Definition & Overview

Decortication is a surgical procedure done in the thoracic region to remove a fibrous tissue that abnormally forms and grows on the surface of the lung, chest wall or diaphragm. The aim of this operation is to remove this restrictive tissue layer (fibrous pleural peel) that covers the lungs to allow them to re-expand and function normally.

Generally, there is a space (called pleural space) in between the lungs and the chest wall, which is lined with a very thin fluid layer for lubrication. This area is moist to allow the lungs to expand and contract smoothly when breathing. However, certain disease or conditions such as pneumonia, infection (empyema) or bleeding can lead to excess fluid that can fill up this gap. This excess fluid can eventually turn into solid and form a fibrous capsule that restricts the lung and entraps it causing breathing problems.

Who Should Undergo and Expected Results

Decortication is a standard procedure for the treatment of patients with complex empyema. Empyema is a condition that usually mimics the symptoms of pneumonia, which include fever, shortness of breath, dry cough, and chest pain. When pneumonia does not improve with treatment, empyema is usually suspected.

In some cases, the formation of fibrous peel overlaying on the lungs may resolve spontaneously without much intervention, or through antibiotics. However, when the symptoms of the pleural peel persist for more than 4-6 weeks, decortication should immediately be performed. Among symptoms of complex empyema that need prompt medical intervention include:

  • Difficulty breathing
  • Decreased breathing
  • High fever
  • Abnormal weight loss
  • Chest pain (usually sudden and sharp)


These symptoms occur due to worsening of empyema. If the inflammation becomes severe, scar tissue can form, causing the chest cavity to become divided into small cavities (a condition called loculation), which is more difficult to treat. If left unattended, the pleural peel will prevent the lungs from expanding, which can sometimes be fatal. Moreover, empyema can worsen into life-threatening complications such as sepsis, which symptoms include very high fever, fast heart rate, chills, low blood pressure, and rapid breathing.

Diagnosis of empyema and determining the presence of pleural peels are established through chest x-rays, ultrasound and CT-scans. Blood tests may also be required to identify the cause of infection. In some cases, a fluid sample in the pleural space is extracted using a needle inserted through the back for further analysis through a procedure called thoracentesis.

How is the Procedure Performed?

Decortication is performed under general anaesthesia. In severe cases, a full thoracotomy may be required where an incision is made into the pleural space of the chest to access the pleural peel and surgically remove it from the surface of the lungs. Decortication through full thoracotomy is a major surgical procedure, and is very complicated to do. A five or six-inch incision is made on the chest wall, through which the pleural peel is accessed and the infection is removed. Drainage tubes are placed to drain blood, which are retained for 4-7 days.

More modern techniques such as thoracentesis (VATS) can be alternatively performed for empyema cases that are discovered early on. This procedure is less invasive than full thoracotomy and involves the use of an endoscope to visually examine the lungs and pleural structures. A thin tube is inserted through the mouth and into the lungs. Several small incisions are then made into the chest to insert drainage tubes that drain out blood during the procedure. The scope accesses the pleural space, as the surgeon examines the entire area. Once empyema is confirmed, the surgeon inserts surgical instruments and makes several small incisions to peel off the fibrous pleural peel layer. Once the pleural capsules are fully removed, the lungs are re-inflated and the incisions are closed with sutures or staples. The entire procedure takes about an hour or two to complete.

After the procedure, patients are usually hospitalised for a few more days to ensure proper healing and restoration of lung function. Antibiotics and pain medications also continue for several days. Follow-up check-ups and X-rays will be required after a certain period to ensure that the pleura has properly healed.

Possible Risks and Complications

Decortication is a procedure with high success rates and lung function restoration is usually remarkable. However, just like any major operation, decortication involves risks and possible complications, which include:

  • Complications due to anaesthesia applied
  • Bleeding
  • Wound infection
  • Pleural cavity infection
  • Pain or numbness at the incision site
  • Inflammation of the lungs (pneumonia)
  • Air leak in the lung wall

    References:

  • Mandal AK, Thadepalli H, Mandal AK, Chettipalli U. Posttraumatic empyema thoracis: a 24-year experience at a major trauma center. J Trauma. 1997 Nov. 43(5):764-71.

  • Hountis P, Chounti M, Matthaios D, Romanidis K, Moraitis S. Surgical treatment for malignant pleural mesothelioma: extrapleural pneumonectomy, pleurectomy/decortication or extended pleurectomy?. J BUON. 2015 Mar-Apr. 20(2):376-80.

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