Indications for Decortication

The most common benign condition involving the pleura is an infection involving the pleural space or empyema. Patients who present with pneumonias often have associated pleural effusions, which can be either parapneumonic effusions or an empyema. The pleural fluid should be sampled with thoracentesis to determine the distinction between paraneumonic effusion and empyema. If the fluid gram stain or culture is positive for a pathogen or the fluid pH is less than 7.1, then an empyema is typically diagnosed. The classification of empyema is based on the temporal evolution of the pleural space infection and dictates the optimal management. The three phases of empyema consist of:

1. Exudative Phase: This initial phase of empyema is characterized by free-flowing purulent fluid through the thorax and associated inflamed parietal pleura. Simple drainage with chest tube thoracostomy and intravenous antibiotics are usually sufficient to manage the pleural effusion.

2. Fibropurulent Phase: This phase is characterized by loculated pleural fluid and fibrinous exudative deposits on the visceral pleural surfaces. Empyemas in this phase often require a VATS or thoracotomy to lyse adhesions, break up loculations, and drained purulent pleural fluid.

3. Fibrous Phase: This phase is characterized by the formation of a thick, fibrous rind on the visceral pleural surface of the lung. A thoracotomy is usually required to achieve a complete decortication.

An early decortication with a VATS approach during the fibropurulent phase is highly effective and can significantly decrease morbidity associated with empyema. VATS offers a decided advantage over simple chest tube thoracostomy because of multiple factors.

1. Loculated purulent fluid can be completely drained because adhesions can be directly visualized and lysed during VATS.

2. Atelectatic lung can be re-expanded under direct vision.

3. Chest tubes can be placed in the appropriate position for optimal drainage in the postoperative period.

The definitive drainage of purulent fluid associated with empyema with VATS can significantly improve patient outcomes and prevent progression to a fibrothorax, which often requires an open thoracotomy. Other indications for decortication include chronic hemothorax and recurrent pleural effusion.

Contraindications for Decortication

Malignant pleural disease

Endobronchial tumor with bronchial obstruction

Chronic respiratory failure and ventilation dependence

Chronically trapped lung with limited pulmonary dysfunction

PREOPERATIVE PLANNING

Patients with empyema should have a preoperative CT scan of the thorax to identify loculated fluid cavities that need to be drained. The location of loculated fluid pockets will assist with the placement of VATS ports. Broad-spectrum antibiotics should be initiated to treat active pneumonia. The antibiotic coverage can be modified after the culture and sensitivities are completed. Large pockets of purulent fluid can be drained with a chest tube thoracostomy prior to a planned VATS decortication. Chest tube drainage is particularly important for patients who present with an empyema and associated signs of sepsis, such as fever, tachycardia, leukocytosis, and hypotension.

SURGERY

Positioning for VATS Decortication

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