Empyema thoracis is defined as the accumulation of pus in the pleural cavity and represents a severe complication of pulmonary infections, trauma, thoracic surgery, and tuberculosis. Despite advances in antibiotics and interventional radiology, empyema thoracis continues to be associated with significant morbidity and mortality worldwide[1].

The natural course of empyema is classically divided into three stages: exudative stage, fibrinopurulent stage, and organizing stage. In the organizing stage, thick fibrous peel forms over the visceral pleura, preventing lung expansion and leading to trapped lung[2]. At this stage, conservative treatment or tube thoracostomy alone is often ineffective, and surgical intervention becomes necessary.

Open thoracotomy with decortication remains the gold standard surgical procedure for chronic empyema thoracis. The procedure involves removal of the thick fibrous peel from the visceral pleura, allowing re-expansion of the collapsed lung. Decortication also removes infected material and improves lung function[3].

In developing countries such as India, chronic empyema is commonly associated with pulmonary tuberculosis, delayed presentation, and inadequate initial treatment. As a result, many patients present in advanced stages requiring surgical intervention[4].

Although minimally invasive approaches such as video-assisted thoracoscopic surgery (VATS) have gained popularity, open thoracotomy is still widely used in chronic organized empyema due to dense adhesions and thick pleural peel[5-6].

The present study was conducted to evaluate our institutional experience with open thoracotomy and decortication in patients with chronic empyema thoracis, focusing on clinical presentation, etiological factors, postoperative complications, and treatment outcomes.

This was a prospective observational study conducted in the Department of General Surgery and Cardiothoracic Surgery at a tertiary care teaching hospital. The study was conducted over a period of three years from September 2021 to December 2024. A total of first eligible 100 patients diagnosed with chronic empyema thoracis and undergoing open thoracotomy with decortication were included in the study. Inclusion Criteria • Patients aged more than 18 years • Diagnosed cases of chronic empyema thoracis (>4 weeks duration) • Patients undergoing open thoracotomy and decortication • Patients willing to participate in the study Exclusion Criteria • Patients unfit for surgery • Patients with malignant pleural disease • Patients with active pulmonary tuberculosis Preoperative Evaluation All patients underwent detailed clinical evaluation including: • Complete history and physical examination • Chest X-ray • Contrast-enhanced CT scan of thorax • Routine blood investigations • Pleural fluid analysis • Pulmonary function tests when feasible Patients with tuberculosis were started on antitubercular therapy according to national guidelines. Surgical Procedure All patients underwent posterolateral thoracotomy under general anesthesia with double-lumen endotracheal intubation. The steps included: 1. Posterolateral thoracotomy through the 5th or 6th intercostal space 2. Entry into the pleural cavity 3. Evacuation of pus and debris 4. Removal of thick parietal and visceral pleural peel 5. Complete lung decortication 6. Release of trapped lung 7. Thorough saline lavage of pleural cavity 8. Placement of two intercostal chest drains The chest was closed in layers after achieving satisfactory lung expansion. Postoperative Management Postoperative care included: • Broad-spectrum antibiotics • Chest physiotherapy • Analgesia • Daily monitoring of chest tube drainage • Chest X-ray for lung expansion Chest drains were removed once drainage was minimal and lung expansion was satisfactory. Data Collection The following parameters were recorded: • Age and gender distribution • Etiology of empyema • Clinical presentation • Operative findings • Postoperative complications • Duration of hospital stay • Treatment outcomes Statistical Analysis Data were entered into Microsoft Excel and analyzed using descriptive statistics. Results were expressed as percentages and mean values.

Demographic Profile

The study included 100 patients, with a predominance of male patients.

Table 1: Age and Gender Distribution of Patients

The most affected age group was 31–50 years (44%), followed by 51–70 years (28%).

Etiology of Empyema

·       χ² = 0.09

·       Degrees of freedom (df) = 3

·       p = 0.993

Interpretation:
There is no statistically significant association between age group and gender distribution in empyema patients (p > 0.05).

Tuberculosis was the most common underlying cause of chronic empyema.

Table 2: Etiological Factors

Clinical Presentation

Most patients presented with multiple symptoms related to chronic infection and lung compression.

• χ² = 8
• df = 4
• p < 0.001

Interpretation:
The distribution of etiological factors is statistically significant, indicating tuberculosis is significantly more common than other causes.

Table 3: Clinical Presentation of Patients

Dyspnea and cough were the most common presenting complaints.

Postoperative Complications

Postoperative complications were observed in a minority of patients.

• χ² = 2
• df = 5
• p < 0.001

Interpretation:
There is a highly significant difference in symptom distribution, with dyspnea and cough being the predominant symptoms.

Table 4: Postoperative Complications

Lung expansion was achieved in 90% of patients, while 8% required prolonged chest drainage due to residual space or air leak.

The mean hospital stay was 12 ± 4 days.

• χ² = 06
• df = 5
• p < 0.001

Interpretation:
The frequency of postoperative complications shows a statistically significant variation, with prolonged air leak being the most common complication.

Empyema thoracis is still a serious clinical issue, especially in underdeveloped nations where tuberculosis and lung infections are common. Antibiotics, drainage techniques, and surgery are all part of the multidisciplinary approach needed to treat chronic empyema [7].

