What are the surgical treatment options for empyema (empyema is a condition characterized by the accumulation of pus in the pleural space)?

From the Guidelines

Surgical treatment for empyema should be considered if there is failure of chest tube drainage, antibiotics, and fibrinolytics, or if the patient has persisting sepsis in association with a persistent pleural collection, despite chest tube drainage and antibiotics. The primary surgical approaches include tube thoracostomy (chest tube placement), video-assisted thoracoscopic surgery (VATS), and thoracotomy. For early-stage empyema (exudative phase), tube thoracostomy with a large-bore chest tube (28-32 French) is often sufficient, combined with appropriate antibiotics tailored to the causative organism 1. If the empyema has progressed to the fibrinopurulent or organizing phase, VATS is recommended for breaking down loculations, removing fibrin deposits, and placing chest tubes for drainage. In advanced cases with thick pleural peel formation, a formal thoracotomy with decortication may be necessary to remove the restrictive pleural rind and re-expand the lung.

Some key points to consider when deciding on surgical treatment for empyema include:

• The stage of empyema, with early-stage empyema potentially being managed with tube thoracostomy and antibiotics, while more advanced cases may require VATS or thoracotomy 1
• The presence of persisting sepsis or a persistent pleural collection, despite chest tube drainage and antibiotics, which may indicate the need for surgical intervention 1
• The use of intrapleural fibrinolytics, such as tissue plasminogen activator (tPA) and DNase, as an adjunct to tube drainage in loculated empyemas 1
• The potential benefits of early surgical intervention, including shorter length of hospital stay and reduced need for repeat intervention, as well as the potential risks and complications of surgery 1

Overall, the choice of surgical approach depends on the empyema stage, patient condition, and local surgical expertise, and should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances. The most recent and highest quality study, published in 2023, suggests that surgical drainage, via VATS or open thoracotomy, may provide better clinical outcomes than chest tube drainage alone, including shorter length of hospital stay and reduced need for repeat intervention 1.

From the Research

Surgical Treatment Options for Empyema

• The surgical treatment of empyema involves various options, including video-assisted thoracoscopic surgery (VATS) and open thoracotomy 2, 3, 4, 5, 6.
• The choice of surgical treatment depends on the stage of empyema, the condition of the underlying lung, and the overall health of the patient 2.

Video-Assisted Thoracoscopic Surgery (VATS)

• VATS is a minimally invasive procedure that has been shown to be safe and effective in the treatment of empyema 3, 4, 5, 6.
• VATS has been compared to open thoracotomy in several studies, with results showing that VATS is associated with shorter operative times, less post-operative pain, and shorter hospital stays 3, 5.
• The conversion rate from VATS to open thoracotomy is relatively low, ranging from 3.1% to 14.2% 3, 4, 5.

Open Thoracotomy

• Open thoracotomy is a more traditional surgical approach that involves making a larger incision in the chest wall 2, 3, 5, 6.
• Open thoracotomy may be necessary in cases where VATS is not feasible or has failed, such as in cases with dense adhesions or complex empyema 2, 3.
• Open thoracotomy has been shown to have similar outcomes to VATS in terms of complication rates and mortality, but may be associated with longer hospital stays and more post-operative pain 3, 5, 6.

Decortication and Pleural Space Obliteration

• Decortication is a surgical procedure that involves removing the fibropurulent material from the pleural space, and is often performed in conjunction with lung resection or pleural space obliteration 2.
• Pleural space obliteration involves filling the pleural space with a material such as muscle flaps or omentum flaps to prevent further accumulation of fluid 2.
• These procedures are often used in the treatment of chronic empyema, and may be necessary to achieve complete resolution of the infection 2.