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Thoracotomy and decortication in empyema: Clinical spectrum and outcome

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Original Article

Thoracotomy and decortication in empyema:

Clinical spectrum and outcome
Shrestha KP*, Adhikari S**, Pokhrel DP***
*Associate Professor, **DM Resident, ***Professor NAMS

ABSTRACT
INTRODUCTION: Pus in pleural cavity is empyema thoracis which may be loculated or free flowing.
More than half of cases result from extension of parenchymal infection to pleura. When pus is
organized or associated with fibrothorax decortication is required which can be achieved either by
thoracoscopic or thoracotomy and decortication to ensure lung expansion and control of pleural
sepsis. The objective of this study is to find out the clinical profile of patients with empyema and
outcome of thoracotomy and decortication.
METHODS: Medical records of forty- seven patients who underwent thoracotomy and decortication
in Cardiothoracic and vascular surgery unit of NAMS, Kathmandu, Nepal from April 2011 to May
2013 were studied. Analysis of data regarding age, sex, signs/symptoms and their duration until
definitive surgery, comorbid conditions, etiology of empyema, imaging study findings, cultures of
pleural fluids, procedures performed before definitive surgery, postoperative stay in the hospital,
morbidity and mortality was done.
RESULTS: Most of the patients were of young age group and male were predominant (81.5%). The
commonest cause of empyema was pneumonia (74.46%). Tubercular empyema was uncommon.
Interestingly two cases of empyema were found with underlying mesothelioma and another two
due to ruptured hydatid cyst. Failure of tube drain due to multiloculated empyema and thickened
visceral pleura were indications of surgery in 89.5%. Pleural fluid culture was positive only in
12.76%. Chest tube was removed on 6th post-operative day. Average post-operative hospital stay
was 8 days.
CONCLUSION: Results of thoracotomy and decortication in chronic empyema is encouraging enough
to opt for decortication in cases where medical and more conservative surgical techniques fail.
KEY WORDS: empyema, thoracotomy, decortication,

INTRODUCTION about 20 %. Sometimes bacteria from abdominal

An empyema thoracis is a collection of pus in pleural
space which may be free-flowing or loculated.
An initial sterile exudation (simple parapnumonic
effusion) in some cases may progress to complicated
parapneumonic effusion & eventually empyema. 1
More than a half of cases result from direct extension of
a parenchymal infection to pleural spaces, post-surgical
infection and penetrating or blunt trauma each account
Correspondence :
Dr Kiran Prasad Shrestha, FRCSEd. CTVS unit,
Department of Surgery, NAMS.
Email: shresthakp8@gmail.com
infection, such as a subdiaphragmatic abscess, cross
the diaphragm and enter the pleural space. Rarely
empyema results following thoracocentesis or pleural
biopsy.2
The common presenting symptoms of empyema are
usually non-specific- dyspnea, fever, cough or chest
pain. However, some patients with empyema present
with only constitutional complaints, such as weight
loss, fatigue, and malaise. Evidence of fluid in the
pleural space is the principal radiographic finding;
most empyema patients also have a recognizable
parenchymal infiltrate.3

