Surgical treatment of chronic empyema

Empyema remains challenging for thoracic surgeons. This review covers diverse aspects of acute empyema and chronic empyema and its surgical treatment. The triphasic nature of thoracic empyema (stages I, II, and III) is also addressed. The principles of empyema treatment are early diagnosis and early treatment. For acute empyema (empyema in stages I and II), early surgical intervention, such as video-assisted thoracoscopic débridement, is recommended when conventional chest tube drainage has failed. Radical treatments of chronic empyema (empyema in stage III) include (1) removal of the empyema space (decortication with or without lung resection) and (2) obliteration of the pleural space with muscle flaps or omentum flaps, or by thoracoplasty. Decortication is the procedure of choice for patients with reexpandable underlying lung. When bronchopleural fistula exists in the underlying lung, the fistula should be securely closed. For those patients whose underlying lung cannot be expected to reexpand, the procedure of choice is either concomitant removal of the affected lung with the empyema space or obliteration of the pleural space. For patients who are not eligible for the above-mentioned radical treatment, open-window thoracostomy can be considered. This procedure is not only performed as a definitive treatment of empyema but also as a preparatory treatment for radical procedures. Radical procedures are performed when patients recuperate. Choosing the most suitable operation based on the stages of empyema, the conditions of the underlying lung, and the conditions of a patient holds the key to success.