Open thoracotomy and decortication for chronic empyema

Abstract

Objectives: Traditionally, chronic empyema has been treated by thoracotomy and decortication. Some recent reports have claimed similar clinical results for videothoracoscopy, but with less morbidity and mortality than open procedures. Our experience with thoracotomy and decortication is reviewed so that the results of this surgical procedure can be adequately evaluated.

Materials and methods: From March 1992 to June 2006, 85 patients diagnosed with empyema were treated at Santo Tomás Hospital by the first author. Diagnosis of chronic empyema was based on the duration of signs and symptoms before definitive treatment and imaging findings, such as constriction of the lungs and the thoracic cage. Thirty-three patients fulfilled the criteria for chronic empyema and underwent open thoracotomy and decortication.

Results: Twenty-seven patients (81.8 %) were male and the average age of the study group was 34 years. The etiology was pneumonia in 26 patients (78.8%) and trauma in 7 (21.2%). The duration of symptoms and signs before definitive treatment averaged 37 days. All patients had chronic empyema, as confirmed by imaging studies and operative findings. Surgery lasted an average of 139 min. There were 3 (9%) complications with no mortality. The post-operative length of stay averaged 10 days. There were no recurrences of empyema.

Conclusions: Open thoracotomy and decortication can be achieved with low morbidity and mortality. Long-term functional results are especially promising. We suggest that the validation of other surgical approaches should be based on comparative, prospective and controlled studies.

Figure 1

A. Chronic empyema. Note the thickness and fibrotic nature of the pleural cortex. B. Purulent material has been removed and the visceral pleural cortex can be observed on the bottom, where it restricts lung expansion. C. The lung has been completely decorticated and there is no residual dead space

Figure 2

A. Chest roentgenogram shows a large left empyema. B. Computed tomography of the chest showing significant restriction of the thoracic cage and thick pleural cortex. C. Postoperative chest roentgenogram with excellent pulmonary expansion (Incidentally, partial removal of a rib can be seen; this was the only patient that required such a procedure)