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 Thoracotomy and decortication in empyema: Clinical spectrum and outcome
Different surgical treatment modalities are used to
manage chronic empyema- open thoracotomy or
video-assisted thoracoscopy and decortication when
medical and conservative surgical techniques (eg.
tube thoracostomy) have not resulted in clearance of
pleural sepsis and lung fails to expand.4 In the present
time video-assisted thoracoscopic surgery (VATS)
is considered as an effective procedure in the early
stages of empyema thoracis. From the mid-1990s
thoracoscopic evacuation of empyema sac has gained
popularity and success rate of 68% to 93% have been
reported. However, in the late stages of empyema
performing VATS becomes difficult and an open
approach is often undertaken to decort the lung.4,5
Due to late presentation of patient usually in organized
stage VATS may not be feasible. Hence thoracotomy
and decortications might be the only surgical modality
left. Decortication is a surgical procedure that removes
a restrictive layer of fibrous tissue overlying the lung,
chest wall, and diaphragm along with its encysted
effusion or empyema sac.6 The aims of decortication
are to remove this layer and allow the lung to re-expand
and control pleural sepsis. When the peel is removed,
compliance of the chest wall and lungs returns and
patient symptoms improve rapidly.7 Tuberculous
empyema is usually first treated with antitubercular
drugs and decortication is only undertaken after long-
term drug therapy fails if required.8,9
Delorme, the great pioneer of chest surgery, was
probably the first to perform a true decortication,
in 1895 and after the First World War, the value of
decortication for pyogenic diseases became firmly
established. Decortication of the lung for clotted
hemothorax was reported first by Burford in 1943.8
There are no absolute contraindications other than
physiological fitness of the patient. Presence of pleural
space infection and large airway stenosis may make
decortications futile. Other relative contraindications
include coagulopathy, severe chest wall infection and
terminal disease. Good-quality data is lacking to decide
the optimum timing of surgery but it has been shown
that early decortications yielded good functional
outcomes.10,11 If pleural infection is controlled,
decortication is not required for thickened pleura
only because this type of thickening usually resolves
spontaneously over several months.3
Decortication in general has an excellent outcome
in young people. The morbidity and mortality after
a decortication is dependent on the patient age,
underlying comorbidities, complications from the
surgery and post-operative chest physiotherapy.
Postoperative complications include bleeding and air
leaks, formation of bronchopleural fistula, damage
to phrenic nerve or diaphragm, hemothorax and
reemergence of pus, peel and entrapment.7
We aimed to review the medical records of patient
who underwent thoracotomy and decortications
for empyema thoracis over a 26-month period at
Cardiothoracic and Vascular unit of the National
Academy of Medical Science, Kathmandu to find out
the clinical profile of patients with empyema and
outcome of thoracotomy and decortication.
METHODS
This is a descriptive, retrospective and observational
study. Medical records of patients who underwent
thoracotomy and decortication for empyema thoracis
in the Cardiothoracic and Vascular surgery (CTVS) Unit
between April 2011 and May 2013 were reviewed.
The information obtained from the records included
sex, age, signs/symptoms and their duration until
definitive surgery, comorbid conditions, etiology of
empyema, imaging study findings, cultures of pleural
fluids, procedures performed before definitive surgery,
postoperative days in the hospital, morbidity, mortality
and follow-up.
Diagnosis of empyema was confirmed by one of the
following criteria:
• drainage of grossly purulent pleural fluid,
• pleural fluid culture or Gram stain positive for
bacteria or
• biochemical parameters of empyema (pH < 7.2,
lactate dehydrogenase level > 1,000 IU/L, glucose
level < 40 mg/dl.).
CT chest was done to describe the location of fluid and
anatomy of pleural space.
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 Thoracotomy and decortication in empyema: Clinical spectrum and outcome
Figure 1: Chest X-ray showing empyema in left
pleural cavity with chest tube in situ.
Figure 2: CT chest of the same patient
The surgical approach was posterolateral thoracotomy
through the bed of 5th or 6th rib using double lumen
endotracheal tube. After entering the pleural cavity,
all purulent materials were evacuated and overlying
cortical peel was removed from costal, diaphragmatic
and visceral surfaces. Two drainage tubes were
placed and wound closed after securing hemostasis.
Previously kept chest tube for drainage was removed,
debridement of the tract done and sutured. Patients
were extubated in the operating room and sent
to the CTVS intensive care unit for postoperative
management. Patients were managed in the intensive
care unit till they require oxygen or vasopressors
support. Active chest physiotherapy was encouraged
along with incentive spirometry from second
postoperative day.
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Figure 3: Surgical specimen of pleura and
organized pus
All patients routinely received antibiotics covering both
aerobes and anaerobes. Chest tubes were removed
when there was no air leakage and drainage was less
than 50 to 100 ml per day. Patients with tuberculosis
continued their anti-tubercular drugs. Reports of pus
culture and histopathological diagnosis of surgical
specimen were recorded. Follow up with chest X-ray
was arranged in OPD at 2 and 6 weeks after discharge.
RESULTS
Forty-seven patients diagnosed with empyema were
treated by thoracotomy and decortications in 26
months period. Forty patients (85.10%) were male and
seven (14.89%) were female. The average age of the
patients was 30 years (range 4 to 66 years). The cause of
empyema was pneumonia in 35 (74.46%), tuberculosis
in three (6.38%), pyopneumothorax in two (4.25%)
and one case of trauma and bronchiectasis each. Two
patients (4.25%) were found to have ruptured hydatid
cyst in the pleural cavity. Histopathological examination
of surgical specimen revealed mesothelioma in 2
patients (4.25%), and adenocarcinoma in one (2.12%).
Multiloculated empyema was documented in forty
patients (85.10%). Four patients (8.51%) were referred
from Patan Hospital and two (4.25%) from Kanti
Children Hospital. Two patients had diabetes mellitus
(4.25%), one patient was hypertensive and the other
one had bronchiectasis. The most common indication
