The efficacy and safety of medical thoracoscopy compared with tube thoracostomy in the treatment of complicated parapneumonic effusion and empyema

To evaluate the efficacy and safety of medical thoracoscopy (MT) compared with tube thoracostomy (TT) for complicated parapneumonic effusion (CPPE) and empyema. We retrospectively analyzed 79 adults with stage 5 CPPE or empyema treated from May 2018 to January 2024. Patients were non-blindly assigned to an MT group (n = 25) or TT group (n = 54) according to attending physician discretion, imaging findings, clinical status, procedural suitability, and physician expertise. Baseline characteristics, pleural fluid biochemistry, clinical improvement, treatment failure, in-hospital mortality, total pre-intervention and post-intervention hospitalization, pleural fluid drainage volume, and postoperative complications were compared. Clinical improvement required symptom resolution plus radiographic reduction without further invasive intervention; treatment failure included persistent sepsis, additional intervention, or pleural-infection-related death. Median total hospitalization was 17 days (inerquartile range [IQR], 13–22) in the TT group and 20 days (IQR, 16–25) in the MT group, without a significant difference ( P  > .05). The MT group had more loculation/septation (92.0% vs 68.5%, P  = .023) and longer pre-intervention hospitalization (7 days, IQR 5–11 vs 2 days, IQR 1–3; P  < .05), suggesting more complex disease and delayed escalation. Post-intervention hospitalization was shorter after MT (10 days, IQR 6–17) than TT (15 days, IQR 11–20) ( P  < .05). Pleural fluid drainage volume was greater after MT (1210 mL, IQR 475–2300) than TT (600 mL, IQR 245–1212) ( P  < .05). Clinical improvement, treatment failure, adverse reactions, and mortality did not differ significantly between groups ( P  > .05). The overall adverse reaction rate was 16.0% after MT and 3.6% after TT ( P  = .076). MT appears feasible and safe for selected patients with CPPE and empyema. It was associated with greater pleural drainage and shorter post-intervention hospitalization than TT, despite use in patients with more complex disease. However, because this retrospective study involved non-blinded treatment allocation, selection bias, baseline imbalance, and a small sample, the findings are hypothesis-generating rather than definitive. MT did not show a statistically significant effect on in-hospital mortality. Prospective randomized studies are needed to define its optimal timing and role in pleural infection management.