What elements of a patient's medical history need to be assessed and what preoperative considerations are essential before performing a thoracotomy with decortication and empyema evacuation for right-sided thoracic empyema?

Medical History Assessment and Preoperative Considerations for Thoracotomy with Decortication

Critical Medical History Elements

Before proceeding to thoracotomy with decortication for right-sided empyema, you must document failure of less invasive treatments—specifically persistent sepsis and pleural collection despite 7 days of chest tube drainage and antibiotics. 1

Essential Historical Components to Assess:

Etiology and Risk Factors:

• Community-acquired versus nosocomial origin (87% are community-acquired; this determines antibiotic selection and predicts treatment response) 2
• Pneumonia history (77% of empyemas originate from pneumonia) 3
• Recent thoracic or esophageal surgery (11% of cases) 3
• Trauma history (9% of cases) 3
• Intraabdominal infection (3% of cases) 3
• Immunosuppression status (mortality reaches 40% in immunocompromised patients—this is critical for risk stratification) 4
• Suspected bronchial obstruction (consider malignancy; bronchoscopy should be performed if high suspicion exists, though tumor is found in only 4% of cases) 1

Treatment Response Timeline:

• Duration of symptoms and prior treatments (chest tube drainage alone succeeds in only 35% of cases initially; postoperative empyemas respond even worse at 12%) 4
• Response to antibiotics and chest tube drainage over 5-8 days (this assessment point determines surgical referral) 1
• Use of intrapleural fibrinolytics (failure of drainage, antibiotics, AND fibrinolytics mandates surgical discussion) 1, 5

Preoperative Considerations

Cardiopulmonary Fitness Assessment

You must verify the patient can tolerate lung resection and general anesthesia through comprehensive physiological testing. 1

Required assessments include:

• Spirometry with lung volumes and gas transfer 1
• Cardiopulmonary exercise testing 1
• Ventilation-perfusion scanning 1
• Exclusion of significant cardiac disease (cardiac stress testing if indicated) 1
• Smoking cessation counseling and support 1

Nutritional Status Optimization

Malnutrition is a critical predictor of mortality and must be aggressively addressed before surgery. 1, 2

Specific nutritional interventions:

• Measure and monitor BMI 1
• Perform formal dietitian assessment 1
• Optimize nutritional status with dietary supplementation (hypoalbuminemia associates with poor outcomes) 1
• Address factors affecting nutrition: gastroesophageal reflux, alcohol intake, smoking, recreational drug use 1
• Document serum albumin levels (reduced albumin predicts early mortality, P=0.01) 2

Laboratory Risk Stratification

Specific preoperative laboratory values predict mortality and must be optimized:

• Red cell distribution width (RDW) (elevated RDW strongly predicts early mortality, P<0.001) 2
• Serum alkaline phosphatase (elevated levels predict mortality, P=0.004) 2
• Hemoglobin (reduced levels predict mortality, P=0.04) 2
• Serum albumin (as noted above) 2

Imaging and Anatomic Assessment

CT scanning with intravenous contrast is essential before surgery to:

• Define thickness of pleural peel versus consolidated lung 1
• Identify intralobar pathology such as lung abscesses (coexisting lung abscess should NOT be surgically drained; antibiotics for empyema will treat the abscess) 1
• Assess for loculations and extent of disease 1

Microbiological Considerations

Obtain pleural fluid cultures before surgery, though recognize microbiological diagnosis is achieved in only 56% of cases. 2

Common pathogens to consider:

• Streptococci (16.3%), staphylococci (15.5%), gram-negative organisms (8.9%), anaerobes (5.7%), pseudomonads (4.4%) 2
• Mycobacteria (9.1%)—tuberculosis is a notable causative organism that changes management 2
• Polymicrobial infections (8.4%) 2

Comorbidity Assessment

Major comorbidities predict early mortality (P=0.01) and must be documented and optimized. 2

Age is an independent predictor of mortality (P=0.006), requiring heightened vigilance in elderly patients. 2

Common Pitfalls to Avoid

Do not delay surgical referral beyond 7 days of failed medical management—persistent sepsis with residual pleural collection despite drainage and antibiotics mandates thoracic surgery consultation. 1

Do not assume chest tube drainage will succeed in postoperative empyemas—these respond to chest tubes in only 12% of cases compared to 67% for parapneumonic empyemas. 4

Do not overlook immunosuppression—mortality in this population reaches 40%, and early aggressive surgical management (rib resection or decortication) is recommended. 4

Do not proceed to surgery without optimizing nutrition—this was recognized as critical to outcomes since World War I but remains frequently overlooked. 1

Ensure adequate analgesia is planned—pleuritic pain and postoperative discomfort affect respiratory mechanics and recovery. 1, 5

Expected Outcomes

All-cause complication rate is 25.1% with 28-day mortality of 5.7%. 2

VATS may reduce hospitalization from 10 to 7 days compared to open thoracotomy (P=0.0005), though conversion to thoracotomy occurs frequently in chronic organized empyema. 2, 3

Open thoracotomy with decortication remains the standard for chronic empyema with thick fibrous peel, requiring sharp dissection of both visceral and parietal pleural rinds. 1