Expert consensus on a stepwise strategy for the surgical management of empyema based on pathological staging (2026 edition)_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

QU Jichen ¹ , GOU Yunjiu ² , CHEN Guangyu ³ , ZHAI Yongfu ⁴ , MA Tinglong ⁵ , ZENG Xiaogang ⁶ , JIN Feng ⁷ , SONG Yanzheng ⁸ , XIE Boxiong ⁹ ,  MA Minjie ¹⁰ ,  LI Bin ¹¹ ,  FAN Jiang ¹² , Thoracic and Cardiovascular Surgery Branch of Gansu Medical Association , Thoracic Minimally Invasive Surgery Professional Committee of Shanghai Research-oriented Hospital Association

1. Department of Thoracic Surgery, Jiuquan Hospital of Shanghai General Hospital, Shanghai General Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, 200400, P. R. China;
2. Department of Thoracic Surgery, Gansu Provincial People's Hospital, Lanzhou, 730030, P. R. China;
3. Clinical Epidemiology Research Center, Xinhua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, 200400, P. R. China;
4. Department of Thoracic Surgery, Jiuquan Hospital of Shanghai General Hospital, Jiuquan, 735000, Gansu, P. R. China;
5. Department of Thoracic Surgery, Heilongjiang Provincial Hospital for Infectious Diseases, Harbin, 150500, P. R. China;
6. Department of Thoracic Surgery, Chengdu Public Health Clinical Medical Center, Chengdu, 610061, P. R. China;
7. Department of Thoracic Surgery, Shandong Public Health Clinical Center, Jinan, 250102, P. R. China;
8. Department of Thoracic Surgery, Shanghai Public Health Clinical Center, Shanghai, 201508, P. R. China;
9. Department of Thoracic Surgery, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, 200433, P. R. China;
10. Department of Thoracic Surgery, The First Hospital & Clinical Medical School, Lanzhou University, Lanzhou, 730030, P. R. China;
11. Department of Thoracic Surgery, The Second Hospital & Clinical Medical School, Lanzhou University, Lanzhou, 730030, P. R. China;
12. Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200400, P. R. China;

Corresponding?author：

MA Minjie, Email: fan_jiang@sjtu.edu.cn; LI Bin, Email: mamj@lzu.edu.cn; FAN Jiang, Email: leebin@lzu.edu.cn

Keywords：

Empyema; pathological staging; video-assisted thoracoscopic surgery; pleural decortication; metagenomic next-generation sequencing; perioperative management; expert consensus

DOI：

10.7507/1007-4848.202603011

Video：

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The surgical management of empyema (excluding those caused by mycobacterium tuberculosis and non-tuberculous mycobacteria) is rapidly evolving towards minimally invasive, precise, and stepwise approaches. The traditional three-stage classification (exudative, fibrinopurulent, and organizing) has limitations in guiding dynamic clinical decision-making. For the first time, this consensus explicitly identifies two critical junctures in the pathological progression of empyema: "early transformation" (stage Ⅰ to Ⅱ) and "late transformation" (stage Ⅱ to Ⅲ), and thereby constructs a corresponding "identification-early warning-intervention" stepwise therapeutic framework. The consensus emphasizes that proactive debridement via video-assisted thoracoscopic surgery should be performed during the early transformation phase to halt disease progression. Conversely, during the late transformation phase, therapeutic goals should be rationally adjusted to prioritize adequate drainage, avoiding futile pleural decortication. Moreover, the consensus underscores the pivotal role of precise perioperative etiological diagnosis [e.g metagenomic nest-generation sequencing (mNGS)] and standardized anti-infective therapy. Integrating practical experiences from multiple thoracic surgery centers in China and relevant evidence-based literature, this consensus formulates recommendations on the precise definitions of staging, surgical indications for each phase, key technical points, perioperative management, and training systems. It aims to promote the standardized and individualized surgical management of empyema, ultimately optimizing patient prognosis.

