Pleural infections have high morbidity and mortality, and their incidence in all age groups is growing worldwide. Pleural effusion develops in 40% of pneumonia patients, but only 15% of patients develop thoracic empyema after antibiotic treatment. Pleural empyema can be differentiated into three phases, exudative (Stage I), fibrinopurulent (Stage II) and organizing (Stage III). It is important to emphases that it is representing as a continuously evolving process that can be stop by therapeutic intervention. The initial exudative stage can be often managed by antibiotics and placement of chest tube. However, it is not effective in the fibrinopurulent or organizing stages, due to fibrin deposits over the parietal pleura and loculation of fluid, that restricts the expansion of the lung. The variety of strategies in the treatment of parapneumonic pleural empyema demonstrates the ambiguity for the method of choice. Many publications demonstrated that an early and aggressive minimally invasive approach for empyema in stage II provides rapid relief from infection and guarantees lower morbidity rate, shorter hospital stay, lower costs and clinical resolution. Though, the role of video assisted thoracic surgery in organizing stage III of pleural empyema is still controversial. The objective of surgical treatment of pleural empyema is to drain infected collections from pleural cavity and to achieve a complete lung re-expansion which is usually trapped due to adhesion’s or thickening of the visceral pleura. Fibrinolysis has been shown to be superior to chest tube drainage alone. There are some trials who documented lower charges with fibrinolysis comparing to VATS procedures. However, a fibrinolitic therapy may make the subsequent operation more difficult. VATS provides higher diagnostic value as good visualization and magnification, direct visualization of all surgical regions, facilitates the evacuation of multilocular effusions, the division of a fibrin septa’s, debridement and decortication, as well as fluid sampling and pleural biopsy.

Keywords: Video-assisted surgery, pleural empyema, fibrinolysis, decortication.

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