Continuous pleural lavage may decrease postoperative morbidity in patients undergoing thoracotomy for stage 2 thoracic empyema.

OBJECTIVE: To assess the impact of postoperative continuous pleural lavage (PCPL) after thoracotomy for the treatment of stage 2 pleural empyema in relation to postoperative length of stay and morbidity. METHODS: Stage 2 pleural empyema was diagnosed with computer tomography. Conservative treatment including antibiotics and pleural aspiration was introduced. 89 patients treated for stage 2 pleural empyema by thoracotomy, pleural discharge evacuation and irrigation after pleural decortication were identified after unsuccessful conservative treatment for 10 days. Whenever pleural discharge remained opaque after operation, PCPL was administered daily through the cranial chest tube and discharge evacuated through the caudal pleural suction (10-15 mmHg) tube. Risk factors related to pleural pus and patient outcome were sought for. RESULTS: Seventy-seven out of 89 patients (86.5%) had clear empyema discharge immediately after pleural decortication and irrigation. Pleural discharge remained opaque despite surgery in 12 out of 89 patients (13.5%) and PCPL was introduced. Presence of a combination of risk factors for pleural empyema, such as dental caries, alcohol abuse or previous inflammatory reaction, was predictive for persistence of opaque pleural discharge after operation (P<0.05). Need for re-thoracotomies (in 11 cases, P=ns) and postoperative deaths (P<0.05) were related with patients who did not have PCPL. The length of the hospital treatment was 20.1+/-3.1 (days+/-SEM) among patients with PCPL and 19.2+/-1.8 without PCPL before possible re-thoracotomy, respectively (P=ns). CONCLUSIONS: Early postoperative (1 day-11 months) mortality was statistically associated with patients having fibrinopurulent empyema but no PCPL. PCPL is a feasible method to clear pleural pus discharge without prolongation of hospitalization and may be recommended after thoracotomy for patients with fibrinopurulent stage 2 empyema.     

Video-assisted evacuation of empyema is the preferred procedure for management of pleural space infections

BACKGROUND: Empyema remains a cause of morbidity and mortality. Thoracoscopy has proved its versatility in the management of pleural space disorders. The suitability of video-assisted thoracic surgery (VATS) for decortication in the management of the fibrotic stage of empyema is unclear. METHODS: VATS evacuation of empyema and decortication was performed on seventeen patients presenting with pleural space infections. A retrospective review was performed and constitutes the basis of this report. RESULTS: VATS evacuation of empyema and decortication was successfully performed in 13 of 17 patients. Blood loss was 325 +/- 331 cc. Mean hospital stay was 18 +/- 10 days. Postoperative hospitalization was 11 +/- 7 days. Chest tubes remained in place for 7 +/- 3 days. There were no operative mortalities. CONCLUSIONS: Video-assisted evacuation of empyema and decortication is an effective modality in the management of the exudative and fibrinopurulent stages of empyema. An organized empyema should be approached thoracoscopically, but may require open decortication.     

The use of talc for pleurodesis in the treatment of resistant empyema

The use of talc in the infected pleural space has not been reported previously. Five patients who had empyema of the pleura in the fibrinopurulent stage and did not respond to treatment with tube drainage and antibiotics were treated by talc insufflation to stimulate pleural adhesions. Pleurodesis was achieved in all 5 patients, with complete recovery from empyema. No untoward effects were observed. These results suggest that talc pleurodesis may be an acceptable solution to the problem of empyema resistant to other methods of treatment.     

Video-thoracoscopic and open surgical management of thoracic empyema

PURPOSE: To evaluate the outcomes of video-thoracoscopic and open surgical management of patients with thoracic empyema. METHODS: We studied 122 patients retrospectively who underwent surgery for thoracic empyema in our hospital between January, 1999 and January, 2005. Patients' medical records, surgical procedures, and outcomes were reviewed. The study identified 97 affected men and 25 affected women with a mean age of 54 years (range 16-78 years). The empyema was parapneumonic in 95 patients (78%). RESULTS: Forty-four patients who had stage II empyema underwent video-assisted thoracic surgery (VATS). The procedure was converted to thoracotomy in 13 patients (29.5%); the morbidity and mortality rates of VATS were 13% and 0, respectively. Seventy-eight patients had stage III empyema and, along with those 13 who were converted, underwent thoracotomy for decortication. The associated morbidity rate was 12%, and the mortality rate was 6.6%. Thoracotomy was considered successful in 90 of 91 patients (99%); one patient needed a reoperative thoracotomy for an organ space/surgical site infection with pus in the pleural cavity. CONCLUSIONS: Many treatment modalities are available for thoracic empyema, depending on the results of appropriate clinical and laboratory investigations. In fibrinopurulent empyema, VATS debridement is safe and effective, with minimal morbidity and no deaths. Lung decortication via thoracotomy is the only option for organized empyema and is associated with a substantial mortality rate.     

