Decortication / Empyema Drainage

Empyema is purulent infection of the pleural space — typically a complication of pneumonia, but also of trauma, prior thoracic surgery, esophageal perforation, or hematogenous seeding. The American Thoracic Society classifies empyema in three stages: stage I (exudative, free-flowing thin fluid), stage II (fibrinopurulent, with loculations and fibrinous strands), and stage III (organized, with a thick fibrous peel encasing the lung and preventing re-expansion).

Stage I empyema is typically managed with antibiotics and chest tube drainage alone. Stage II often responds to chest tube with intrapleural fibrinolytics (tPA + DNase) or VATS debridement. Stage III — organized empyema with trapped lung — requires decortication: surgical removal of the fibrous peel that encases the lung and prevents re-expansion.

Decortication is indicated for organized empyema with trapped lung, persistent pleural collection despite adequate drainage, failure of fibrinolytic therapy, and post-pneumonic fibrothorax with impaired ventilation. Timing matters: early decortication (within 2–4 weeks of the initial infection) is technically easier and yields better functional results because the peel has not yet matured into dense scar.

Patient selection considers operative risk against the magnitude of the planned procedure. In frail patients with extensive empyema, alternatives include open thoracostomy (Eloesser flap) or chronic tube drainage as a less morbid option.

Workup includes chest CT (delineating the empyema, lung trapping, and any underlying parenchymal disease), pulmonary function testing to assess preoperative reserve, and culture-directed antibiotic therapy in advance of operation. Bronchoscopy may be added to evaluate for endobronchial pathology if the underlying cause is unclear.

Single-lung ventilation with a double-lumen endotracheal tube is required for the affected side to be operated on. Antibiotics are continued throughout the perioperative period and tailored to culture results.

Video-assisted thoracoscopic decortication is the first-line approach for empyema that is not yet densely organized. Three to four ports are placed; the empyema is entered, gross debris evacuated, loculations broken down, and the visceral and parietal peels carefully stripped from the underlying lung and chest wall. The lung is reinflated and inspected for adequate re-expansion. Two chest tubes are typically left, one apical and one basilar.

VATS is most successful in stage II and early stage III empyema. In late stage III with a dense, mature peel, VATS may not provide adequate exposure or the peel cannot be safely separated without parenchymal injury — conversion to thoracotomy is appropriate.

Open decortication is performed through a posterolateral thoracotomy, providing maximal exposure. The pleural space is entered and the peel is dissected from the surface of the lung — the technically demanding portion of the operation. The plane is between the visceral peel and the lung surface; staying superficial avoids parenchymal injury and air leak.

After the visceral peel is removed, the lung must re-expand fully. Persistent inability to re-expand indicates either inadequate removal of the peel, endobronchial obstruction, or parenchymal destruction. The parietal peel is removed where it interferes with chest wall mechanics. Two large-bore chest tubes (28–32 Fr) are placed.

Chest tubes remain in place until drainage is minimal (typically <150 mL/day of serosanguinous output) and there is no air leak. Aggressive pulmonary toilet, incentive spirometry, and early ambulation are critical. Pain control — typically with thoracic epidural or intercostal nerve blocks — is essential to permit deep breathing.

Postoperative air leak is the most common complication. Prolonged air leak (>5–7 days) may be managed with continued chest tube drainage with Heimlich valve at home, blood patch, or rarely re-exploration. Persistent fluid output may require radiology to assess for residual empyema requiring re-drainage.

Most patients achieve good lung re-expansion and resolution of infection after decortication. Functional improvement is most marked in patients operated on earlier in the disease course. Mortality is low in well-selected patients but rises with malnutrition, comorbidities, and delayed presentation.

Operative complications include parenchymal injury with air leak, bleeding, injury to mediastinal structures, and recurrent empyema. Postoperative complications include prolonged air leak, atelectasis, pneumonia, and chronic chest wall pain (post-thoracotomy syndrome).

On the boards, decortication questions tend to test the stages of empyema and the indications for surgery vs medical management, the choice between VATS and open approach, and the management of postoperative air leak.