Purpose of review: Thoracic empyema is the accumulation of frank pus within the pleural cavity. Its cause is often multifactorial and may include direct contiguous spread of infection, penetrating chest trauma or an iatrogenic cause secondary to surgical instrumentation of the pleural space. Current management of empyema is based on local empirical practice as there is no consensus on an optimal regimen. Over the past decade, surgical management of empyema has attracted great interest, leading to specific recommendations.
Recent findings: Video-assisted thoracoscopic surgery (VATS) has revolutionized surgical management of patients with empyema. Thoracoscopic management of empyema includes VATS debridement and decortication. VATS debridement has been employed by many centres as the primary treatment option for early-stage empyema. However, this is still contentious as some surgeons continue to advocate initial trials of chest tube drainage and antibiotic-mediated pleural space obliteration prior to any form of surgery. A more aggressive approach is to move directly to VATS decortication, which has shown great promise in the management of chronic empyema. More complex, mulitloculated empyemas would previously have been managed solely by complex open surgical procedures such as open window thoracostomy or thoracomyoplasty. However, recent studies have shown VATS decortication to produce equivalent resolution rates to the higher morbidity open approaches.
Summary: A summary of the most recent opinions and results in the thoracoscopic and open surgical management of thoracic empyema is outlined. Early VATS debridement effectively manages simple parapneumonic effusions. VATS decortication has equivalent efficacy to open decortication at managing both chronic and early-stage empyemas.