for surgery (89.95%) were multi-loculated empyema
and thickened visceral pleura with failure of tube drain
followed by bronchopleural fistula (10.86%) not better
even after 2 weeks.
Table 1: Causes of Empyema
Causes No of patients in %
Post-pneumonic 74.46
Post tubercular 6.38
Malignancy 6.38
Pyopneumothorax 4.25
Ruptured hydatid cyst 4.25
Bronchiectasis 2.12
Post- traumatic 2.12
 Thoracotomy and decortication in empyema: Clinical spectrum and outcome
Analysis of presenting symptoms revealed that fever
was present (>38.2°C) in 42 (91.3%) patients, chest pain
in 43 (93.47%), dyspnea in 34 (73.91%) and hemoptysis
in 9 (19.56%). All patients were treated with antibiotics
for a variable period of time before being admitted to
our unit. The commonest antibiotic was ceftriaxone
(54%) followed by piperacillin-tazobactam (26%) and
all patients got metronidazole. Three patients (6.38%)
were on ATT for more than 8 weeks.
All patients had chest tube inserted for variable
period (range 2-4 weeks). Pleural fluid was routinely
cultured but bacterial growth was found in 6 patients
(12.76%) only. Streptococcus pneumonia was isolated
in two patients (4.25%) whereas Klebsiella pneumonia,
Pseudomonas aeruginosa, Staphylococcus aureus and
S. epidermidis one each.
The first chest tube was removed on third post-
operative day (range 1 to 3 days) and the second on
sixth post-operative day (range 4 to 29 days). Forty
patients (85.10%) did not have complications. Four
patients (8.51%) required post-operative negative
sunction for fluid drainage and two patients (4.25%)
had air-leak from the tube for more than two weeks
requiring the tube drainage for 4 weeks but required
no other intervention. One patient with diabetes
developed acute renal failure post-operatively and
required hemodialysis for 3 months before his renal
function recovered completely. Repeat thoracotomy
and decortications required in one young girl because
of persistent drainage of fluid in excess of 300 ml and
lung not expanding completely even after 2 weeks.
Left pneumonectomy was done in a patient with
bronchiectasis who had distorted and fibrotic lung
which failed to inflate with intraoperative positive
pressure ventilation. Wound was infected in 4 (8.51%)
patients requiring secondary suture. Ten patients
(21.27%) required ionotropic support (dopamine) up
to 48 hours. The average postoperative stay was 8
days (range 6 to 36 days).
Table 2: Post-operative complications
Complications No of cases in percentage
Wound infection 8.51
Air leak 4.25
Acute renal failure 2.12
Persistent drainage 2.12
All patients achieved full expansion of lung
radiologically and could return to normal activities.
DISCUSSION
An empyema represents the end stage of a complicated
parapneumonic effusion. Though parapneumonic
effusion occurs in 20-40% of patients hospitalized
with bacterial pneumonia, only a small percentage (10
to 15%) have complicated effusions, and empyema
develops in only 5 to 10%.12 Decortication by
thoracoscopy or thoracotomy is necessary in patients
with established empyema for the removal of all
fibrous tissue from the visceral pleura and parietal
pleura to ensure lung expansion and clearing pus
and debris from the pleural space.13 Video-assisted
thoracoscopic surgery (VATS) has been treatment of
choice for empyema especially in fibrinoproliferative
stage. The duration of chest tube drainage and
hospitalization are shorter, less painful and better
cosmetic results have been reported with VATS.14,15
Most of the patients presenting late in organized stage
where VATS becomes difficult. In patients who are too
debilitated to undergo surgery, open drainage is an
option.16 Use of fibrinolytic agents is controversial and
clearly depends on the stage of the parapneumonic
effusions. In the early fibrinolytic stage, fibrinolytics
may shorten the clinical course. In established
empyemas, the Multicenter Intrapleural Streptokinase
trial showed that streptokinase was of no benefit in
decreasing the rate of mortality, length of hospital stay
and need for surgery.17
The commonest cause of empyema in this study was
post-pneumonia (74.6%) but post-tubercular was lower
(6.38%) which is comparable with other studies.10,13
Though tuberculous pleuritis is common, it is rarely
complicated by fibrothorax. The other reason could be
due to recommendation of surgical intervention only
after at least 2 months of antitubercular drugs.3,5,8 There
are a few case reports of malignant mesothelioma
complicated by empyema- one of them was associated
with tubercular pleuritis. 18,19 The cause of empyema in
two of our patients with mesothelioma and one with
adenocarcinoma could be due to thoracocentesis. Out
of two cases of ruptured hydatid cyst one had solitary
cyst localized in right chest wall but the other patient
had cysts in right lung, liver and right ovary. Following
cystectomy and clearing pleural space the latter was
referred to general surgery after 8 post-operative
days. Review of literatures revealed that lungs are the
second most commonly involved organs (20-30%), the
first being liver (60%). Cysts can involve chest wall or
Volume 12│Number 2│Jul-Dec 2012 23
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 Thoracotomy and decortication in empyema: Clinical spectrum and outcome
lung parenchyma. Involvement of liver in pulmonary
hydatid disease is reported in 10-40% of the time.14,20
Common presentation of pulmonary hydatid cyst is
fever, cough and chest pain but one third will present
only following cyst rupture or secondary cyst infection.
Incidence of cyst rupture in pleura is about 5%. 20,21,22
The positive yield of pleural fluid culture is reported
60-70% in different literature.7,9 The reasons of very
low positive culture (12.76%) in our set up could be
due to use of multiple antibiotics before sample is
taken and lack of anaerobic culture.
Nonfatal postoperative complications were comparable
with other studies 2,5
There are a few limitations of the study. The number
of cases was relatively small. Being a retrospective
study it was not possible to find the mean duration
of disease before definitive treatment. Biochemical
parameters of pleural fluid such as pH, glucose and LDH
were found in only 13% cases. Pre and post operative
spirometry would have been better parameters for
outcome of procedures rather than radiology and
clinical parameters.
CONCLUSION
The commonest cause of chronic empyema was
pneumonia. Thoracotomy and decortication yielded
very good result with only minor complications. The
results of this study were encouraging enough to opt
for decortication in cases where medical and more
conservative surgical techniques fail.
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