Overview
Definition:
Decortication is a surgical procedure to remove a thick, inelastic peel or membrane (false membrane or peel) that has formed over the lung surface, typically as a consequence of chronic inflammation, infection, or trauma
This peel restricts lung expansion and can lead to respiratory compromise
Thoracotomy is the surgical approach used to access the pleural space and perform the decortication.
Epidemiology:
The incidence of conditions requiring decortication, such as chronic empyema and fibrothorax, is influenced by factors like the prevalence of pneumonia, tuberculosis, and surgical site infections
It is a relatively uncommon but significant complication of pleural diseases, affecting all age groups but particularly those with compromised immune systems or pre-existing lung conditions.
Clinical Significance:
Decortication is crucial for restoring lung function in patients with restrictive lung disease due to pleural encasement
Failure to address this can lead to chronic dyspnea, recurrent infections, pulmonary hypertension, and reduced quality of life
For surgical residents, understanding the indications, techniques, and complications is vital for managing complex thoracic pathologies.
Indications
For Decortication:
Chronic empyema that has failed to resolve with antibiotics and chest tube drainage
Fibrothorax where a thick peel restricts lung expansion
Trapped lung after pleurodesis or pneumonectomy
Organizer pneumonia
Malignant pleural effusions with significant pleural thickening and entrapment
Cases of loculated effusions resistant to simple aspiration.
For Thoracotomy Approach:
Thoracotomy provides direct visualization and adequate space for aggressive lysis of adhesions and removal of thick peel
It is often necessary for complete decortication, especially when the peel is dense or extensive
Minimally invasive approaches may be considered for less complex cases, but thoracotomy remains the gold standard for extensive decortication.
Contraindications:
Severe coagulopathy
Uncontrolled sepsis
Moribund patients with irreversible respiratory failure
Inability to tolerate a major surgical procedure due to comorbidities
Active pneumonia in the ipsilateral lung
Extensive pulmonary parenchymal disease that would preclude functional recovery.
Preoperative Preparation
History And Examination:
Thorough history focusing on duration of symptoms, previous infections, and prior thoracic interventions
Physical examination to assess respiratory status, evidence of effusion, and chest wall abnormalities.
Imaging:
Chest X-ray for initial assessment of pleural space
Contrast-enhanced CT scan of the thorax is essential to delineate the extent of the peel, assess lung involvement, identify loculations, and evaluate the mediastinal and hilar lymph nodes
Ultrasound may be used to guide diagnostic thoracentesis.
Pulmonary Function Tests:
PFTs are crucial to assess baseline lung function and predict postoperative recovery
Parameters like FEV1, FVC, and DLCO are important
Arterial blood gas analysis provides information on oxygenation and ventilation.
Optimization:
Antibiotic therapy for active infection
Nutritional support and physiotherapy to optimize respiratory muscle strength
Bronchodilators if underlying airway disease is present
Correction of coagulopathy and electrolyte imbalances
Smoking cessation counseling.
Procedure Steps
Anesthesia And Positioning:
General anesthesia with double-lumen endotracheal tube for single-lung ventilation
Lateral decubitus position with the affected side uppermost.
Thoracotomy Incision:
Posterolateral or anterolateral thoracotomy incision, typically in the 4th or 5th intercostal space, depending on the extent of disease.
Pleural Exploration:
Upon entering the pleural space, the extent and thickness of the peel are assessed
Any purulent material or organized debris is evacuated.
Decortication Technique:
The peel is meticulously dissected from the visceral pleura and lung surface
Dissection begins at the hilum and proceeds peripherally
Care is taken to avoid injury to the lung parenchyma, intercostal vessels, and nerves
Cavities or loculations are opened and debrided.
Lung Reinflation:
Once decortication is complete, the lung is fully inflated to ensure it expands adequately and that there are no air leaks
Chest drains (usually two) are inserted, one in the apical and one in the basal position, to drain air and fluid.
Chest Closure:
Intercostal muscles and subcutaneous tissues are approximated, and the skin is closed in layers
Intercostal drains are connected to an underwater seal drainage system.
Postoperative Care
Pain Management:
Aggressive pain control is essential using epidural analgesia, patient-controlled analgesia (PCA) with opioids, or intercostal nerve blocks
This facilitates deep breathing and early mobilization.
Respiratory Support:
Early mobilization, incentive spirometry, and chest physiotherapy are vital to prevent atelectasis and pneumonia
Humidified oxygen therapy as needed
Monitoring of oxygen saturation and arterial blood gases.
Drain Management:
Chest drains are monitored for drainage volume, character, and air leak
Drains are typically removed when drainage is minimal (<100-150 ml/24h) and there is no air leak.
Antibiotics:
Continue appropriate antibiotics if an infectious process was the cause of the empyema or if there is a concern for postoperative infection
Prophylactic antibiotics may be considered in select cases.
Mobilization:
Early ambulation is encouraged to promote lung expansion, venous return, and prevent deep vein thrombosis and pulmonary embolism.
Complications
Early Complications:
Bleeding requiring re-operation
Persistent air leak leading to prolonged drainage and potential need for re-operation
Respiratory failure and pneumonia
Bronchopleural fistula
Injury to phrenic nerve or recurrent laryngeal nerve.
Late Complications:
Chronic pain syndrome
Empyema recurrence
Residual pleural thickening and restrictive lung disease
Adhesions leading to reduced lung function
Scars and cosmetic deformities.
Prevention Strategies:
Meticulous surgical technique to minimize trauma and bleeding
Adequate chest drainage and early removal once appropriate
Aggressive pain management to facilitate deep breathing
Early mobilization and physiotherapy
Prompt recognition and management of postoperative complications
Judicious use of intraoperative antibiotics.
Prognosis
Factors Affecting Prognosis:
The underlying etiology (e.g., chronic empyema vs
malignancy)
The duration and severity of the pleural disease
The degree of lung entrapment and the extent of decortication
Preoperative pulmonary function
Patient's overall health and comorbidities
Presence of postoperative complications.
Outcomes:
Successful decortication can lead to significant improvement in lung function and resolution of dyspnea, especially in cases of chronic empyema or fibrothorax
Patients with underlying malignant disease have a poorer prognosis related to the cancer itself
Long-term survival depends on the underlying pathology and the success of the procedure in restoring lung mechanics.
Follow Up:
Regular follow-up with chest X-rays and pulmonary function tests is recommended
Patients should be monitored for signs of recurrence, infection, or persistent restrictive physiology
Education on breathing exercises and lifestyle modifications is important.
Key Points
Exam Focus:
Understand the definition and indications for decortication
Differentiate between uncomplicated pleural effusion and complicated empyema requiring decortication
Recognize the role of CT scan in preoperative assessment
Be familiar with the standard thoracotomy approach and the steps of decortication
Key complications include bleeding, air leak, and recurrent empyema.
Clinical Pearls:
The goal is to achieve a fully expanded lung with a functional pleural space
Meticulous dissection is key to avoid lung injury
Adequate chest tube placement and management are critical for success
Pain control is paramount for postoperative recovery
Early mobilization is a cornerstone of care.
Common Mistakes:
Inadequate preoperative assessment leading to unexpected findings or technical difficulties
Insufficient debridement of the peel, leading to incomplete lung expansion
Aggressive dissection causing parenchymal injury or bleeding
Poor pain control resulting in shallow breathing and atelectasis
Delayed recognition of complications like persistent air leak or bronchopleural fistula.