thoracotomy intraoperatively.

The patient’s RAPID score was 6 [renal (urea) 2, age 2, fluid purulence 1, infection source 0, dietary (albumin) 1], placing him in the high-risk group. Given the reported 90-day mortality rate of approximately 22–30% for this group (5,12), the prognosis was considered poor. Recently, there have been efforts to use the RAPID score as a reference for surgical decision-making. One study suggests that early surgical intervention in patients with low RAPID scores may contribute to shorter hospital stays and lower rates of organ failure (4). However, the surgical indication for patients with high-risk RAPID scores remains inconclusive (5). In addition, the present case should not be interpreted as evidence supporting routine surgical intervention in frail, high-risk empyema patients. Despite the high-risk classification, VATS was selected for this patient based on the following considerations: stable vital signs, no signs of sepsis progression, and the presence of stage II empyema, for which VATS is considered optimal treatment (5). Additionally, the patient had no cognitive impairment and expressed a strong desire to undergo surgery. He also actively participated in postoperative rehabilitation to support recovery.

In some cases of acute multiloculated empyema, intrapleural fibrinolytic therapy may be used to promote drainage by degrading fibrin. This may involve co-administration of tissue plasminogen activator and deoxyribonuclease, or intrapleural urokinase alone. The combination therapy has been reported to reduce the need for surgical intervention (13) and is recommended in the British Thoracic Society guideline (11), depending on the patient’s condition. Considering the previous studies (14,15), fibrinolytic therapy should have been indicated in the present case because of high American Society of Anesthesiologists physical status. Although this patient had been under antiplatelet therapy, fibrinolytic therapy would have been performed safely without increased rates of pleural bleeding because he had not undergone anticoagulation (16). In the current case, surgery was prioritized according to the patient’s wishes.

During the perioperative period, aspirin was withheld and replaced with heparin to reduce the risk of prolonged postoperative bleeding. However, a recent study suggests that perioperative aspirin use does not negatively affect outcomes in VATS (17). Furthermore, some reports support the continuation of aspirin during the perioperative period in older adults with a history of cardiovascular disease, given its antithrombotic benefits (18,19). Therefore, continued aspirin administration might have been a viable option in this case.

Conclusions

We achieved a favorable outcome by performing VATS for acute empyema in an older adult with multiple comorbidities, a poor performance status, ongoing antiplatelet therapy, and a high RAPID score. Further evidence is needed to clarify the appropriateness of surgical intervention in high-risk patients with elevated RAPID scores.

Acknowledgments

We thank Angela Morben, DVM, ELS, from Edanz (https://jp.edanz.com/ac), for editing a draft of this manuscript.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-220/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-220/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-220/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Cargill TN, Hassan M, Corcoran JP, et al. A systematic review of comorbidities and outcomes of adult patients with pleural infection. Eur Respir J 2019;54:1900541. [Crossref] [PubMed]
2. Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc 2006;3:75-80. [Crossref] [PubMed]
3. Rahman NM, Kahan BC, Miller RF, et al. A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural infection. Chest 2014;145:848-55. [Crossref] [PubMed]
4. Liou AA, Anderson B, Whitehurst C, et al. The role of the RAPID score in surgical planning for empyema. J Thorac Dis 2023;15:985-93. [Crossref] [PubMed]
5. Simon L, Belaroussi Y, Vayssette A, et al. Role of RAPID score and surgery in the management of pleural infection: a single center retrospective study. J Thorac Dis 2023;15:5340-8. [Crossref] [PubMed]
6. Eastern Cooperative Oncology Group. ECOG performance status. 2025. Available online: http://ecog-acrin.org/resources/ecog-performance-status
7. Chen TK, Knicely DH, Grams ME. Chronic Kidney Disease Diagnosis and Management: A Review. JAMA 2019;322:1294-304. [Crossref] [PubMed]
8. Hurwitz EE, Simon M, Vinta SR, et al. Adding Examples to the ASA-Physical Status Classification Improves Correct Assignment to Patients. Anesthesiology 2017;126:614-22. [Crossref] [PubMed]
9. Ricciardi S, Giovanniello D, Carleo F, et al. Which Surgery for Stage II-III Empyema Patients? Observational Single-Center Cohort Study of 719 Consecutive Patients. J Clin Med 2022;12:136. [Crossref] [PubMed]
10. Towe CW, Carr SR, Donahue JM, et al. Morbidity and 30-day mortality after decortication for parapneumonic empyema and pleural effusion among patients in the Society of Thoracic Surgeons' General Thoracic Surgery Database. J Thorac Cardiovasc Surg 2019;157:1288-1297.e4. [Crossref] [PubMed]
11. Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society Guideline for pleural disease. Thorax 2023;78:s1-s42. [Crossref] [PubMed]
12. Corcoran JP, Psallidas I, Gerry S, et al. Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: the PILOT study. Eur Respir J 2020;56:2000130. [Crossref] [PubMed]
13. Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med 2011;365:518-26. [Crossref] [PubMed]
14. Taniguchi J, Matsui H, Nagai T, et al. Association between intrapleural urokinase monotherapy and treatment failure in patients with pleural infection: a retrospective cohort study. BMC Pulm Med 2023;23:273. [Crossref] [PubMed]
15. Alemán C, Porcel JM, Alegre J, et al. Intrapleural Fibrinolysis with Urokinase Versus Alteplase in Complicated Parapneumonic Pleural Effusions and Empyemas: A Prospective Randomized Study. Lung 2015;193:993-1000. [Crossref] [PubMed]
16. Akulian J, Bedawi EO, Abbas H, et al. Bleeding Risk With Combination Intrapleural Fibrinolytic and Enzyme Therapy in Pleural Infection: An International, Multicenter, Retrospective Cohort Study. Chest 2022;162:1384-92. [Crossref] [PubMed]
17. Yu WS, Jung HS, Lee JG, et al. Safety of thoracoscopic surgery for lung cancer without interruption of anti-platelet agents. J Thorac Dis 2015;7:2024-32. [Crossref] [PubMed]
18. Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014;370:1494-503. [Crossref] [PubMed]
19. Graham MM, Sessler DI, Parlow JL, et al. Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery. Ann Intern Med 2018;168:237-44. [Crossref] [PubMed]