Modern tailored therapy for pleural empyema

In spite of the development and widespread avail-ability of modern antibiotics, pleural empyema still represents a serious intrathoracic disease -associated with significant morbidity and mortality. Patients with complicated parapneumonic effusions and empyema have an increased morbidity and mortality due at least in part to inappropriate and delayed management of pleural space infections. Timely diagnosis of pleural empyema and rapid initiation of the appropriate surgical treatment modality represent keystone principles for efficient treatment of thoracic -empyema. Simple drainage, minimally invasive surgical treatment modalities (VATS) and image-guided small-bore catheters in combination with adjunctive fibrinolytic drugs have extended the potential therapeutic arsenal. Individual case management with a flexible selection of the most appropriate treatment modality by experienced thoracic surgeons may lead to improved outcomes. In this context a summary of the most recent opinions and results in thoracic empyema management is outlined in the present review.     

Intrapleural streptokinase in the management of empyema.

BACKGROUND--Significant morbidity and mortality result from the ineffective evacuation of empyema. Failure of conventional first line treatment with closed intercostal tube drainage and antibiotic therapy may result in fibrin deposition and loculated empyema. Enzymatic debridement using intrapleural instillation of streptokinase is a non-invasive therapeutic option which may obviate the need for surgical intervention. METHODS--Eleven adults with multiloculated post-pneumonic empyemas who had failed to respond satisfactorily to intercostal tube drainage and antibiotic therapy were treated with intrapleural streptokinase between November 1992 and January 1994. A small catheter was inserted under ultrasound guidance into a loculation within the pleural space. Aliquots of 250,000 units of streptokinase in 100 ml normal saline were instilled into the pleural cavity and the tube clamped for four hours. Response was assessed by clinical outcome, measurement of drain output after unclamping, and subsequent pleural ultrasound, chest radiography, or both. RESULTS--Streptokinase enhanced drainage in all patients. Complete resolution of the empyema with re-expansion of the underlying lung was effected in eight patients, all of whom remain well. Further resolution of minimal pleural thickening was shown on subsequent chest radiographs. Two patients with considerably thickened visceral pleura following empyema drainage underwent successful decortication. The other, with myocarditis and a pyopneumothorax, underwent surgery for non-resolution of the pneumothorax but died perioperatively from cardiac failure. The number of streptokinase instillations per patient ranged from two to six (median three), and the volume of empyema fluid drained per patient ranged from 100 ml to 4870 ml (median 900 ml). Streptokinase was well tolerated in all patients. CONCLUSIONS--Intrapleural streptokinase is an effective adjunct in the management of complicated empyema and may reduce the need for surgery.     

Experiences in stage-adapted therapy of pleural empyema]

INTRODUCTION: Up till now the phases adapted treatment of a pleural empyema unfortunately is still not obvious, but recently the operative spectrum has been widened in the field of video-assisted thoracoscopic surgery (VATS) of the pleural empyema. PATIENTS AND METHODS: In the present study we examined all our patients with a pleural empyema and we followed them for a postoperative period of 4 years analysing our therapy-efficacy and our treatment concept of pleural empyema. RESULTS: 52 out of 102 patients--who suffered from a pleural empyema in the last 10 years--were reexamined postoperatively. In 96% of the 102 cases we found a phase II-III empyema. Initially all patients were treated with a closed-chest-tube drainage, followed by an operation in 78%. In 6 cases a video-assisted-thoracoscopic evacuation of the cavity with an early decortication was performed. All the 52 patients who were treated in an early phase showed the best functional results 4 years later. CONCLUSION: Especially in phase III the open operative revision of a pleural empyema is the method of choice. In the fibrinopurulent phase the drainage therapy may be sufficient. If the empyema cavity is divided we recommend the early video-assisted-thoracoscopic revision of the thoracic empyema.     

