Overview
Definition:
Thoracic empyema decortication is a surgical procedure involving the removal of a thickened, inelastic peel (necrotic tissue, fibrin, and fibrous membrane) from the visceral and parietal pleura
This peel encases the lung, restricting its expansion, and is typically a consequence of chronic or inadequately treated pleural infection (empyema)
Open decortication usually refers to a thoracotomy approach, providing direct access to the pleural space.
Epidemiology:
Empyema incidence varies globally, often linked to pneumonia, thoracic surgery, trauma, and aspiration
Community-acquired empyema is more common than hospital-acquired
Risk factors include advanced age, immunosuppression, diabetes, and alcoholism
The incidence of chronic, fibrotic empyema requiring decortication is lower but significant.
Clinical Significance:
Untreated or chronic empyema can lead to significant morbidity and mortality due to persistent infection, lung parenchymal destruction, and respiratory compromise
Decortication is crucial for lung re-expansion, resolution of infection, pain relief, and restoration of pulmonary function
It is a vital procedure for surgical residents to understand for managing complex pleural diseases.
Indications
Indications For Decortication:
Failure of initial drainage (tube thoracostomy) to resolve empyema
Formation of a thick, inelastic peel encasing the lung, visualized on imaging (CT scan)
Persistent fever and sepsis despite antibiotic therapy and drainage
Loculated effusions that cannot be adequately drained by closed methods
Trapped lung syndrome secondary to chronic empyema.
Timing Of Surgery:
Ideal timing is usually after the acute inflammatory phase has subsided but before extensive fibrosis makes the peel intractable
Typically, this is between 1 to 4 weeks after the onset of empyema, but may be delayed in chronic cases
Early decortication can be performed in select cases if initial drainage fails.
Contraindications:
Absolute contraindications are rare but include severe comorbid conditions precluding major surgery or anesthesia
Relative contraindications include unreconstructable lung parenchymal disease, uncontrolled sepsis, or severe coagulopathy
Patient optimization is key.
Diagnostic Approach
History And Physical Exam:
Key history points include onset and duration of symptoms, preceding pneumonia or surgery, sputum production, pleuritic chest pain, and fever
Physical examination may reveal tachypnea, decreased breath sounds, dullness to percussion, and egophony over the affected area.
Imaging Modalities:
Chest X-ray (initial diagnosis of pleural effusion)
Ultrasound (assessing for complexity and guiding aspiration/drainage)
CT scan of the thorax (essential for delineating the empyema, assessing peel thickness, loculations, and lung involvement, guiding surgical approach)
MRI may be useful for soft tissue evaluation.
Laboratory Investigations:
Complete Blood Count (leukocytosis, anemia of chronic disease)
Inflammatory markers (CRP, ESR)
Sputum microscopy, culture, and sensitivity (identifying organism)
Pleural fluid analysis (pH, glucose, protein, LDH, cell count, Gram stain, culture, cytology)
Blood cultures if sepsis is suspected.
Differential Diagnosis:
Complicated parapneumonic effusion
Malignant pleural effusion
Hemothorax
Chylothorax
Benign pleural tumors
Organization of pulmonary infarct.
Surgical Procedure
Preoperative Preparation:
Optimization of nutritional status, correction of anemia, control of comorbidities (diabetes, cardiac issues), adequate antibiotic coverage, and ensuring adequate pulmonary function
Bronchodilators and respiratory physiotherapy may be initiated
Preoperative bronchoscopy can be considered if suspicion of endobronchial obstruction.
Anesthesia And Positioning:
General anesthesia with double-lumen endotracheal tube for single-lung ventilation is typically used
The patient is positioned in a lateral decubitus position on the contralateral side, allowing optimal access to the hemithorax.
Thoracotomy Approach:
A posterolateral thoracotomy incision is most common, providing excellent exposure of the entire hemithorax
Rib-spreading retractors are used to open the intercostal space
The parietal pleura is carefully dissected to expose the pleural cavity.
