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

From the Guidelines

Surgical treatment for chronic empyema should be considered if patients have persisting sepsis in association with a persistent pleural collection, despite antibiotics, chest tube drainage, and fibrinolytics, with video-assisted thoracoscopic surgery (VATS) being a preferred approach for early surgery. The decision to involve a surgeon early in the decision-making process should be encouraged, and referral should not automatically mean surgery is inevitable 1.

Key Considerations

• Patients with complex empyema, significant lung pathology, bronchopleural fistula with pyopneumothorax, and secondary empyema are more likely to require surgical treatment 1.
• VATS achieves debridement of fibrinous pyogenic material, breakdown of loculations, and drainage of pus from the pleural cavity under direct vision, leaving three small scars 1.
• Open thoracotomy with decortication involves removing the thick fibrous peel that forms around the lung in chronic empyema, allowing the trapped lung to re-expand and fill the pleural space 1.
• The use of VATS will depend on the availability of equipment and someone suitably trained to use it 1.

Recent Guidelines

• The British Thoracic Society guideline for pleural disease suggests that different surgical approaches can be used to access the infected space in pleural infection, including endoscopic techniques (VATS) and open techniques (thoracotomy) 1.
• The guideline also investigates what the best surgical method is for treating pleural infection, including drainage, debridement, and visceral decortication 1.

Surgical Methods

• VATS is a preferred approach for early surgery, with benefits including less postoperative pain, a shorter hospital stay, and a better cosmetic result 1.
• Open thoracotomy with decortication is a more invasive procedure, but may be necessary for patients with complex empyema or those who cannot tolerate VATS 1.
• Other surgical methods, such as mini-thoracotomy and debridement, may also be effective and safe, but the choice of surgical approach will depend on individual patient factors and local expertise 1.

From the Research

Surgical Treatment Options

• Open thoracotomy and decortication is a traditional treatment for chronic empyema, with studies showing low morbidity and mortality rates 2
• Video-assisted thoracoscopic surgery (VATS) decortication is an alternative method for early stage III empyema, with potential benefits including less morbidity and mortality compared to open procedures 3
• Decortication via thoracotomy is considered a standard treatment method for chronic empyema, especially for patients with reexpandable underlying lung 4

Patient Selection and Treatment Outcomes

• Patient selection is crucial, with factors such as the stage of empyema, underlying lung condition, and overall patient health influencing treatment choice 4, 5
• Studies have reported varying success rates for different treatment approaches, including open decortication, VATS decortication, and radical treatments such as lung resection and muscle flap reinforcement 6, 4
• Complications and mortality rates vary depending on the treatment approach and patient population, with reported complication rates ranging from 9% to 40.7% and mortality rates ranging from 1.3% to 6% 2, 6, 4

Treatment Principles and Goals

• Early diagnosis and treatment are key principles in managing empyema, with the goal of preventing progression to chronic empyema 4, 5
• Radical treatments aim to remove the empyema space, obliterate the pleural space, and restore lung function, with the choice of treatment depending on the stage of empyema and underlying lung condition 4, 5
• Individualized treatment approaches are essential, taking into account the patient's specific condition and needs 4, 5