Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Surgical Management of Complex Pleural Infections

  Complex pleural infections range from complicated parapneumonic effusion to organized empyema with a thick, restrictive peel. These conditions can progress quickly, impair ventilation, and produce systemic inflammation even after antibiotics have been started. Effective care depends on matching antimicrobial treatment and drainage to the stage of disease.

  Surgery becomes important when infected pleural fluid is loculated, fails to drain through a catheter, or prevents lung re-expansion. The best approach is rarely determined by imaging alone. Clinical trajectory, comorbidities, duration of infection, pleural anatomy, and the patient’s ability to tolerate anesthesia all influence the decision.

  Modern management favors early multidisciplinary assessment. Respiratory physicians, thoracic surgeons, radiologists, infectious disease specialists, anesthesiologists, and critical care teams may all contribute to selecting the safest route from source control to recovery.

  How infection becomes surgically complex

  A pleural infection often develops through progressive stages. Initially, free-flowing inflammatory fluid may respond to antibiotics and image-guided drainage. As fibrin is deposited, septations form and the collection becomes multiloculated. Later, a thick fibrous cortex can encase the lung, creating trapped lung and persistent restriction.

  The microbiology may also complicate treatment. Streptococci, staphylococci, anaerobes, and mixed oral flora are common causes of community-acquired disease, while hospital-acquired infections may involve resistant gram-negative organisms or methicillin-resistant Staphylococcus aureus. Culture results should guide antibiotic refinement, but negative cultures do not exclude infection.

  Computed tomography helps define the distribution of fluid, pleural thickening, gas, calcification, and adjacent lung disease. Ultrasound is especially useful for identifying septations and guiding drainage. Neither study, however, replaces repeated clinical evaluation and assessment of drainage effectiveness.

  When operative treatment is indicated

  Surgical consultation should occur early when there is a large, loculated collection, persistent fever or sepsis, worsening respiratory compromise, or incomplete drainage despite a well-positioned catheter. A nonexpanding lung, dense pleural rind, bronchopleural fistula, foreign material, or suspected malignancy can also shift management toward an operation.

  The timing of intervention matters. Delay allows organization of the pleural space and may convert a relatively straightforward minimally invasive procedure into a more extensive decortication. At the same time, immediate surgery is not appropriate for every patient. Frailty, severe respiratory failure, anticoagulation, renal dysfunction, and advanced cancer require individualized risk assessment.

  Intrapleural enzyme therapy may be considered in selected patients with loculated infection, particularly when surgery carries substantial risk. Failure of medical therapy or enzyme-based treatment should prompt reassessment rather than repeated ineffective drainage attempts.

  Selecting the operative approach

  Video-assisted thoracoscopic surgery is commonly used for early or moderately organized empyema. It permits evacuation of pus, division of septations, irrigation, pleural biopsy when indicated, and removal of accessible fibrinous material through small incisions. Early thoracoscopy can reduce the duration of sepsis and improve lung expansion in suitable candidates.

  Open thoracotomy may be required when the pleural peel is extremely thick, the anatomy is hostile, bleeding occurs, or thoracoscopic visualization and instrumentation are inadequate. Decortication removes the restrictive cortex from the visceral pleura and allows the underlying lung to re-expand. The procedure can be technically demanding when infection has extended into the chest wall, diaphragm, or mediastinum.

  Clinical situation	Common strategy	Main objective	Important limitation
  Free-flowing infected effusion	Antibiotics plus image-guided catheter drainage	Control infection and remove fluid	May fail if loculations develop
  Multiloculated empyema	Catheter drainage, selected intrapleural therapy, or VATS	Break septations and achieve source control	Delay can lead to organization
  Organized empyema with trapped lung	VATS decortication or open decortication	Release the lung from the fibrous peel	Greater operative blood loss and physiologic stress
  Persistent space or fistula	Tailored surgery, possible muscle or omental flap	Obliterate dead space and control contamination	Often requires staged reconstruction
  High-risk or nonoperative patient	Drainage, antibiotics, palliative or hybrid strategy	Limit sepsis while reducing procedural harm	Residual restriction or recurrent infection may persist

  Principles of perioperative care

  Antibiotic therapy should begin promptly when pleural infection is suspected, with coverage adjusted according to community or healthcare exposure, local resistance patterns, culture findings, and renal function. Treatment duration depends on source control, organism, response, and residual disease rather than a fixed schedule alone.

  Adequate drainage and specimen collection are essential. Fluid should be sent for aerobic and anaerobic cultures, while pleural tissue may be useful when malignancy, tuberculosis, or an unusual inflammatory disorder is possible. The surgeon should remove purulent material and fibrinous debris while avoiding unnecessary injury to the lung or diaphragm.

  Pain control directly affects recovery because splinting can worsen atelectasis and limit coughing. Multimodal analgesia, early mobilization, respiratory physiotherapy, nutritional support, and venous thromboembolism prevention should be integrated into the postoperative plan. Persistent air leak, bleeding, residual sepsis, respiratory failure, and recurrent pleural collection require prompt investigation.

  Managing high-risk patients

  Older adults and patients with chronic obstructive pulmonary disease, bronchiectasis, heart failure, chronic kidney disease, or poor nutritional status may have limited reserve. Preoperative optimization should address reversible problems without creating avoidable delays. Smoking cessation, bronchodilator therapy, correction of severe anemia, and nutritional assessment can improve tolerance of surgery.

  Patients receiving anticoagulants or antiplatelet agents require coordinated planning between the surgical, anesthesia, and prescribing teams. The urgency of infection control must be balanced against bleeding risk. Regional analgesia or less invasive access may be valuable, but the choice depends on coagulation status and the planned procedure.

  A frailty-focused discussion is particularly important when extensive decortication is being considered. The objective may be complete anatomical clearance in a fit patient, while a high-risk patient may benefit more from controlled drainage, limited debridement, or a staged approach.

  Practical priorities for the operating team

  • Involve thoracic surgery early when drainage is incomplete or the lung remains trapped.
  • Use imaging to map loculations, pleural rind, fistulas, and structures that may affect access.
  • Obtain appropriate pleural fluid and tissue cultures before narrowing antimicrobial therapy.
  • Choose VATS, open decortication, or a nonoperative pathway according to disease stage and physiologic reserve.
  • Plan postoperative respiratory rehabilitation, nutrition, analgesia, and surveillance before the operation.

  Measuring recovery after source control

  Clinical improvement should include falling temperature, reduced inflammatory markers, better oxygenation, and relief of dyspnea. Radiographs may remain abnormal for weeks, so imaging must be interpreted alongside functional progress. Ultrasound or CT is useful when fever, leukocytosis, hypoxemia, or poor expansion suggests residual disease.

  Long-term consequences can include pleural thickening, restrictive ventilatory impairment, chronic pain, recurrent infection, and bronchopleural fistula. Pulmonary function testing and follow-up imaging may be appropriate for patients with persistent symptoms or extensive disease. Early recognition of these problems allows rehabilitation and additional intervention before disability becomes established.

  Successful treatment of complex pleural sepsis depends on timely source control, technically appropriate surgery, and coordinated medical support. Review the patient’s clinical course, imaging, microbiology, and operative risk as a single picture, then involve the relevant specialists without delay when the infection is not resolving.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)