Awake Pleural Decortication for Empyema Thoracis

Empyema thoracis is defined as the presence of purulent fluid within the pleural cavity. Despite proper management is still debated, widespread agreement exists amongst thoracic surgeons that an immediate surgery is more likely to result in favorable outcome than conservative treatment. In recent years, the use of video-assisted thoracic surgery has gained acceptance as a valuable option in this setting, since satisfactory re-expansion of the trapped lung can be achieved in more than 90% of patients with a minimal surgical traumatism. A further development in the field of minimally-invasive approach for empyema thoracis is represented by the renewed interest in videothoracoscopic operations performed in spontaneous ventilating patients, through local or locoregional anesthesia techniques. In our experience, awake videothoracoscopic decortication performed under thoracic epidural anesthesia proven feasible and well tolerated in most instances. In addition, conversion to thoracotomy was possible in more than 20% of patients without switching to general anesthesia. In this chapter, we focus on clinical and technical aspect of this novel surgical approach, which could represent a reliable treatment tool especially in high-risk patients with early-stage empyema thoracis.