Overview
Definition:
Decortication for empyema is a surgical procedure to remove the thickened fibrous peel (necrotic debris and inflammatory exudate) from the visceral and parietal pleura, typically performed via Video-Assisted Thoracoscopic Surgery (VATS)
This is crucial for re-expansion of the lung and resolution of chronic empyema.
Epidemiology:
Empyema incidence varies globally, often associated with pneumonia, thoracic surgery, or trauma
The incidence of chronic empyema requiring decortication is lower but still significant, especially in developing countries
Risk factors include delayed treatment of pneumonia, immunocompromise, and poor nutritional status.
Clinical Significance:
Untreated or inadequately treated empyema can lead to significant morbidity and mortality
Decortication is vital for lung re-expansion, preventing lung entrapment, and resolving chronic infection, thereby improving respiratory function and quality of life for patients
It is a key procedure in thoracic surgical training for DNB and NEET SS examinations.
Indications
Indications For Surgery:
Failure of medical management or simple drainage
loculated empyema
chronic empyema with thick peel
persistent fever and sepsis despite antibiotics
lung entrapment by peel
significant hemoptysis associated with empyema.
Timing Of Surgery:
Early decortication (within the first few weeks of empyema onset) generally leads to better outcomes
However, VATS decortication can be performed even in chronic cases with appropriate patient selection and preparation.
Contraindications:
Severe underlying lung disease precluding adequate ventilation post-re-expansion
significant coagulopathy
active sepsis that cannot be controlled medically
widespread pleural tumor involvement
patient refusal or inability to tolerate anesthesia.
Diagnostic Approach
History Taking:
Detailed history of preceding pneumonia, duration of symptoms, fevers, chills, cough, dyspnea, chest pain
previous thoracic interventions
comorbidities
recent travel or exposures.
Physical Examination:
Assess vital signs (fever, tachypnea, tachycardia)
Examine chest for asymmetry, decreased breath sounds, dullness to percussion, egophony
Palpate for chest wall tenderness or subcutaneous emphysema.
Imaging Modalities:
Chest X-ray (PA and lateral) to show effusion, loculations, and pleural thickening
Ultrasound of the chest to guide aspiration and identify loculations
CT scan of the thorax is essential for delineating the extent of empyema, assessing the thickness and location of the peel, and evaluating underlying lung parenchyma
MRI may be used if malignancy is suspected.
Laboratory Investigations:
Complete Blood Count (CBC) for leukocytosis and anemia
Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) for inflammatory markers
Blood cultures to identify causative organism
Sputum Gram stain and culture
Pleural fluid analysis (cytology, microbiology, pH, glucose, LDH).
Surgical Management Vats Decortication
Preoperative Preparation:
Optimization of patient's nutritional status and cardiorespiratory reserve
Administration of appropriate antibiotics
Chest physiotherapy
Preoperative antibiotics covering common pathogens (e.g., cephalosporins, clindamycin).
Vats Procedure Steps:
General anesthesia with double-lumen endotracheal tube for single-lung ventilation
Insertion of 2-3 ports in the chest wall (camera port, instrument ports)
Insufflation of CO2 at low pressure may be used to improve visualization
Identification of the peel
Careful dissection of the peel from the visceral and parietal pleura using electrocautery, ultrasonic dissector, or harmonic scalpel
Lung mobilization and release
Lavage of the pleural space
Placement of one or two chest tubes for drainage and lung re-expansion
The goal is complete removal of the peel and complete lung expansion.
Instrumentation:
Thoracoscope, light source, video monitor, insufflator (optional), graspers, dissectors (e.g., ultrasonic dissector, harmonic scalpel), scissors, suction, chest tube insertion device.
Anesthesia Considerations:
Requires general anesthesia with ability for lung isolation (double-lumen tube or bronchial blocker) for optimal surgical field and lung deflation.
Postoperative Care
Chest Tube Management:
Chest tubes are typically connected to an underwater seal drainage system, with or without suction
Monitor for drainage amount, color, and air leak
Chest X-ray to assess lung expansion and tube position
Early mobilization is encouraged.
Pain Management:
Effective multimodal analgesia including patient-controlled analgesia (PCA), epidural analgesia, or intercostal nerve blocks
Oral analgesics as needed.
Antibiotic Therapy:
Continue intravenous antibiotics tailored to pleural fluid culture results for an appropriate duration (often 7-14 days or longer depending on clinical response).
Respiratory Support:
Encourage deep breathing exercises, incentive spirometry, and early ambulation to prevent atelectasis and pneumonia
Supplemental oxygen as needed
Weaning from mechanical ventilation if required.
Complications
Early Complications:
Persistent air leak
bleeding
intrathoracic infection
bronchopleural fistula
phrenic nerve injury
residual hemothorax or loculations
failure of lung re-expansion
cardiovascular instability.
Late Complications:
Chronic pain
pleural thickening
lung entrapment if decortication was incomplete
respiratory insufficiency
fungal empyema
empyema necessitans.
Prevention Strategies:
Meticulous surgical technique to minimize trauma
thorough lavage to remove debris
adequate chest tube drainage
prompt management of air leaks
early and effective pain control
aggressive chest physiotherapy and mobilization
judicious antibiotic use.
Prognosis
Factors Affecting Prognosis:
Stage of empyema at presentation (e.g., FEV stages)
causative organism
patient's immune status and comorbidities
completeness of decortication
promptness of surgical intervention
post-operative complications.
Outcomes:
Successful VATS decortication leads to significant improvement in symptoms, lung function, and quality of life
Complete resolution of infection is expected in most cases
Mortality rates are significantly lower for early intervention and VATS compared to open thoracotomy for empyema.
Follow Up:
Regular follow-up appointments with chest X-rays to monitor lung expansion and pleural space
Assessment of respiratory function
Rehabilitation may be necessary
Duration of follow-up depends on complexity and resolution.
Key Points
Exam Focus:
Key indications for VATS decortication versus simple drainage
steps of VATS decortication
common complications and their management
factors influencing prognosis in empyema
interpretation of CT findings in empyema.
Clinical Pearls:
Thickened peel in chronic empyema is often avascular and can be dissected from the lung parenchyma
Always ensure complete release of the peel for full lung re-expansion
Consider an intraoperative bronchoscopy if a bronchopleural fistula is suspected
Chest tube removal criteria: minimal drainage (<100-150 ml/24h), no air leak, and adequate lung expansion on X-ray.
Common Mistakes:
Delaying surgical intervention in the presence of sepsis or lung entrapment
Incomplete peel removal leading to persistent symptoms
Inadequate pain management contributing to poor respiratory effort
Overlooking underlying lung parenchymal disease during CT interpretation.