- Author: Shabir Bhimji, MD, PhD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
Decortication is a surgical procedure that removes a restrictive layer of fibrous tissue overlying the lung, chest wall, and diaphragm. The aim of decortication is to remove this layer and allow the lung to reexpand. When the peel is removed, compliance in the chest wall returns, the lung is able to expand and deflate, and patient symptoms improve rapidly.
In most people, the pleural space is less than 1 mm thick. When this space is violated by any number of pathological disorders, the distribution of certain cells and fluid can be altered, with serious medical consequences. One common pathological process that affects the pleural space is fibrothorax, which is an abnormal accumulation of fibrous tissues over the lung or visceral pleura. The fibrous tissues that deposit over the lung parenchyma can be so intense that the underlying lung fails to expand. Over time, the lung becomes entrapped or encased.
Although decortication is an effective surgical procedure for this condition, its success depends on careful selection of patients. As in all thoracic surgery procedures, the preoperative workup should be thorough and the surgery should be done at a particular timed interval. Moreover, the surgeon should also be technically skilled at entering the chest and removing the peel. In some cases, the intercostal space is fused and it is almost impossible to enter the chest cavity.
See the images below.
The primary indication for decortication in a patient with fibrothorax is presence of symptoms due to lung restriction resulting from development of a thick fibrinous peel. The timing of surgery is vital for success. In many cases, the peel may spontaneously resolve and the symptoms may subside. Most surgeons will perform a decortication for the following conditions:
The pleural peel has been present for more than 4-6 weeks
Lung symptoms are disabling
There is radiological evidence of a trapped lung
Decortication is frequently necessary when other minor interventions (eg, chest tube) have not resulted in clearance of the infection or hemothorax. Tuberculous empyema is usually first treated with drugs and decortication is only undertaken after long-term drug therapy fails.
Other than the physiological fitness of the patient, there are no absolute contraindications to decortication. In some patients who also have underlying lung disease, removal of the peel may not help the lung expand and thus surgery would be futile.
Other conditions that may make decortication futile include the presence of a pleural space infection and large airway stenosis. In such cases, the lung will not expand to fill the pleural space. A more extensive pleuropneumonectomy may be the only option, but only if the patient has been worked up preoperatively. Pleuropneumonectomy is a major undertaking with a very high mortality.
Decortication may not be possible in presence of uncontrolled lung infection or contralateral lung disease, or for a chronically debilitated patient. Medical optimization may be required prior to undertaking surgery in these patients. Ideally, the patient's nutritional status should first be normalized (with nasogastric feedings if necessary) and sepsis should be controlled with appropriate antibiotic therapy.
Other relative contraindications include coagulopathy, severe chest wall infection, and terminal disease.
Decortication gives the best results in patients who seek early treatment. Fibrothorax is a time-dependent process and can be prevented. Depending on the cause, insertion of a chest tube to remove an effusion or hemothorax may prevent the development of fibrothorax.
Among patients with chest trauma who suffer a hemothorax, placement of a chest tube and complete drainage usually prevents development of fibrothorax. Numerous studies have shown that early and complete evacuation of clotted hemothorax and parapneumonic effusions leads to decreased morbidity and mortality.
Some of the reasons that may explain an incomplete return of lung volume include elevation of the diaphragm, mediastinal shift, intercostal muscle fibrosis, or decrease in size of the thoracic cavity. Some experts believe that the longer the empyema is allowed to progress, the less the likelihood that lung function will return back to normal. Although some authors report an association between shorter course of disease and improved outcomes, this is not a universal finding among all surgeons.
Even though no studies have been done to explain failure of the lung to expand after so-called successful decortication, the most likely reason is either technical difficulties or incomplete removal of the peel. In many cases, the plane of dissection can be difficult. Too much persistence in removing the thin peel can also injure the underlying lung parenchyma and result in massive air leaks.
Inability to define the plane of dissection between the peel and the visceral pleura is an especially troublesome technical challenge that can adversely affect results. If visceral pleurectomy is performed, air leakage and postoperative hemorrhage may compromise pulmonary function. Care must be taken throughout the operation to protect the phrenic nerve from injury; fortunately, this usually is not an issue, because the mediastinal pleura is rarely involved in the inflammatory process. Incomplete parietal pleurectomy or inability to free the diaphragm may also compromise results.
