Decortikation

Decortication, in a thoracic medical context, is a surgical procedure aimed at removing the thick fibrous layer that encases or restricts the lung, known as the pleural peel. The operation frees the lung from organized scar tissue in the pleural space to allow re-expansion and improved function. It is most commonly performed to treat organized pleural empyema or a trapped lung following infection or inflammation.

Indications for decortication include chronic or organized pleural empyema where conventional drainage and antibiotics have failed, and persistent lung restriction with poor expansion after infection. It may also be considered when a rind of fibrous tissue prevents adequate lung inflation and causes ongoing dyspnea or recurrent infections.

Techniques and intraoperative aspects can vary. Decortication can be performed via video-assisted thoracoscopic surgery (VATS) or open thoracotomy. The procedure involves removing the pleural peel from the visceral and parietal pleura, debridement of infected material, and ensuring lung re-expansion. A chest tube is typically placed postoperatively to drain air and fluid.

Outcomes and prognosis depend on disease duration, extent of the peel, and the patient's overall condition. Successful decortication often leads to improved lung volumes, better oxygenation, and reduced infection risk, with recovery ranging from several weeks to months. Potential complications include bleeding, prolonged air leak, infection, respiratory failure, and residual restriction.

Alternatives and adjuncts include prolonged antibiotic therapy, chest drainage with intrapleural fibrinolytics for certain empyemas, or less invasive approaches when feasible. Decortication is considered when these measures do not achieve adequate lung re-expansion.