Decortication Technique:
The peel is meticulously dissected from the visceral and parietal pleura, often starting from the hilum and working peripherally
Careful attention is paid to avoid injury to the lung parenchyma and major vessels
Hemostasis is paramount
Once the peel is removed, the lung should expand spontaneously or with positive pressure ventilation
Chest tubes are inserted for drainage and re-expansion.
Postoperative Care
Pain Management:
Aggressive pain control is crucial for early mobilization and pulmonary physiotherapy
Epidural analgesia, patient-controlled analgesia (PCA) with opioids, and non-opioid analgesics are utilized
Intercostal nerve blocks may also be considered.
Chest Tube Management:
Chest tubes are typically connected to an underwater seal drainage system, with or without suction
Monitoring of drainage volume, character, and air leaks is essential
Chest tubes are usually removed when drainage is minimal and lung expansion is satisfactory, as confirmed by imaging.
Respiratory Physiotherapy:
Early ambulation, deep breathing exercises, incentive spirometry, and chest physiotherapy are vital to prevent atelectasis, pneumonia, and promote full lung expansion
Mobilization of the patient should commence as soon as pain is controlled.
Monitoring:
Close monitoring of vital signs, respiratory status, fluid balance, and signs of infection
Serial chest X-rays to assess lung re-expansion and pleural space
Monitoring for complications such as bronchopleural fistula, recurrent empyema, or bleeding.
Complications
Early Complications:
Hemorrhage (from pleural adhesions or lung parenchyma injury)
Persistent air leak
Bronchopleural fistula (BPF)
Recurrent empyema
Pneumonia
Atelectasis
Injury to surrounding structures (phrenic nerve, intercostal vessels)
Hemodynamic instability.
Late Complications:
Chronic pain syndrome
Restrictive lung disease
Situs inversus or abnormal lung anatomy due to scarring
Re-accumulation of pleural fluid
Persistent cough
Empyema necessitatis.
Prevention And Management:
Meticulous surgical technique to minimize bleeding and air leaks
Adequate chest tube drainage
Prompt recognition and management of BPF (e.g., bronchoscopy with plugging, re-exploration)
Aggressive physiotherapy to prevent atelectasis and pneumonia
Early antibiotic therapy for suspected recurrent infection.
Prognosis
Factors Influencing Outcome:
The extent of lung parenchymal damage, patient's overall health status, adequacy of surgical resection, and promptness of treatment initiation significantly impact prognosis
Early and complete decortication generally leads to better outcomes.
Expected Outcomes:
Successful decortication usually results in complete resolution of infection, lung re-expansion, relief of symptoms, and improvement in pulmonary function
Most patients experience a significant return to normal activity levels over several months.
Follow Up:
Regular clinical follow-up is recommended, typically including chest X-rays, to monitor for recurrence of effusion, lung expansion, and overall recovery
Pulmonary function tests may be performed to assess functional improvement
Long-term follow-up may be required for patients with significant lung damage or chronic sequelae.
Key Points
Exam Focus:
Understand the stages of empyema (acute, organizing, chronic/fibrotic)
Recognize imaging findings suggestive of peel formation
Know the indications for decortication versus less invasive procedures
Master the surgical steps and potential complications of open decortication.
Clinical Pearls:
The "gold standard" for diagnosis of a peel dictating need for decortication is CT scan
Distinguish between simple pleural effusions and empyema requiring drainage
Meticulous dissection is key to avoiding pleural injury and parenchyma damage during decortication
Lung entrappment is the primary indication for this procedure.
Common Mistakes:
Inadequate drainage of empyema, leading to chronicity
Delaying surgical intervention until extensive fibrosis makes decortication difficult or impossible
Incomplete peel removal
Aggressive dissection leading to lung parenchymal injury or air leaks
Insufficient postoperative pain management or physiotherapy.