Stage-adapted therapy of pleural empyema. Results during 1992-1998

Despite the decreasing number of patients suffering tuberculosis and the use of modern broad spectrum antibiotics the pleural empyema did not lose its relevance. The main reasons are increasing numbers of patients with drug and alcohol abuse or immunodeficiency of different causes. We retrospectively analysed the data of 73 patients treated of pleural empyema between 1992 and 1998. Considering the known stages of pleural empyema we present the corresponding therapeutic results. All patients classified as stage I were treated with a chest drain and cure was achieved in all of them (100%). The treatment for patients classified as stage II was different: 5 out of 32 were treated with a continuous irrigation and suction chest drain system. 18 patients first underwent thoracoscopy and were afterwards treated with a continuous irrigation and suction system. Another 9 patients primarily underwent an early open decortication. In 40% the treatment with the suction and irrigation system was successful. Using video-assisted thoracoscopy (VATS) cure was achieved in 94.4%, with open decortication in 100%. The preferred treatment of patients classified as stage III is the open decortication. After the first operation 80% (30 patients) were cured. 6 patients needed thoracoplastic procedures after the first intervention. No patient was discharged neither with a permanent chest drain nor a permanent thoracic window. With the results a cause dependent analysis of morbidity and mortality was done. The overall morbidity rate was 27.9% and the overall mortality 5.4%. The treatment of pleural empyema still remains to be problematic. Corresponding to our results pleural empyema classified as stage I is best treated with a simple chest tube. The video-assisted thoracoscopy (VATS) lacks of complications and is a very efficient method in treating stage II. The method of choice in stage III is the open decortication which in the case of a chronic and recurrent or persistent infection should be followed by a thoracoplastic procedure.     

Single-trocar thoracoscopy under local anesthesia for pleural space infection

Objective

The role of single-trocar thoracoscopy for complicated parapneumonic effusion (CPE) and pleural empyema is not established as yet. The aim of this study was to report our experience and analyze the efficacy and safety of debridement by single-trocar thoracoscopy for the patients with CPE and multiloculated empyema.

Methods

We performed a retrospective study reviewing the medical records of the patients treated parapneumonic effusion and multiloculated empyema by single-trocar thoracoscopy under local anesthesia at our department from January 2000 to December 2012.

Results

A total 29 patients with CPE and multiloculated empyema were treated by single-trocar thoracoscopy. As the staging of pleural infection, class 5 and class 7 by Light classification were 21 and 8 patients, respectively. The onset of the symptom was on average 13.9 ± 11.7 days before the procedure. This procedure was successful in 23 of 29 patients (79.3 %) without further operation under general anesthesia. Complication occurred in 1 case of 29 patients (3.4 %). Six patients required subsequently the operation under general anesthesia, and one of the 6 patients died to multiple organ failure caused by sepsis. A microbiological diagnosis could be made in fifteen patients (51.7 %).

Conclusions

Debridement by single-trocar thoracoscopy can be an acceptable approach as the first-line procedure in patients with CPE and empyema. This procedure can provide not only appropriate and expeditious treatment but also information of pleural cavity to decide indication for thoracotomy under general anesthesia.     

Pediatric thoracoscopic training in an experimental pleural empyema rabbit model

BACKGROUND: Thoracoscopy has proved to be effective in the treatment of stage 2 (fibrinopurulent) empyema, but this technique requires different abilities from those needed in open surgery. The aim of this study is to evaluate the usefulness of an experimental empyema in rabbits as a thoracoscopic training model. MATERIALS AND METHODS: Twenty New Zealand rabbits were anesthetized with acepromazine and ketamine. A Veress needle was introduced into the pleural space, and a turpentine and saline solution were injected. Twenty-four hours later, 1016 colony-forming units of Escherichia coli and 1 g of agar in 1 mL of saline solution were injected. The rabbits were operated on 96 hours after bacterial injection by 30 pediatric surgeons attending a hands-on pediatric laparoscopic course. The contralateral lung was selectively intubated and three ports were placed to perform an empyema debridement. The surgeons evaluated the model using subjective criteria from an evaluation form. RESULTS: One animal died (5%) and 2 (10%) did not form empyema. The other 17 rabbits (85%) presented with a fibrinopurulent empyema. All usual surgical steps could be performed. As regards the surgeons' opinion of the model, 23 (76.7%) considered it very good while 7 (23.3%) thought it was good. Twenty-three (76.7%) answered that the empyema stage was correct for thoracoscopic treatment. CONCLUSION: As reflected by our experience and the survey completed by the 30 pediatric surgeons, this empyema model in rabbits is very useful for thoracoscopic training.     

