Browse the corpus

Lung decortication is a surgical procedure to remove a thick, fibrous pleural rind that restricts lung expansion, most commonly resulting from chronic empyema, hemothorax, or fibrothorax. The operation restores pulmonary compliance, reestablishes normal intrathoracic mechanics, and improves ventilation–perfusion matching by allowing the lung to fully reexpand. Optimal outcomes depend on patient selection, as those with significant pleural fibrosis but preserved parenchymal function experience the greatest benefit. Preoperative imaging, careful surgical planning, and meticulous intraoperative technique are essential to minimize complications and achieve functional recovery. By participating in this course, clinicians enhance their understanding of the indications, anatomy, physiology, and surgical principles underlying lung decortication. They gain competence in identifying appropriate surgical candidates, interpreting imaging to guide operative planning, and applying evidence-based perioperative management strategies to optimize patient outcomes. Interprofessional collaboration and care coordination principles will be emphasized to promote patient safety, minimize complications, and improve postoperative respiratory function and quality of life. Objectives: Create individualized perioperative care pathways incorporating preoperative pulmonary optimization, pain management, and postoperative rehabilitation. Differentiate reversible restrictive pleural processes from irreversible parenchymal disease to ensure appropriate surgical selection. Determine the optimal surgical referral and intervention timing to prevent progressive lung entrapment and respiratory compromise. Collaborate with an interprofessional team including surgeons, anesthesiologists, pulmonologists, infectious disease specialists, nurses, respiratory therapists, and rehabilitation professionals to optimize patient outcomes. Access free multiple choice questions on this topic.

Approximately 1 million patients are hospitalized in the United States each year with pneumonia. Of those hospitalized for pneumonia, 20% to 40% will develop a parapneumonic effusion, and 5% to 10% of these parapneumonic effusions will progress to an empyema (approximately 32,000 patients per year in the United States). Approximately 15% of these patients with empyema die, and 30% require an operation on their chest to clear the infection.[1][2] Lung decortication is a well-established procedure that Delorme first performed in 1895 to treat empyema.[3] This procedure is primarily indicated in chronic empyema thoracis (pyogenic or tuberculous), hemothorax, pleural thickening, and other similar conditions. Decortication involves excision the restrictive layer of the thick fibrinous peel overlying the lung, chest wall, and diaphragm. The decortication extends over the visceral pleura covering the lung surfaces, including the fissures, along the parietal pleura of the chest wall and diaphragm. Notably, the mediastinal surface of the lung is generally spared, except where adhesions can be safely released without risk to vital mediastinal structures. This thick fibrinous peel results from the ingrowth of the fibroblasts during the advanced stages of empyema.[4] Apart from its proven utility in advanced stages of empyema, favorable outcomes have been shown by Shin et al when decortication was adopted as the first-line treatment for empyema.[5] The primary objectives of this surgical procedure are to restore lung expansion, remove the source of infection, and prevent deformity due to fibrothorax.

The common complications of lung decortication include: Hemorrhage Blood loss from the raw lung surfaces can result in a significant hemorrhage. A postoperative blood profile should be performed to determine the need for a blood transfusion. Persistent air leak and bronchopleural fistula Minor air leaks can occur during the decortication process. However, these leaks resolve spontaneously after a few days. Large leaks must be closed with formal suturing to avoid the development of a bronchopleural fistula. Persistent lung collapse Collapse and nonexpansion of the lung parenchyma are frequently observed in the postoperative period following decortication. Incentive spirometry and chest physiotherapy play crucial roles in the re-expansion of the underlying parenchyma. However, some patients may not show adequate lung expansion due to diseased or destroyed lungs. Injury to vital structures Decortication must be performed carefully by experienced surgeons. If the limits of peel removal are not followed, injury to vital structures, including subclavian vessels, diaphragm, esophagus, and pericardium, is common. Retained infective focus and sepsis During decortication, the pus must be thoroughly removed, and pleural toileting performed. Retained pus is a nidus of infection and may lead to sepsis in the postoperative period. Severe postoperative pain Any thoracotomy, especially those with rib resection, may lead to significant pain in the postoperative period. Adequate postoperative analgesia is a must and may require a combination of intravenous and epidural analgesia. Chest wall deformity and scoliosis

Effective care for patients undergoing lung decortication requires a coordinated, multidisciplinary approach emphasizing clinical skill, strategic planning, and seamless communication among healthcare professionals. Clinicians must possess strong diagnostic and procedural skills to identify candidates who most benefit from surgery—those with significant pleural fibrosis but relatively preserved lung parenchyma. Radiologists contribute by providing detailed interpretation of chest radiographs and computed tomography scans, guiding operative planning, and confirming the extent of pleural thickening. Surgeons, anesthesiologists, and intensivists collaborate to ensure preoperative optimization, intraoperative precision, and vigilant postoperative monitoring. Nurses are critical in perioperative care, pain management, respiratory assessment, and early mobilization, which are key to preventing complications such as atelectasis or pneumonia. Interprofessional communication and care coordination are essential for improving outcomes and patient safety. Pharmacists are crucial in selecting and managing antibiotics, anticoagulants, and analgesics. At the same time, respiratory therapists provide postoperative pulmonary hygiene and ventilatory support. Case managers and rehabilitation specialists coordinate discharge planning and follow-up care to facilitate a smooth recovery. Regular interdisciplinary case discussions, standardized care pathways, and shared documentation systems enhance team performance, reduce errors, and ensure patient-centered continuity of care. This collaborative framework improves functional recovery and quality of life and reinforces a culture of safety and accountability throughout the surgical continuum.