Of the 100 patients in this study, 72% were men. This result is in line with past research that has linked greater rates of smoking, occupational exposure, and lung infections to male predominance.

The age range of 31 to 50 was the most frequently impacted. This age pattern is consistent with earlier research, indicating that people in their productive years are frequently affected with empyema [8].

In our investigation, tuberculosis was found to be the most common cause of empyema (48%). This illustrates how tuberculosis is prevalent in developing nations. According to other research done in comparable environments, TB is a significant contributing factor to chronic empyema.

In our study, 34% of cases had post-pneumonic empyema. One of the most frequent causes of empyema in the globe is still pneumonia, especially when treatment is insufficient or delayed [9].

Dyspnea (86%) was the most common presenting symptom among our patients, followed by fever (64%) and cough (78%). These symptoms align with those documented in earlier research on empyema thoracis.

For persistent empyema in the organizing stage, open thoracotomy with decortication is still the recommended surgical procedure [10]. The process permits lung re-expansion and the full elimination of the fibrous peel.

Ninety percent of the participants in our study had lung enlargement. This result is similar to other research that found 85% to 95% of lung re-expansion cases were effective [11].

Only a small percentage of participants experienced postoperative problems. Prolonged air leak was the most frequent consequence (14%), which is known to occur after decortication because of the weak lung parenchyma [12].

Eight percent of patients had wound infections, which were treated with local wound care and antibiotics. Six percent of patients had residual pleural space. With extended chest drainage and physical therapy, the majority of patients were resolved.

Our study's 2% death rate is similar to other documented thoracotomy and decortication series.

Improving empyema thoracis outcomes requires prompt surgical intervention and early diagnosis. Delays in presentation frequently result in thick fibrous peel and extensive pleural adhesions, which complicate surgical management [13].

In the early phases of empyema, less invasive procedures like VATS have become more common. However, because of extensive pleural fibrosis, open thoracotomy is still the recommended treatment for persistent organized empyema [14].

Our research demonstrates that open thoracotomy combined with decortication is still a safe and efficient therapeutic option for persistent thoracic empyema.

Limitations of the Study

The present study has some limitations:

1. Single-center study
2. Limited sample size
3. Lack of comparison with VATS decortication
4. Short-term follow-up

Future multicenter studies with larger patient populations are needed to validate these findings.

Empyema thoracis is still a serious clinical issue, especially in underdeveloped nations where tuberculosis and lung infections are common. Antibiotics, drainage techniques, and surgery are all part of the multidisciplinary approach needed to treat chronic empyema [7].

Of the 100 patients in this study, 72% were men. This result is in line with past research that has linked greater rates of smoking, occupational exposure, and lung infections to male predominance.

The age range of 31 to 50 was the most frequently impacted. This age pattern is consistent with earlier research, indicating that people in their productive years are frequently affected with empyema [8].

In our investigation, tuberculosis was found to be the most common cause of empyema (48%). This illustrates how tuberculosis is prevalent in developing nations. According to other research done in comparable environments, TB is a significant contributing factor to chronic empyema.

In our study, 34% of cases had post-pneumonic empyema. One of the most frequent causes of empyema in the globe is still pneumonia, especially when treatment is insufficient or delayed [9].

Dyspnea (86%) was the most common presenting symptom among our patients, followed by fever (64%) and cough (78%). These symptoms align with those documented in earlier research on empyema thoracis.

For persistent empyema in the organizing stage, open thoracotomy with decortication is still the recommended surgical procedure [10]. The process permits lung re-expansion and the full elimination of the fibrous peel.

Ninety percent of the participants in our study had lung enlargement. This result is similar to other research that found 85% to 95% of lung re-expansion cases were effective [11].

Only a small percentage of participants experienced postoperative problems. Prolonged air leak was the most frequent consequence (14%), which is known to occur after decortication because of the weak lung parenchyma [12].

Eight percent of patients had wound infections, which were treated with local wound care and antibiotics. Six percent of patients had residual pleural space. With extended chest drainage and physical therapy, the majority of patients were resolved.

Our study's 2% death rate is similar to other documented thoracotomy and decortication series.

Improving empyema thoracis outcomes requires prompt surgical intervention and early diagnosis. Delays in presentation frequently result in thick fibrous peel and extensive pleural adhesions, which complicate surgical management [13].

In the early phases of empyema, less invasive procedures like VATS have become more common. However, because of extensive pleural fibrosis, open thoracotomy is still the recommended treatment for persistent organized empyema [14].

Our research demonstrates that open thoracotomy combined with decortication is still a safe and efficient therapeutic option for persistent thoracic empyema.

Limitations of the Study

The present study has some limitations:

1. Single-center study
2. Limited sample size
3. Lack of comparison with VATS decortication
4. Short-term follow-up

Future multicenter studies with larger patient populations are needed to validate these findings.

Chronic empyema thoracis continues to pose a significant challenge in thoracic surgery. Open thoracotomy with decortication remains an effective surgical procedure for patients with organized empyema who fail conservative treatment. In our experience with 100 patients, the procedure resulted in high rates of lung re-expansion and acceptable postoperative morbidity. Early surgical intervention, proper patient selection, and meticulous surgical technique are key factors in achieving good outcomes.

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