Fibrothorax refers to a pleural cavity that has thickened visceral and parietal pleurae secondary to undrained pleural fluid. As a result, chronic inflammation ensues over time, resulting in a thick peel on both pleural surfaces. This phenomenon commonly results in “trapped lung,” a lung that is unable to expand because of the thick “rind” that surrounds it. Decortication is a surgical procedure that removes the thick rind on the lung, permitting the lung to re-expand and fill the pleural space. The term decortication was first coined by the French surgeon Delorme in 1894.1
PATHOPHYSIOLOGY OF FIBROTHORAX
The most common cause of fibrothorax is a parapneumonic effusion that was incompletely drained or never drained. Other causes of fibrothorax include untreated empyema, hemothorax, or chronic pleural effusion secondary to underlying medical or surgical comorbidity. It is important to know whether an effusion is transudative or exudative before operating on it. While a transudative effusion can reabsorb once the underlying medical condition is addressed, an exudative effusion needs an intervention such as a tube thoracostomy or surgical drainage.
The evolution of any effusion can be divided into three stages that represent a continuous spectrum. The process first starts with extravasation of fluid from capillaries due to inflammation or merely increased pulmonary interstitial pressure (phase 1), which is followed by infiltration of macrophages and subsequently fibroblasts resulting in a fibrinopurulent phase (phase 2). If the fluid is not drained in phase 1 or 2, further development of a thick fibrous peel around the fluid collection ensues (phase 3), sometimes forming loculated pockets. This compresses the normal lung and compromises its function, thus resulting in reduced breathing capacity and giving it a restrictive physiology (Fig. 133-1).
Schematic demonstrating the thickened visceral and parietal pleura in a patient with fibrothorax.
Most patients with fibrothorax present with dyspnea on exertion. While a large effusion may present with shortness of breath even at rest or with minimal exertion, most patients with fibrothorax will admit having dyspnea for a period of weeks to months before seeking medical help. And while some patients can report the inciting event (such as being diagnosed with pneumonia and being treated for it), most cannot. A patient who appears septic is most likely suffering from empyema and needs an expedited workup. On physical exam, one may appreciate limited excursion on the affected hemithorax, decreased breath sounds, and dullness to percussion.
In order to understand the underlying clinical process that may have resulted in a fibrothorax, it is important for the surgeon to elicit a good history from the patient. Causes of chronic effusion such as congestive heart failure, end-stage renal dialysis, hepatic insufficiency, history of any recent surgeries ...