If patients are appropriately selected, complete reexpansion of the lung after decortication can usually be achieved. Occasionally, however, an issue related to residual pleural space might arise after an otherwise technically satisfactory decortication. If this space is not obliterated, failure is inevitable.
The results after decortication are often fruitful. The morbidity and mortality after a decortication is dependent on the patient age, underlying comorbidities, and development of complications from the surgery. Decortication in general has an excellent outcome in young people.
In younger patients with benign causes of fibrothorax, the outcome is excellent and quality of life is much improved. Most patients begin to feel relief of symptoms soon after surgery. In elderly patients with multiple comorbidities, recovery is often slow but symptom relief is also better. The majority of patients regain their previous exercise endurance and are able to return back to their original work.
However, when the procedure is done in patients with compromised lung function, the morbidity can be high. Besides surgery itself, the thoracic incision and general anesthesia also carry a high morbidity in people with no lung reserve. Old data suggest that the overall mortality in healthy people is less than 1% but may run as high as 4-6% in individuals with underlying lung disease. However with video-assisted thoracoscopic surgery (VATs), the current mortality rates are slightly lower.[6, 7, 8]
To avoid complications, the surgeon has to pay attention to detail. The peel should be removed with great care and injury to nearby organs should be avoided. If the decortication is done adequately, lung function improvement is remarkable. However, the ultimate return of lung function depends on preoperative lung disease.
If the lung parenchyma was normal prior to surgery, then complete reexpansion of the lung and obliteration of the pleural space is certainly possible. In most cases, lung volumes improve after decortication, but it is rare to see return to preoperative values.
The boundaries of the pleural space are the visceral pleura, which envelops the lungs, and the parietal pleura, which is the inner lining of the thoracic cavity. The goal of decortication is to remove all the fibrinous peel and necrotic tissue, and help the lung reexpand and equally important not to leave any residual air spaces.
The two most common problems encountered when performing decortication are a pleural cavity infection and fibrosis. It is difficult for the underlying lung to expand when there is a thick peel overlying the parenchyma. Consequently, there is a large residual space left in the chest cavity that almost always gets infected. Therefore, for the surgeon to have good success with decortication, timing of surgery is crucial.
If the disease has been chronic, the rib spaces are often fused and the chest cavity is severely constricted. Entry into the chest can be very difficult. If the peel is very thick and adherent, injury to the lung parenchyma can occur with moderate air leak. If the lung has an inherent disorder, the possibility of reexpansion may not occur. Finally, decortication is not a trivial procedure and can be very bloody; thus, the patient must also be physiological fit to undergo the procedure. All these factors must be considered when planning a decortication.
Moreover, once inside the chest cavity, no lung may initially be visible because of the thick fibrous peel. The peel can vary in thickness from a few millimeters to few centimeters. One may also find necrotic debris and abscess along the chest cavity. It is important to avoid dissection along the medial border of the lung because the heart chambers are close by. The dissection should be started on lateral aspects or near the fissures. In most cases, the lower lobe is fused with the diaphragm and one can easily enter the abdominal cavity if the dissection is too deep.
For safe decortication, the chest cavity is best entered at the 5th/6th intercostal space and dissection should be started where the peel is the thinnest and easily removed. It is important to reassess the anatomy every few minutes to prevent injury to the organs. Blind digital peeling should be avoided, especially near the apex of the lung. This area is best approached when the upper lobe can be retracted inferiorly and the lung apex is visible. Severe bleeding from injury to the subclavian vessels and pulmonary artery has been reported.
Because extensive decortication or radical pleurectomy can be associated with air leaks, methods have been described to reconstruct the diaphragm to help lower the incidence of postoperative complications.[13, 14, 8]
When performing a VATS procedure, one must be aware of the adjacent structures to avoid injury. On the superior aspect, the subclavian vessels can be found lying deep to the pleura but clearly visible. Along the medial border, one may come across the thymus, trachea, heart, phrenic nerve, aorta (on right), vena cava (on left), and the esophagus (posteriorly). In the posterolateral chest, one may come across the sympathetic chain, azygous vein, and the diaphragm (inferiorly).[1, 9]
Patient Education & Consent
An informed consent should be obtained from all patients. The possibility that a VATS procedure may be converted to an open thoracotomy should be included in the discussion.
