What Is Empyema & How Is Surgery For Empyema Thoracis Helpful?


Empyema thoracis is a serious medical condition in which pus accumulates in the pleural space of the lungs. It is a life-threatening condition that can be caused by a bacterial infection, tuberculosis, a foreign body in the chest, or a complication of another medical condition. The underlying cause of empyema must be identified and managed before proceeding with any treatment. Surgery is often recommended to remove the infected pus and to restore normal lung function. This type of surgery can be a complex and lengthy procedure that requires the expertise of a thoracic surgeon. In this article, we will discuss what is empyema and how surgery can help treat it. We will review the different types of surgeries available and explain how a thoracic surgeon can help you manage your condition.

What is Empyema Thoracis?

Empyema is a medical condition in which pus collects in the pleural space of the lungs. An empyema is classified as a suppurative lung infection. Suppuration is the formation of pus. Because it is a serious condition so it requires prompt diagnosis and treatment since it can be fatal.

The pleural space is the area outside the lungs where the pleural membranes (lung membranes) surround the lungs. The pleural membrane is a thin sheet of tissue that covers the inside of the chest wall and the outside of the lungs. It is made up of two layers – the parietal layer and the visceral layer. The visceral layer lines the outer surface of the lung and the parietal layer lines the chest wall. The pleural space is normally filled with a small amount of a clear, thin fluid that lubricates the inside of the chest, allowing the lungs to move back and forth during breathing. Often patients need surgery for empyema thoracis if they cannot be managed conservatively.

Causes of Empyema

It can result from a variety of bacterial infections that spread from the chest into the pleural space. Pleural empyema can result from an existing lung infection, such as tuberculosis or bacterial pneumonia. It can also occur after a lung infection that has been treated with antibiotics. This can occur if the infection is not completely eradicated or if the antibiotics are not effective against the infecting bacteria.

Other common reasons are:

  • Complication of abdominal infections (sub phrenic abscess or necrotizing pancreatitis or spontaneous bacterial peritonitis),
  • Following chest trauma (infected retained clotted hemothorax or esophageal perforation) and
  • Following certain surgeries (post lung resection or post pneumonectomy empyema)

Stages of Empyema and Stage-wise Treatment

The evolution of Empyema goes through three stages.

First Stage: The first is the presence of free-flowing fluid (effusion) which usually resolves with antibiotics and non-invasive treatment. If it is left untreated the effusion becomes complicated.

Second Stage: In this there is a deposition of fibrin and membranes which leads to formation of septations or loculations in the fluid leading to comparmentalization of the fluid into different pockets. Both antibiotics as well as some form of pleural drainage is required in this stage.

Third Stage: If the loculated fluid is not drained the fluid will start organising (third stage) into thick pus and the fibroblasts will coalesce to form a thick pleural peel between the visceral and parietal pleura. This peel can ultimately encase the underlying lung and will prevent the lung from expanding. For an easy understanding the collapsed underlying lung can be compared to an orange and the thickened pleural peel around the lung to the peel of the fruit. This stage requires Surgery for Empyema Thoracis because the lung is usually trapped and unable to expand.

Symptoms & Signs

The symptoms of empyema vary depending on the underlying cause and the extent of the infection. Most patients experience symptoms similar to pneumonia, including fever, chills, cough, chest pain, and difficulty breathing. Other symptoms of may include chest pain behind the breastbone, pleuritic pain (pain that worsens when taking a deep breath), and low oxygen levels in the blood. As the infection spreads, patients may experience sweating, high fevers, and general weakness.

Patients who may be experiencing symptoms of empyema should consult a health care professional so as to determine the cause of their symptoms. A health care professional can perform a physical examination, take a medical history, and order diagnostic tests like a Chest X ray, CT scan and analysis of the pleural fluid/pus. If Pleural Empyema is diagnosed, it may need surgery.

CT scan
CT image of Right sided Empyema

Surgery for Empyema Thoracis

In many cases, empyema thoracis requires surgical treatment. A thoracic surgeon will examine the patient to identify the extent of the infection and the location of the pus. They will review the patient’s medical history and current medications to determine the best treatment plan. The surgery for empyema thoracis is called “Drainage and Decortication”

The goals of this surgery are:

  1. To remove all the pus and purulent fluid that has collected outside the lungs by breaking all the loculi
  2. To free the lung completely by mobilizing it from hilum to hilum and apex to diaphragm
  3. To remove the cortex (peel) that has formed around the lung (compared to peeling of orange) which is preventing it from expanding fully
Thickened pleural peel
Pleural Peel or Cortex

Traditionally the approach used for empyema surgery is an open approach called a “Thoracotomy”, which is a large cut on the side of the chest and involves cutting the muscles and spreading the ribs. This allows the surgeon to put his hands inside the chest to operate.

Surgery for Pleural Empyema

Surgery for Empyema Thoracis
VATS Decortication

Uniportal VATS Drainage and decortication of empyema is a special type of VATS surgery, because it utilizes only a single 3-4cm incision to perform this surgery. Occasionally these surgeries may not be possible by VATS but would need a conventional open surgery approach especially when the pleura has calcified or in case of fibrothorax.

Watch a VATS Decortication Video.

Advantages of Surgery for Empyema Thoracis by VATS

VATS decortication usually translates to lesser post operative pain, faster recovery and a shorter hospital stay. It is also a cosmetically superior approach with very tiny scars that almost disappear after a while. So it is our preferred approach for drainage and decortication of empyema.

Complications of Surgery for Empyema Thoracis

The most common complication is an infection at the site of the incision. This is often preventable with proper surgical techniques, including using sterile equipment, proper hand washing, and the use of antibiotics. Other complications of surgery include bleeding, blood clots, an allergic reaction to the antibiotics, and damage to nearby organs. A particular complication called “Air leak” is often encountered. This is a result of peeling of the thick layer of cortex from the lung surface because of which the lung surface becomes raw and leaks air. If this air leak persists for more than 5 days we may have to keep the chest drain for a long period of time.

Recovery from Pleural Empyema surgery

After a patient has undergone surgery for empyema thoracis, they are monitored in a hospital setting. In most cases, patients are required to stay in the hospital for 3 to 7 days after the surgery. During this time, they are monitored for signs of an infection or complications related to the surgery. But the amount of time a patient spends in the hospital depends on the extent of the infection and the type of surgery performed. After the patient has been discharged from the hospital, they are typically prescribed some medicines. It can take several weeks for the incision sites to heal. Patients may require them to take time off work after the surgery to recover.

Watch here a Pateint’s Experience of Surgery for Empyema thoracis.


In most cases, a thoracic surgeon will be able to help you manage your condition. They can provide you with the best surgical options to treat the infection and prevent it from returning. They can also provide emotional support while you are recovering from the surgery. He or she can help you manage your condition during every stage of your diagnosis and treatment. When you are deciding which type of surgery to undergo, your surgeon can provide you with the best options based on the extent of your condition. They can also help you manage any potential complications and help you recover as quickly as possible.

If you or any of your known are suffering from this disease please get in touch with Dr. Kamran Ali who is the best surgeon for empyema in Delhi NCR with extensive experience in managing this disease with superb outcomes.

Like this article?

Leave a comment