Overview
Definition:
Stage III empyema, also known as organized empyema or chronic empyema, is characterized by the formation of a thick, fibrous peel (necrotic debris and fibrin) encasing the lung, significantly restricting its expansion
Open decortication is a surgical procedure aimed at removing this peel to allow lung re-expansion and resolve the infection.
Epidemiology:
Empyema incidence varies but is often associated with pneumonia, thoracic trauma, and post-surgical complications
Stage III represents a later, more complex stage, often occurring weeks to months after the initial insult
Risk factors include delayed diagnosis, inadequate initial treatment, and immunocompromised states.
Clinical Significance:
Untreated or inadequately treated Stage III empyema can lead to severe respiratory compromise, chronic pain, bronchopleural fistula formation, and prolonged morbidity
Successful decortication is crucial for restoring lung function, alleviating symptoms, and preventing long-term sequelae, making it a vital skill for thoracic surgeons.
Indications
Surgical Indications:
Persistent fever despite antibiotics
Large encapsulated pleural collections on imaging
Unresolved symptoms (dyspnea, chest pain) attributable to the peel
Failure of less invasive management (e.g., VATS with incomplete peel removal)
Significant restriction of lung function confirmed by pulmonary function tests.
Timing Of Surgery:
Generally performed when the empyema has organized, typically after the acute inflammatory phase subsides, often 2-3 months post-insult
However, early decortication may be considered in selected cases if the patient is septic and stable for surgery.
Contraindications:
Absolute contraindications are rare but include unresectable lung disease, severe comorbidities that render the patient unfit for major thoracic surgery, or a lack of encapsulated peel (e.g., simple parapneumonic effusion).
Preoperative Preparation
Diagnostic Workup:
Comprehensive chest imaging (CT scan with contrast is essential to delineate the peel and assess lung involvement)
Thoracentesis for pleural fluid analysis (Gram stain, culture, cytology, pH, LDH, protein)
Blood tests: CBC, electrolytes, renal and liver function tests, coagulation profile
Pulmonary function tests to assess respiratory reserve.
Optimization Of Patient:
Aggressive antibiotic therapy targeting the identified pathogen
Nutritional support to improve healing potential
Optimization of cardiopulmonary status
Bronchodilator therapy if underlying COPD or asthma is present
Smoking cessation advice.
Anesthesia Considerations:
General anesthesia with double-lumen endotracheal tube for single-lung ventilation
Epidural or intercostal nerve block for postoperative pain management
Careful fluid management to avoid overload.
Procedure Steps
Surgical Approach:
Open thoracotomy, typically a posterolateral or anterolateral approach depending on the location of the empyema
Muscle-sparing thoracotomy may be considered
Video-assisted thoracoscopic surgery (VATS) can be an alternative for carefully selected cases, but open decortication is often preferred for dense peels.
Decortication Technique:
The primary goal is complete removal of the visceral pleural peel
This involves careful dissection, often starting from the hilum and working outwards
Use of blunt and sharp dissection is crucial
The peel may be adherent to lung parenchyma, requiring meticulous freeing to avoid injury
Specialized instruments like rib spreaders and electrocautery may be used.
Pleural Space Management:
After decortication, the pleural space is thoroughly irrigated and debrided of all pus and necrotic material
Chest tubes (typically two: one for drainage, one for suction) are inserted to re-expand the lung and manage any residual air or fluid
The tubes are connected to an underwater seal drainage system, often with negative pressure suction.
Chest Tube Management:
Chest tubes are usually kept in place until drainage is minimal (e.g., <100-150 mL/24h), air leak ceases, and the lung is fully expanded radiographically
Gradual clamping and removal are performed as per protocol.
Postoperative Care
Pain Management:
Multimodal analgesia including IV opioids, NSAIDs, and regional anesthesia (epidural or intercostal blocks) is essential for effective pain control and early mobilization.
Respiratory Support:
Encourage deep breathing exercises, incentive spirometry, and early mobilization to prevent atelectasis and pneumonia
Monitor oxygen saturation and respiratory rate closely
Chest physiotherapy may be beneficial.
Antibiotic Therapy:
Continue antibiotics as guided by pleural fluid cultures and sensitivity patterns, or broad-spectrum coverage if no organism is identified
Duration typically extends for several weeks.
Monitoring:
Close monitoring of vital signs, chest tube output, and for signs of complications
Daily chest X-rays are usually performed initially to assess lung expansion and identify effusions or pneumothorax.
Complications
Early Complications:
Persistent air leak
Hemorrhage
Recurrent empyema
Bronchopleural fistula
Atelectasis
Pneumonia
Acute respiratory distress syndrome (ARDS)
Nerve injury.
Late Complications:
Chronic pain
Restricted lung function
Bronchiectasis
Fungal empyema
Pleural thickening leading to restrictive lung disease.
Prevention Strategies:
Meticulous surgical technique to ensure complete peel removal and air-tight closure
Adequate chest tube drainage
Aggressive postoperative physiotherapy and mobilization
Timely and appropriate antibiotic use
Patient selection for surgical intervention.
Key Points
Exam Focus:
Stage III empyema involves a thick, organized peel requiring decortication
CT scan is crucial for assessment
Open thoracotomy is the gold standard for extensive peels
Complete removal of the peel is paramount
Chest tubes are essential for post-operative management.
Clinical Pearls:
In chronic empyema, consider the possibility of tuberculosis
Be prepared for dense adhesions and potentially friable lung parenchyma during decortication
Early mobilization and adequate pain control significantly impact recovery
Multidisciplinary approach including pulmonologists and infectious disease specialists is often beneficial.
Common Mistakes:
Incomplete decortication leading to persistent symptoms or recurrence
Overzealous dissection causing lung parenchymal injury or hemorrhage
Inadequate chest tube management or premature removal
Underestimation of the inflammatory process and patient comorbidities.