In the preoperative workup, it is important to find out the cause of the fibrothorax. The two most common causes that lead to fibrothorax in North America are traumatic hemothorax and parapneumonic effusion.[15, 16, 17]
All thoracic surgery procedures carry definite risks as well as benefits. Preoperative identification and amelioration of these risks will enhance postoperative outcomes. Factors that increase postoperative risk include the following:
American Society of Anesthesiologists Physical Status class 2 or higher 
Coronary artery disease
Chronic obstructive pulmonary disease
Extensive lung resection
Extensive bleeding during surgery
If the patient has any of the above issues, it is important to work up the patient to avoid unnecessary complications. Important details in the preoperative workup should include the following:
Thorough history and physical
Pulmonary function test
Cardiopulmonary exercise test
Routine pulmonary function tests that must be done for all patients undergoing thoracic surgery include lung volume, lung mechanism, airflow, and gas exchange. These tests can help define the degree of lung dysfunction and help the surgeon stratify the risk.
Pulmonary function testing may reveal moderate to severe lung function in patients with fibrothorax. However, these values should not be a contraindication to surgery because the majority of patients will improve once the peel is removed.
It is also important to assess the cardiac risk factors in patients undergoing decortication. Thoracic surgery procedures have the highest incidence of associated postoperative congestive heart failure, arrhythmias, and myocardial reinfarction. A thorough cardiac history is vital in the preoperative valuation of patients and the findings should be correlated with appropriate physical findings and results of laboratory testing.
Patients who are completely asymptomatic and have no cardiac risk factors for coronary artery disease regardless of age do not need testing. Patients with symptomatic heart disease or laboratory evidence of a cardiac dysfunction suggestive of cardiac disease need further assessment. If symptoms of cardiac disease are present, stress testing should be considered.
Preoperative education of the patient should include techniques of maintaining good bronchial hygiene. The patient must be taught how to generate an effective cough. Pillows should also be provided to help the patient forcefully exhale.
The first imaging modality in a patient with suspected fibrothorax or empyema is always a chest radiograph. However, computed tomography (CT) scanning of the chest is routine as it offers better resolution, location, and defines the fibrous peel and disease process. A CT scan can also assess the presence of any associated lung disease (eg, pneumonia, bronchiectasis, cancer).
The presence of other lung diseases, such as tuberculosis or mesothelioma, may play a significant role in surgical decision making. It is important to rule out cancer in the differential diagnosis of fibrothorax because the treatment option for a malignant mesothelioma is quite different from a benign fibrothorax.
The improvement in shortness of breath, reexpansion of lung, and parenchymal function may be estimated based on the lung function tests and CT scan. Eventually, it is the surgeon's clinical judgment that plays a key role in the decision to perform surgery or undertake a conservative medical approach.
The majority of early parapneumonic effusions are thin and readily aspirated. In the fibropurulent stage, the fluid becomes viscous and a chest tube may not always work, especially if the fluid is loculated or there is clotted blood. In such cases, cleaning of the chest can be performed with VATS. The thin peel can be removed and all the debris removed. This allows the underlying lung to reexpand.
The patient is positioned in the lateral decubitus position with the affected side up. An axillary roll is essential, and a sandbag may be used for support. Great care should be taken to pad all pressure points. Both the front and back of the patient should be supported with a sandbag. Pillows should be placed in between the lungs. The patient's entire chest is prepared with povidone-iodine (Betadine) and draped. The draping should be wide enough just in case there is a need for a thoracotomy.
Monitoring & Follow-up
The management of a patient who has undergone a decortication is no different than a patient who has undergone a lobectomy. Unlike a lobectomy, decortication results in faster recovery of lung function.
The decision to initiate or continue mechanical ventilation is usually based on an assessment of gas exchange, impending respiratory failure, and the ability to protect the airways. Some patients have an indwelling arterial line placed by anesthesia in the operating room to facilitate one lung anesthesia. Arterial blood gas should be frequently sampled to assess both PaO2 and PaCO2. Most patients do well with oxygen delivery by a face mask or nasal cannula. The majority of patients can be extubated in the operating room.
If a monitored bed on the surgical floor is not available, an overnight stay in the intensive care unit (ICU) is recommended. The majority of patients who undergo thoracic procedures are observed in the ICU or a stepdown unit for 12-24 hours. If the course is uneventful, the patient may be discharged to a monitored surgical floor. To reduce fluid overload, most thoracic patients are kept on the dry side. Unless the patient is not eating at all, the intravenous fluids are maintained at a minimum.
