Decortication and Pleurectomy

Abstract

The pleural space is a potential cavity between the lung and the chest wall—more specifically, between the visceral and parietal pleura. The pleura typically is less than 1 mm thick in the normal, healthy patient. However, a variety of pathologic processes can occur that alter the transport of cell and fluid within the pleural space. The processes compromising the pleural space can lead to severe clinical symptoms and resultant patient compromise. Blood and infection (bacterial and mycobacterium) remain the common causes of fibrothorax. The authors review the common causes, pathophysiology, and diagnosis of fibrothorax; management and indications for decortication; technical aspects of the operation and management of residual pleural space issues; and the expected outcomes.Comparative data as to optimal therapy are lacking, and clinical judgment is typically the driver of care decisions. As such, a multidisciplinary approach is a key factor to ensuring optimal patient outcomes. Thoracoscopy appears to have a clear clinical advantage over open thoracotomy in managing the earlier stages of empyema and clotted hemothorax. Technical goals of thoracoscopy must not be compromised. Complete lung expansion and avoidance of pulmonary parenchymal injury are critical. The successful management of the patient with fibrothorax requires adherence to basic surgical tenets: appropriate patient selection for surgery, preoperative optimization, exacting attention to the technical aspects of the procedure, and timely interventions for perioperative events. The combined expertise of the pulmonary medicine team, radiology, and the surgical team is typically needed to ensure optimal patient-centered outcomes.This review includes:5 Figures, 3 Tables, and 24 References.