Decortication / Empyema Drainage
What the Examiner Expects
Surgical removal of the thick fibrous peel (cortex) encasing the lung in the setting of organized empyema (stage III), allowing the trapped lung to re-expand and fill the pleural space. The examiner expects you to stage empyema using the American Thoracic Society classification: Stage I (exudative — free-flowing parapneumonic effusion, treat with antibiotics and thoracentesis/tube thoracostomy), Stage II (fibrinopurulent — loculated fluid with fibrin strands, treat with VATS debridement or intrapleural fibrinolytics), Stage III (organized — dense fibrotic peel trapping the lung, requires decortication). VATS is the preferred approach when feasible; thoracotomy for dense, chronic peels.
Key Examiner Focus Points
- Indicated for organizing empyema (stage III) with trapped lung
- Removes the fibrous peel (cortex) from the visceral pleura to allow lung re-expansion
- Stage I (exudative): tube thoracostomy and antibiotics
- Stage II (fibrinopurulent): VATS with lysis of adhesions and debridement
- Stage III (organized): formal decortication via VATS or thoracotomy
Common Curveballs
Tube thoracostomy output suddenly stops but the effusion has not resolved on chest X-ray
Clogged or malpositioned tube, or the effusion has become loculated. Obtain CT chest to assess for loculations. Options: reposition or replace the tube, instill intrapleural fibrinolytics (TPA + DNase per MIST2 protocol), or proceed to VATS for debridement and lysis of loculations.
After decortication, the lung fails to fully expand
Assess for persistent air leak (bronchopleural fistula), residual cortex, or chronic lung disease preventing expansion. If the lung cannot fill the pleural space, a residual space will develop (risk of recurrent empyema). Options include muscle flap transposition (latissimus dorsi, serratus) or open window thoracostomy (Eloesser flap) for chronic drainage.
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