Video-assisted thoracoscopic surgery and open decortication for pleural empyema.

Video-assisted thoracoscopic treatment is an elegant method for the treatment of ATS stage II fibrinopurulent empyema. It has been shown to be superior to repeat instillation of fibrinolytic agents into the chest cavity. However, a more chronic empyema (organizing empyema, ATS stage III empyema) requires open decortication in order to prevent ongoing infection and late restriction. Conversion thoracotomy should be liberally used if a chronic stage III empyema is found at VATS exploration since open decortication is still the best treatment modality for chronic empyema.