Postoperative management of the chest tube is dictated by culture results, intraoperative findings, and the patient's clinical status. Chest tubes are monitored for both air leak and fluid drainage every 8 hours. Blood work is usually done once on the following day to assess the hemoglobin and renal function. A postoperative chest radiograph is routine. Unless the patient has a problem, some doctors only order radiographs before and after removal of a chest tube.
Judicious use of analgesia is necessary. Patient-controlled analgesia is routinely available in most hospitals and helps ease the pain for the next several days. Once the chest tubes are removed, the patient can be placed on transdermal fentanyl and augmented with nonsteroidal anti-inflammatory drugs. Whenever possible, surgeons should attempt an intercostal block. Very fine catheters can be placed along the posterior rib angles. Bupivacaine and epinephrine can be infused intermittently via these catheters.
Other factors in the postcare include chest physiotherapy, tracheal suctioning, and ambulation. To prevent atelectasis, incentive spirometry is vital and should be apart of preoperative teaching. The cardiovascular system also has to be closely monitored after surgery. Arrhythmias and myocardial infarction can occur; thus, cardiac monitoring for the first 48 hours is required. The incidence of cardiac complications is higher in the elderly and those with preexisting cardiac risk factors.
Most patients remain in the hospital until the chest tubes have been removed and they are able to tolerate diet. Physical therapy is a vital component of postoperative care and should be encouraged. Deep vein thrombosis prophylaxis is highly encouraged, even if patients are ambulatory. Because patients may be present or past smokers, oxygen and nebulizer therapy is often administered. The average stay after a thoracotomy procedure varies from 3-5 days, but patient who undergo VATS may be able to go home within 48-72 hours.
Numerous series show that VATS allows for rapid recovery, significantly less pain, and reduced postoperative complications. Irrespective of the type of surgery, most patients need a prescription strength pain pill for a few days at home. Others may benefit from a fentanyl patch.
All patients are seen within 5-7 days after discharge. At the first postoperative visit, the staples may be removed and a wound check is performed. A chest radiograph is done to assess for presence of full lung expansion, pneumothorax, or pleural effusion. All patients are encouraged to continue with physical therapy.
Decortication is associated with a wide range of complications, including infections (perioperative sepsis syndrome), bronchopleural fistulas, bleeding, and persistent air leak. Prolonged air leak or bronchopleural fistula may require a second surgery in some cases.
Most air leaks seal within a few days, but large leaks may persist for weeks.
Bleeding can occur from the lung or pleural surface or from lysis of adhesions. Thus, it is vital to ensure good hemostasis prior to leaving the operating room. Most surgeons secure blood vessels with a suture as well as a clip.
Residual air space is a frequent problem and can occur when there is injury to the lung parenchyma.
Infection of the pleural space can occur when a residual air space persists. In some cases, the patient may need a muscle flap or an apical tent to close off the residual space and eliminate the infection.
Respiratory failure is not a direct complication of surgery. Patients who have borderline lung function are more likely than healthy people to develop respiratory distress in the postoperative period. If the preoperative workup was not adequate or if a high-risk patient underwent surgery, tha patient may require prolonged ventilation and even a tracheostomy.
Cardiac complications may include acute myocardial infarction and arrhythmias.
As with all thoracic surgical procedures, a bronchoscopy is performed prior to positioning the patient. It is essential to identify any large airway pathology, such as bronchial stenosis, broncholith, malignancy, or mucus plug that may be the cause of lung collapse.
The patient is intubated and surgery is done under general anesthesia. Single lung ventilation is rarely necessary because the lung on the affected side is already compressed from the fibrothorax. In fact, surgery becomes easier when the lung is expanded.
Video-Assisted Thoracoscopic Surgery
Video-assisted thoracoscopic surgery (VATS) is an option for most patients with thoracic pathology. This technique has been shown to have better outcomes, less pain, and shorter recovery than the open approach. VATS is currently the gold standard for early cases of empyema. VATS is a better alternative to thoracotomy and is done under general anesthesia using a camera and two trocar ports. The VATS technique is very similar to the open technique, except instruments are used to retract and dissect.