Video-assisted thoracoscopic surgery for children with stage II empyema

Children with stage II empyema often fail traditional medical management, frequently succumbing to the effective albeit morbid clutches of thoracotomy. Video-assisted thoracoscopic surgery (VATS) has been recently introduced as a viable and potentially less morbid alternative to open thoracotomy. We review our VATS experience in children with empyema, assessing surgical outcome. Between August 1996 and March 1999, 13 patients at our institution with stage II empyema that did not respond to conventional medical management underwent a modified VATS with decortication. Data from retrospective chart review reflects intraoperative findings and postoperative course, including average time to defervescence, removal of thoracostomy tube, and hospital discharge. VATS was completed in all 13 patients. All intraoperative cultures of pleural fluid and fibrinopurulent debris obtained at VATS showed no growth. The average time to defervescence was 2.2 days (range, 0-4 days) and to removal of thoracostomy tube 3.6 days (range, 2-5 days). Average total chest tube days in patients with pre-VATS thoracostomy (n = 6) was 14.5 days (range, 8-37 days) versus 3.1 days (range, 2-5 days) in patients (n = 7) who underwent primary VATS (t test, p < 0.05). The average time to surgical discharge after VATS was 5.8 days (range, 3 to 19 days). All patients were well on follow-up clinic visits without delayed complications. VATS can be performed safely and effectively in children with stage II empyema, thus avoiding the morbidity of open thoracotomy and decortication. Importantly, early application of VATS significantly relieves patients of unnecessary days of thoracostomy drainage.     

Surgical treatment of chronic empyema

Empyema remains challenging for thoracic surgeons. This review covers diverse aspects of acute empyema and chronic empyema and its surgical treatment. The triphasic nature of thoracic empyema (stages I, II, and III) is also addressed. The principles of empyema treatment are early diagnosis and early treatment. For acute empyema (empyema in stages I and II), early surgical intervention, such as video-assisted thoracoscopic débridement, is recommended when conventional chest tube drainage has failed. Radical treatments of chronic empyema (empyema in stage III) include (1) removal of the empyema space (decortication with or without lung resection) and (2) obliteration of the pleural space with muscle flaps or omentum flaps, or by thoracoplasty. Decortication is the procedure of choice for patients with reexpandable underlying lung. When bronchopleural fistula exists in the underlying lung, the fistula should be securely closed. For those patients whose underlying lung cannot be expected to reexpand, the procedure of choice is either concomitant removal of the affected lung with the empyema space or obliteration of the pleural space. For patients who are not eligible for the above-mentioned radical treatment, open-window thoracostomy can be considered. This procedure is not only performed as a definitive treatment of empyema but also as a preparatory treatment for radical procedures. Radical procedures are performed when patients recuperate. Choosing the most suitable operation based on the stages of empyema, the conditions of the underlying lung, and the conditions of a patient holds the key to success.     

Position paper on video-assisted thoracoscopic surgery as treatment of pediatric empyema

Pediatric empyema can be managed with a variety of modalities, and the evidence for an ideal management strategy is limited. Early or simple effusions can be treated with antibiotics alone or with drainage when respiratory distress occurs. Once fibrinopurulent empyema has developed, therapy may involve either chest tube placement with instillation of fibrinolytics or video-assisted thoracoscopic surgery with pleural decortication. In late or fibrotic empyema, an assumption persists that the fibrotic peel must be managed by decortication that can be done either thoracoscopically or through a minithoracotomy incision.This position paper is coauthored by the New Technology Committee of the American Pediatric Surgery Association. The goal is to discuss the ongoing controversies and summarize, in an evidence-based manner, the various treatment options and to suggest a reasonable therapeutic algorithm for the care of children with empyema.     

