Empyema Thoracis- The Role of Open Thoracotomy with Decortication in the Era of Video-assisted Thoracoscopic Surgery

Vikram  Sindgikar, Tejaswini Vallabha, Mallikarjun Patil, Girish Kullolli, Samhitha Reddy

Department of General Surgery, BLDEDU’s Shri B M Patil Medical College Hospital, Vijayapur, Karnataka, India

Correspondences to: Vikram Sindgikar; email:vikram.sindagikar@bldedu.ac.in
Received: 30 Sep 2021; Revised: 23 Jun 2022; Accepted: 27 Jun 2022; Available online: 26 Aug 2022



Empyema Thoracis, a condition in which purulent fluid accumulates within the pleural cavity, is commonly caused by bacterial infection (both Gram-positive and Gram-negative), such as Mycobacterium tuberculosis, and rarely by fungal infection. Timely intervention significantly reduces morbidity and mortality. Surgical intervention is needed in advanced disease. This study aimed evaluate decortications performed through video-assisted thoracoscopic surgery (VATS) and open thoracotomy.

Materials and methods

This retrospective study included 47 patients who underwent decortications by either VATS or open thoracotomy for empyema Thoracis at the Department of Surgery of, BLDE DU Shri B M Patil Medical College from May 2015 to August 2020.


Tuberculosis was the most common etiological factor for empyema Thoracis. In 19 patients who underwent VATS decortications, VATS was converted to open thoracotomy in 11 patients. Only 8 patients achieved successful decortication with VATS. Thirty-nine patients (including 11 whose VATS was converted to open thoracotomy) underwent successful open thoracotomy decortications. Thirty-two patients had postoperative bronchopleural fistula, and all cases were successfully managed conservatively. The timing of the surgical intervention is critical in reducing morbidity and mortality. The more advanced the disease, the higher the failure rate of VATS in attaining complete decortications.


Open thoracotomy decortication remains the gold standard in attaining complete decortications in advanced empyema Thoracis.

Key words: Empyema Thoracis, Tuberculosis, Open thoracotomy, Video-assisted thoracoscopic surgery, Decortication

Ann Afr Surg. 2022; 19(4): 175-179


Conflicts of Interest: None

Funding: None

© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.


Empyema thoracis is the collection of purulent fluid within the pleural space (i.e., between the parietal pleura and the visceral pleura). It is one of the complications of pneumonia usually caused by bacterial infections. In western countries, Gram-positive bacteria predominate, whereas in India (1), especially in the northern part of Karnataka, tuberculosis continues to be the common cause of empyema in adults. In children, Gram-positive bacterial infections are common. Patients usually presents with lower respiratory tract symptoms such as fever, productive cough, and breathlessness. Initially, the disease starts as an exudative effusion, progressing into multi-loculation, later forming a thick layer of inflammatory exudate coating the viscera, leading to fibrosis and lung collapse. Thus, the formation of thick corticate makes the disease less amenable to medical management and signifies advanced disease, requiring surgical intervention.   Morbidity significantly increases as the disease progresses from effusion to lung collapse. Thus, early intervention reduces the morbidity and mortality of the patient as well as financial burden the disease entails. Modalities of treatment ranges from needle aspiration, intercostal tube drainage, and surgical intervention such as video-assisted thoracoscopic surgery (VATS) or open thoracotomy decortication. Globally, surgical intervention is shifting from open surgical procedures to minimally invasive procedures, with definite advantages. However, whether open thoracotomy with decortication is becoming obsolete is unknown. Furthermore, is the era of open surgical procedures ending? This study aimed to compare the two surgical procedures, open thoracotomy with decortications and VATS decortications, in the treatment of empyema thoracis.

Materials and Methods

This retrospective study was conducted at the De