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Empyema and Decortication

Empyema is infected fluid or pus in the pleural space around the lung. Pneumonia is the most common cause of empyema. A small number of people who develop a pneumonia develop pus around the lung. If pus stays around the lung for a number of days, the body reacts and produces strands of fibrous tissue. After 2 weeks the fibrous tissue thickens and starts to coat the lung like a thick layer of orange peel. This peel traps the lung and the lung cannot expand properly. Most people feel very unwell with an empyema.

How is an empyema treated?

The body may clear infected fluid with the help of antibiotics.

A chest drain is often needed to get rid of the infected fluid. If this does not clear the infection a keyhole operation may be needed to help clear the infection. Once peel covers the lung, or if a keyhole operation does not clear the infection enough, a bigger operation is needed to free the lung. The operation to remove infected fibrous tissue is called decortication.

For some people it may be better to create an opening between the ribs to allow infected fluid out of the chest. This is referred to as a window. It may be used with infections that have come back or been very difficult to treat.


What does surgery involve?

Surgery is done with you fully asleep and can be done via keyhole surgery (VATS) or open surgery (thoracotomy). During surgery you lie on your side with your arm raised. Surgery usually takes between one and two hours.

Keyhole surgery (VATS)

VATS stands for Video Assisted Thoracoscopic Surgery. Up to 4 small cuts are made, each about 5cm (2 in) long. These are used for the instruments and small camera to go into the chest. Infected fluid is removed from inside the chest along with the infected fibrous tissue. The muscles and skin are stitched together again at the end of surgery.

Open surgery (thoracotomy)

Open surgery is done with one longer cut under the shoulder blade between 2 ribs. The 2 ribs are parted to get into the chest. One rib may be cut to give more space, ribs are not removed. Infected fluid is removed and thick fibrous tissue is taken off the surface of the lung to free the lung. At the end of surgery the 2 ribs are held back together with strong stitches. The muscles and skin are also stitched back together.

1 or 2 chest drains are put in at the end of the operation and held in placed with a stitch. These remove any fluid or air from around the lung.


A part of rib is removed from the side of the chest, the skin and muscle are stitched a way that keeps a hole for fluid to drain from. The hole is then covered by a bag, to collect the fluid. The hole can be closed once the infection has been cleared.


What is recovery like?

Everyone recovers at their own pace, you may need more time than the timelines. This is because your body is fighting an infection as well as healing from surgery.

You may need to continue antibiotics after surgery. If certain types of bacteria are grown from the infected fluid you may need antibiotics for a number of weeks. In some cases intravenous antibiotics can be given at home.

Breathing exercises will be very important to help clear the infection.


What are the risks?

The risks here are a guide; your own risk may vary. You should discuss the risks and benefits of surgery with your surgeon, especially if you are worried.

General risks of thoracic surgery apply to decortication.

The following are also risks of decortication:

Minor more common risks

Air leaking from the lung into the chest drain for a few days is common after lung surgery. Occasionally this lasts for longer, possibly weeks. A chest drain will need to be in place until this settles, you may be able to go home with the chest drain still in and come back for regular check-ups until the air leak settles.

Your kidneys may not work as well after surgery but this is usually temporary and gets better with extra fluid.

Major less common risks

Shortness of breath may severe enough to require help from a ventilator machine. This can be with a face mask with you fully awake. It may also be need via a tube in your windpipe with you under sedation. If you need help breathing via a tube for a long time it may be better to have a temporary tracheostomy. This is a tube put in through the neck which is removed once breathing improves.

Empyema itself has a risk of death that is 15 to 20 in 100. The risk of death from the operation is 2 in 100 nationally, so 98 in 100 people recover from the surgery.


What are the alternatives to surgery?

Surgery for empyema is lifesaving. Antibiotics are given both if you have surgery and if you do not have surgery.

If you do not want surgery or are not well enough to have an operation other options may include:

  • Medication via the drain to break down fibrous tissue. This is only suitable for certain patients; it works best if given early once fibrous stands are found to have developed.
  • Having a chest drain in for a prolonged period of time.
  • Palliative care