Video thoracoscopic treatment in pleural empyema

BACKGROUND: To evaluate the possible role and the effectiveness of videothoracoscopy (VATS) in the treatment of pleural empyema. METHODS: Personal experience on 40 cases of pleural empyema treated by (VATS) during 5 years is reported. The underlying diseases were: pneumonia (32), pneumothorax (3), tuberculosis (2), abdominal diseases (2) and lung cancer (1). Before VATS at least one thoracentesis was performed to evaluate the characteristic of the pleural fluid. RESULTS: Due to complications related to thick pleural adhesions, in one case (2.5%) the procedure was converted to open surgery, while in the remaining 39 cases VATS was able to achieve a complete cleaning of the pleural space with re-expansion of the pulmonary parenchyma. The improvement of the clinical symptoms were observed after a mean period of 3.5 days (range: 1-12 days). Chest tube was removed in a mean period of 4.8 days (range: 3-11 days); five patients had prolonged air leak from 6 to 10 days after surgery. CONCLUSIONS: In conclusion we are of the opinion that VATS has to be considered a very important mean for the treatment of pleural empyema; its use in the fibrinopurulent phase of the disease should give very good results, while in the following phase its indications are controversial.     

Role of decortication in management of parapneumonic empyema thoracis in children

Background

Parapneumonic empyema thoracis is a rare complication of bacterial pneumonia in children that emencely increases the morbidity. Classically parepneumonic effusions are divided into three stages. Stage I or exudative stage, Stage II or fibrinopurulent stage and stage III or organised effusion stage. The present study was designed to highlight the role of open decortication by thoracotomy in cases of para-pneumonic empyema of stage II and stage III disease in children.

Methods

A prospective observational study was done on 31 children of less than 15 years of age, who presented with stage II and stage III parapneumonic empyema thoracis. They underwent decortication surgery through postero-lateral thoracotomy.

Results

Out of the 31 children included in this study, there were 21 boys (67.74 %) and 10 girls (32.26 %). The average duration of symptoms was 17.84 days. The mean duration of post-operative chest drain was 2.55 days. Staphylococcus aureus was the most frequently encountered organism isolated in culture of fibrino-purulent material from the pleural cavity in 12 cases (38.7 %). Mean duration of total hospital stay was 8.3 days.

Conclusion

Decortication by thoracotomy is a safe and effective approach for stage II & III parapneumonic empyema thoracis in children leading to early recovery and less hospital stay.     

Usefulness of thoracoscopic surgery in the diagnosis and management of thoracic diseases

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been recently utilised in the diagnosis and management of thoracic diseases. In this article we report our series of patients with established indications for VATS treatment. METHODS: Over the past 6 years we performed 104 VATS procedures for diagnostic and therapeutic purposes in 95 men and 39 women. The specific indications for VATS were: lung biopsy for undiagnosed diffuse lung disease, mediastinal biopsy and cysts, pleural effusion, empyema, pneumothorax and bullous lung disease, pericardial effusion and cyst, parvertebral abscess and solitary pulmonary nodules. RESULTS: There was no operative mortality. Postoperative non-fatal complications were seen in 7 cases. The overall median duration of chest tube drainage was 2.5 days and the mean postoperative stay 3 days. In diffuse lung disease a tissue diagnosis was obtained in all cases. Definitive diagnosis in the patients with undiagnosed pleural effusion was obtained in 90% of cases and the overall diagnostic rate was 98.5%. The success rate of the empyema (stage II) treatment and the therapeutic procedures is 100% after a mean follow-up of 12 months (range 6-30). Conversion to thoracotomy was needed in 6 cases. In all patients the postoperative pain was controlled with intake of non-narcotic analgesics with satisfactory results. CONCLUSIONS: VATS is worth considering and has been established as procedure of choice, with exceptional results in various chest diseases such as undiagnosed pleural effusions, recurrent, post-traumatic or complicated spontaneous pneumothorax, stage II empyema, accurate staging for lung cancer in the resection of peripheral solitary pulmonary nodule less than 3 cm, and lung biopsy for pulmonary diffuse disease.     

