Surgical interventions for pleural infection

Abstract

Pleural infection (PI) remains a serious clinical condition associated with high morbidity, prolonged hospitalisation and significant mortality, despite advances in medical therapy. Characterised by infection and inflammation within the pleural cavity, PI is increasingly complicated by antimicrobial resistance. While antibiotics and drainage constitute first-line treatment, surgical intervention becomes essential in advanced or refractory cases. Video-assisted thoracoscopic surgery (VATS) has emerged as the preferred minimally invasive approach in early-stage disease, offering advantages such as reduced post-operative pain, shorter hospital stays and faster recovery. In more complex stages, open decortication or thoracotomy may still be required. This narrative review explores the full spectrum of surgical strategies - including VATS, open decortication, open window thoracostomy, vacuum-assisted closure therapy and the innovative FlexVATS technique - highlighting their indications, timing and evolving roles in contemporary practice. We also underscore the importance of post-operative care, emphasising respiratory rehabilitation, pain management, nutritional support and infection surveillance. Prognostic tools, particularly the RAPID score, are discussed for their potential to guide early risk stratification and optimise timing of surgical intervention. Given the complex nature of PI, a multidisciplinary approach involving thoracic surgeons, pulmonologists, infectious disease specialists, physiotherapists and nutritionists is essential. A patient-centred, multimodal treatment strategy tailored to disease stage and individual risk factors remains the cornerstone of successful recovery. Continued research into long-term outcomes and advanced diagnostics is critical to improving care in this challenging clinical domain.

FIGURE 1

a) Posteroanterior chest radiograph showing an encapsulated right pleural empyema. b) Right thoracic cavity ultrasound scan showing an echogenic pleural effusion with multiple septations/loculations, associated with underlying lung consolidation. c) Axial chest computed tomography (CT) scan showing a right pleural collection with thickened surrounding pleura and multiple gas bubbles. d) Coronal chest CT scan showing a multiloculated left pleural collection with small intrapleural air bubbles and associated lung atelectasis.

FIGURE 2

Management of pleural empyema according to the American Thoracic Society stages. VATS: video-assisted thoracoscopic surgery.

FIGURE 3

Surgical techniques. a) Video-assisted thoracoscopic surgery (VATS) debridement: intraoperative view of a septated and multiloculated pleural empyema. b) VATS debridement: lysis and suction of pleural pseudomembranes, fibrinous deposits and necrotic tissue. c) VATS debridement: purulent material draining from loculated collections and pleural peel. d) Pleural decortication performed via posterolateral thoracotomy.

FIGURE 4

Open window thoracostomy (OWT). a) Early-stage OWT showing fibrinopurulent material at the cavity bed. b) Chronic OWT with a clean cavity bed and evident granulation tissue.