Surgery for thoracic empyema: personal experience and current highlights.

Thoracic empyema remains challenging for thoracic surgeons. The principles of empyema treatment are early diagnosis and early treatment. Decision-making involves a triad consisting of the etiology of empyema, general condition of the patient and stage of disease. For acute empyema, early surgical intervention, such as video-assisted thoracoscopic debridement, is recommended when conventional chest tube drainage has failed. Radical treatments of chronic empyema 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 re-expandable underlying lung. For patients who are not eligible for the above-mentioned radical treatment, open-window thoracostomy can be considered. The current attitudes show that the present concepts are based mainly on expert opinion. No exclusive sequence of procedures leading to a uniformly predictable successful outcome is available. Individualized approaches can be recommended based on institutional practice and local protocols.