The role of thoracoscopy in the treatment of pleural empyema in children

Background The treatment of empyema with pleural drainage is a widely accepted surgical procedure. Currently, thoracoscopy often is used to treat this disease in some thoracic surgery centers. This report aims to present the authors’ experience with the treatment of pleural empyema and the benefits of thoracoscopy. Methods From 1997 to 2005, 49 children with a diagnosis of pleural empyema were treated by means of thoracoscopy in the authors’ department. The study group consisted of 21 girls and 28 boys, ages 1 to 17 years (mean age, 9.2 years). Thoracoscopic cleaning and drainage of the pleural cavity was performed for all the patients. Results Intraoperatively, stage I empyema was recognized in 7 children (14.3%), stage II in 30 children (61.2%), and stage III in 12 children (24.5%). Very good results were obtained for all the patients. There were no intra- or postoperative major complications. The drainage time was less than 5 days for 63.3% of the children. In the remaining group of patients, drainage exceeded 8 days only for 16.3%. The postoperative time was short. Emptying of the pleural cavity and full lung decompression were achieved in all cases. In four cases, pleural biopsy showed TB, which enabled early proper treatment. Conclusions Thoracoscopy can offer good visualization and cleansing of the empyema chambers, establishing efficient drainage even for patients with advanced stages of pleural empyema. Thoracoscopy enables collection of material not only for bacteriologic, but also for histopathologic examination. The method is minimally invasive, and risk for complication is comparable with that for classical thorax drainage.     

Video-assisted thoracoscopic surgery (VATS) for the management of parapneumonic pleural empyema

Parapneumonic pleural empyema has been classified by international societies and by pleural diseases experts into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, Light has classified pleural empyema according to radiological, physical and biochemical characteristics, and the American College of Chest Physicians (ACCP) has categorised patients with pleural empyema according to the risk of a poor outcome. According to these classifications, the management of the pleural empyema is based on the stage of the disease. The recommended treatment options in (ATS) stage I disease (Light classes I-III, ACCP categories I and II) are therapeutic thoracentesis or tube thoracostomy and antibiotics when necessary. In (ATS) stage II disease (Light classes IV-VI, ACCP category III), thoracoscopy (VATS) is the treatment of choice because it has a higher efficacy than treatment strategies that utilise tube thoracostomy or catheter-directed fibrinolytic therapy alone, whereas in (ATS) stage III disease (Light class VII, ACCP category IV), decortication via thoracoscopy or thoracotomy is the treatment of choice.     

Surgical Treatment of Postpneumonic Empyema

Postpneumonic empyema complicates 5% of all pneumonia cases. The loculated fibrinopurulent stage cannot be resolved by drainage tube insertion alone; it requires a débriding limited thoracotomy. Recent reports of series seem to indicate that video-assisted thoracic surgery (VATS) can replace thoracotomy advantageously. Eighty-six cases of postpneumonic empyema were operated on in our institution during the last 12 years: 33 cases (group I) using limited thoracotomy (1985–1991) and 53 by VATS (1992–1996). Data were collected prospectively for group II and retrospectively for the first group. The two populations were comparable in age, gender, stage of disease, and co-morbid status. There were no significant differences between the groups. VATS débridement for loculated fibrinopurulent postpneumonic empyema offers better results than thoracotomy in terms of resolution of the disease and length of stay in hospital. It also seems to be more advantageous, resulting in fewer surgical sequelae, lower cost, less labor impediment, and better cosmesis.     

Empyema thoracis

Empyema thoracis is a common benign pathology of the pleural space causing severe morbidity and mortality rates of 10–20%. Often it develops from a parapneumonic effusion over a period of 2–6 weeks. Most patients that develop an empyema are frail with significant co-morbidity, immunocompromise or have had recent thoracic instrumentation. Initial presentation often features unilateral chest pain, tachypnoea, dyspnoea, pyrexia and features of sepsis. Blood analysis reveals leucocytosis with elevated inflammatory markers (e.g. C-reactive protein). Empyema progresses through a continuum of three stages (exudative, fibrinopurulent and organized), becoming more complex and challenging to treat. Initial management includes establishing a diagnosis with imaging and pleural aspiration. A combination of physiological support, commencement of antibiotics and tube drainage is successful in most patients. Intrapleural administration of fibrinolytics (combination of DNAase and recombinant tissue plasmin activator) have been shown to reduce hospital stay and need for surgery in prospective randomized controlled trials. Surgery is reserved for refractory cases or those with delayed presentation. video-assisted thoracoscopic surgery allows debridement of the pleural cavity and accurate drain placement. More extensive decortication is often performed through thoracotomy. Options for compromised and frail patients exist but usually involve long-term drainage and the acceptance of respiratory compromise.