Local anesthesia is injected into the skin sites where the ports are to be inserted into the chest cavity. In general, the camera is usually in the midaxillary line and portholes are made on either side of the camera. The entire surgery can be performed with the 3 ports; rarely, a 4th port may be required for retraction of the tissues or for suctioning of smoke, pus, or blood.
During the early disease process, the peel is usually thin and easily removed from the lung parenchyma; in such cases, VATs is the ideal modality of treatment. The thoracoscopy approach can help remove the peel, clean the necrotic debris, and break up any loculations. With the chronic process, a thoracoscopy is often difficult because the ribs may be fused and the peel may be very thick. Chances of injury are very high in the chronic cases; thus, thoracoscopy is best avoided.
The fibrin peel is removed in a piecemeal fashion from the parietal and visceral pleura. Great care is required when removing thin peel from the visceral pleura because this can lead to air leaks. During the surgery, the scope may be alternatively placed in the different ports to obtain a better view of the lung. The peel may be removed with a grasper or peanut dissector.
Once the peel has been removed and the pus suctioned out, the chest cavity is irrigated. Two chest tubes are inserted via the port sites. The scope is removed and the underlying subcutaneous tissues and skin are closed.
The patient should be positioned in the lateral decubitus position. The chest is entered at the premarked intercostal space, which is usually the 5th or 6th intercostal space. An axillary thoracotomy also may be performed, but this exposure is only good for apical disease and does not give great exposure to the lower chest. See the image below.
Although some surgeons prefer to spare the latissimus dorsi and serratus muscle, this is sometimes difficult to do in patients with empyema. Often the muscles are edematous or contracted and hard to dissect off the chest wall. However, all attempts must be made to preserve the muscles because they may be needed to cover residual airspace or air leak.
In many cases of chronic empyema, the procedure can be made easier by first resecting a rib in a subperiosteal fashion. This maneuver also provides an intercostal muscle flap, avoids breaking another rib during chest opening, and facilities good exposure to the entire chest.
In most chronic cases, the pleura are fused and it is simply easier to perform pleurectomy. If the adhesions between the visceral and parietal pleura are not dense, then one may proceed with sharp dissection of the adhesions.
Once the correct plane of dissection is visualized, the peel can be removed relatively easily. However, in most cases, the peel is removed in segments. The entire lung must be checked to make sure that the peel has been removed; otherwise there will be failure to reexpand the lung.
A pleurectomy that is too deep may cause parenchymal injury with resulting air leaks. These air leaks can prolong hospital stay. The anesthesiologist should be asked to gently inflate the lung during the procedure. This allows the peel to become more prominent and easily detached from the lung surface. Traction and countertraction is key. Of course, it is inevitable that some minor injury to lung parenchyma will result, but the resultant air leaks usually seal over very quickly.
Sometimes a scalpel may have to be used to make an incision in the thick peel and define the plane of dissection. The peel can be grasped with a hemostat and then dissected with a peanut dissector or the back end of a DeBakey forceps.
Patience is key to performing decortication. Speed simply increases the chance of injury to the lung parenchyma with more air leaks. The peel should be followed, lateral, medially, and superiorly over the lung surface. It is vital to remove the peel from the lung fissures and all the way down to the diaphragm.
In most cases, the thickest segment of the peel is along the costodiaphragmatic surface. Most of the peel here can be removed with finger dissection, but care should be undertaken when placing the fingers along the medial border. Here one can injure the phrenic nerve, the blood vessels, and diaphragm. If the peel thins out or is difficult to remove, one should not persist but go to anther site. Some segments of the peel should be sent for pathological and microbial analysis.
Once the peel is removed, the lung is checked to confirm that it is capable of complete reexpansion. Any large parenchymal air leaks that are noted may be overseen, but this step often is not necessary. There are several pulmonary sealants now commercially available that can reasonably close air leaks.
One chest tube is placed along the base of the diaphragm and one is placed in the apex. The chest should be irrigated and all blood should be suctioned, as it can be a nidus for infection.
For some patients, neither VATS nor an open thoracotomy may be appropriate; in such cases, there are other options. On rare occasions, thoracoplasty with multiple rib resections may be considered to obliterate any infection in the residual space by bringing the chest wall down to fill the space. One may leave a chest tube for prolonged periods; remove a segment of the rib in the most dependent position to allow for drainage. These secondary options are only for frail and ill patients. For most patients with diffuse pleural disease, decortication is still the criterion standard.
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