A robotic approach to purulent pericarditis: a case report

Introduction

Purulent pericarditis is a relatively rare condition typically seen in children and immunocompromised patients. It carries a significant mortality risk which approaches 100% if left untreated (1,2). Common pathogens include Streptococcus, Staphylococcus, Haemophilus, and Mycobacterium species (2). Treatment depends on chronicity and extent of infection, condition of the patient, and presence of loculated areas of purulence. Antibiotics, drainage procedures including pericardiocentesis with or without drain placement, fibrinolytic irrigation, and surgical pericardial window with debridement are the mainstays of treatment (3). The use of the current robotic platform for pulmonary and mediastinal surgery is well-reported although the specific use of a robotic approach for pericardiectomy has only been reported in small case series typically for constrictive pericarditis (4-7). Minimally invasive approaches including a well-established video-assisted thoracoscopic technique for pericardiectomy have allowed for the avoidance of median sternotomy or thoracotomy. In the few reported cases, robotic pericardiectomy has been reported to be well-tolerated with minimal complications. To date no reports of robotic-assisted pericardial drainage and debridement for purulent pericarditis have been described. We present a rare case of a robotic-assisted treatment for purulent pericarditis. We present this case in accordance with the CARE reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-23-74/rc).

Case presentation

A 35-year-old male with no significant past medical history presented to an outside hospital emergency department (ED) with chest pain radiating to his back and right shoulder, nausea and vomiting as well as fevers, night sweats, weight loss over the previous 3 weeks. The symptoms began about 1 week after a lumbar spine steroid injection. Laboratory workup was significant for a leukocytosis of 13,000/µL [normal range, 4,500–11,000 leukocytes/µL, C-reactive protein of 89 mg/L (normal range, <10 mg/L), and an erythrocyte sedimentation rate of 125 mm/h (normal range, 0–15 mm/h]. Computed tomography (CT) of the chest demonstrated hilar and mediastinal lymphadenopathy. Based on these results there was concern for lymphoma and he was referred to medical oncology as an outpatient. Before any additional workup could be completed, patient presented again to the ED for worsening of his pain and shortness of breath. CT scan at that time revealed a large pericardial effusion with signs of tamponade and multifocal pneumonia (Figure 1). He was started on piperacillin-tazobactam and resuscitated. Of note, blood cultures were negative throughout his course. He underwent a pericardiocentesis with drain placement. Output was noted to be high, opaque in color, and on culture was positive for Streptococcus constellatus (S. constellatus). A transesophageal echocardiogram demonstrated preserved left ventricular function with a small mobile mitral valve echodensity concerning for endocarditis. He was transitioned to penicillin G. An endobronchial ultrasound biopsy of his mediastinal lymphadenopathy was negative for malignancy. Due to the persistent high output from the pericardial drain, he was transferred to our institution for management. Thoracic surgery was consulted to evaluate the patient for a pericardial window and surgical debridement of pericardial loculations. Over the course of treatment, the patient underwent staged bilateral robotic pericardial windows with debridement of the pericardial space (Video 1). 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 Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report, accompanying images, and video were not obtained from the patient or the relatives after all possible attempts were made.

Figure 1 Radiographic studies from the day of presentation. Chest X-ray (image left) suggestive of cardiomegaly and computed tomography of the chest with IV contrast (image right) demonstrating a large circumferential pericardial effusion. IV, intravenous.

Operative technique

The patient was taken to the operating room (OR), intubated with a double-lumen endotracheal tube without difficulty, and positioned in right lateral decubitus. He was prepped and draped in sterile fashion. The eighth intercostal space near the mid axillary line was entered with an 8 mm optical robotic port. Upon entering, the lung was noted to be adhered to the pericardium. Three additional robotic ports were inserted in a standard lobectomy formation based on the 9^th interspace.

The lung was completely mobilized off the pericardium and diaphragm. A spot posterior and inferior to the phrenic nerve anterior to the hilum of the lung was chosen for the pericardial window. The pericardium was incised, and purulent fluid was immediately noted. A sample of the fluid was sent for cytology and culture. The pericardium was then widely opened to achieve adequate drainage. A fibro-purulent exudate was noted over the epicardium of the heart. The pericardial sac was then irrigated with warm normal saline and a complete left-sided decortication of the visible epicardium of the heart was accomplished. Hemostasis was achieved and a 24-French Blake drain was placed along the diaphragm up the posterior of the chest wall up to the tip of the apex. The patient was extubated without complication. The patient did well in the post-operative period and was discharged home. He returned one month later with a similar presentation, likely related to residual loculations in the right pericardial space which were not able to be fully accessed from the left hemithorax during the index operation. An identical robotic procedure was conducted on the right side with complete resolution of the infection.

Discussion

This report describes the successful use of the current robotic platform for treatment of purulent pericarditis caused by S. constellatus. While S. constellatus is a common microorganism within the normal flora of the body, it is a rare cause of purulent pericarditis especially in the immunocompetent (8). This presentation appears to be random and the origin is unknown. Due to the chronic and complicated nature of this presentation the patient required bilateral robotic pericardial resections and drainage. The benefits of the robotic approach allowed for the fine dissection and debridement of severely inflamed and chronically infected tissue surrounding vital structures, including the heart. The patient, due in part to the minimally invasive nature of the operation, had an uneventful recovery. While data is limited in the value of the robotic-assisted thoracoscopic surgery (RATS), mostly retrospective single-center experiences, we believe that RATS allowed for a safer and more effective surgical approach in this case (9). RATS potentially allows for shorter operative times, less blood loss, and shorter hospital length of stay (9,10). The use of the robotic platform is not without controversy especially in the setting of an effective approach such as video-assisted thoracoscopic surgery. RATS does increase the cost of the operation, potentially longer operative times depending on the training of the operative team, and requires additional training for the surgeon which may limit the wide adoption of this technique. This report is limited in nature by the fact that this is a single patient treated in this manner. As surgeons become more comfortable and experienced with robotic approaches, we may see significant benefits compared to traditional minimally invasive techniques.

Conclusions

Our case highlights the value of the robotic-assisted thoracoscopic surgery for the treatment of complicated purulent pericarditis. RATS is an emerging surgical approach that has the potential to benefit complex patients with complex conditions.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-23-74/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-23-74/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-23-74/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 Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report, accompanying images, and video were 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/.

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