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1. Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc, 2006, 3(1): 75-80.
2. Shen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg, 2017, 153(6): e129-e146.
3. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 2008, 336(7650): 924-926.
4. 瞿冀琛, 張文天, 蔡劍橋, 等. 肺部手術后慢性疼痛中西醫結合診療中國專家共識(2026版). 中國胸心血管外科臨床雜志, 2026, 33(4): 522-534.Qu JC, Zhang WT, Cai JQ, et al. Expert consensus on the integrated traditional Chinese and Western medicine diagnosis and treatment of chronic post-surgical pain (2026 edition). Chin J Clin Thorac Cardiovasc Surg, 2026, 33(4): 522-534.
5. Davies HE, Davies RJO, Davies CWH. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax, 2010, 65(Suppl 2): ii41-ii53.
6. Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline. Chest, 2000, 118(4): 1158-1171.
7. Sasse S, Nguyen T, Teixeira LR, et al. The utility of daily therapeutic thoracentesis for the treatment of early empyema. Chest, 1999, 116(6): 1703-1708.
8. Idell S. Coagulation, fibrinolysis, and fibrin deposition in acute lung injury. Crit Care Med, 2003, 31(4 Suppl): S213-S220.
9. Chen KY, Liaw YS, Wang HC, et al. Sonographic septation: a useful prognostic indicator of acute thoracic empyema. J Ultrasound Med, 2000, 19(12): 837-843.
10. Moffett BK, Panchabhai TS, Anaya E, et al. Computed tomography measurements of parapneumonic effusion indicative of thoracentesis. Eur Respir J, 2011, 38(6): 1406-1411.
11. Porcel JM. Advances in the diagnosis and management of pleural effusions. Curr Opin Pulm Med, 2018, 24(4): 321-328.
12. Wait MA, Sharma S, Hohn J, et al. A randomized trial of empyema therapy. Chest, 1997, 111(6): 1548-1551.
13. Bilgin M, Akcali Y, Oguzkaya F. Benefits of early aggressive management of empyema thoracis. ANZ J Surg, 2006, 76(3): 120-122.
14. Chambers A, Routledge T, Dunning J, et al. Is video-assisted thoracoscopic surgery decortication superior to open surgery in the management of adults with primary empyema? Interact Cardiovasc Thorac Surg, 2010, 11(2): 171-177.
15. 陳春源, 王志剛, 梁柱, 等. 單操作孔電視胸腔鏡和開胸手術治療慢性膿胸的療效比較. 廣東醫學院學報, 2015, 33(2): 166-168.Chen CY, Wang ZG, Liang Z, et al. Comparison of single-port video-assisted thoracoscopic surgery and thoracotomy for chronic empyema. J Guangdong Med Coll, 2015, 33(2): 166-168.
16. Lardinois D, Gock M, Pezzetta E, et al. Delayed referral and gram-negative organisms increase the conversion thoracotomy rate in patients undergoing video-assisted thoracoscopic surgery for empyema. Ann Thorac Surg, 2005, 79(6): 1851-1856.
17. Stefani A, Aramini B, Della Casa G, et al. Preoperative predictors of successful surgical treatment in the management of parapneumonic empyema. Ann Thorac Surg, 2013, 96(6): 1812-1819.
18. Kho P, Karunanantham J, Leung M, et al. Debridement alone without decortication can achieve lung re-expansion in patients with empyema: an observational study. Interact Cardiovasc Thorac Surg, 2011, 12(5): 724-727.
19. Rzyman W, Skokowski J, Romanowicz G, et al. Decortication in chronic pleural empyema--effect on lung function. Eur J Cardiothorac Surg, 2002, 21(3): 502-507.
20. Gokce M, Okur E, Baysungur V, et al. Lung decortication for chronic empyema: effects on pulmonary function and thoracic asymmetry in the late period. Eur J Cardiothorac Surg, 2009, 36(4): 754-758.
21. Scarci M, Abah U, Solli P, et al. EACTS expert consensus statement for surgical management of pleural empyema. Eur J Cardiothorac Surg, 2015, 48(5): 642-653.
22. Maskell NA, Davies CW, Nunn AJ, et al. U. K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med, 2005, 352(9): 865-874.
23. Farjah F, Symons RG, Krishnadasan B, et al. Management of pleural space infections: a population-based analysis. J Thorac Cardiovasc Surg, 2007, 133(2): 346-351.
24. Chung JH, Lee SH, Kim KT, et al. Optimal timing of thoracoscopic drainage and decortication for empyema. Ann Thorac Surg, 2014, 97(6): 224-229.
25. Casali C, Storelli ES, Di Prima E, et al. Long-term functional results after surgical treatment of parapneumonic thoracic empyema. Interact Cardiovasc Thorac Surg, 2009, 9(1): 74-78.
26. Semenkovich TR, Olsen MA, Puri V, et al. Current state of empyema management. Ann Thorac Surg, 2018, 105(6): 1589-1596.
27. Nayak R, Brogly SB, Lajkosz K, et al. Outcomes of operative and nonoperative treatment of thoracic empyema: a population-based study. Ann Thorac Surg, 2019, 108(5): 1456-1463.
28. Omid M, Rafieezadeh A, Anaraki KT, et al. Comparing the efficacy of video assisted thoracoscopic surgery (VATS) vs intrapleural fibrinolytic therapy in children with pleural empyema. Pediatr Surg Int, 2025, 41(1): 111.
29. Pan H, He J, Shen J, et al. A meta-analysis of video-assisted thoracoscopic decortication versus open thoracotomy decortication for patients with empyema. J Thorac Dis, 2017, 9(7): 2006-2014.
30. Towe CW, Carr SR, Donahue JM, et al. Morbidity and 30-day mortality after decortication for parapneumonic empyema and pleural effusion among patients in the Society of Thoracic Surgeons' General Thoracic Surgery Database. J Thorac Cardiovasc Surg, 2019, 157(4): 1288-1297. e4.
31. Tong BC, Hanna J, Toloza EM, et al. Outcomes of video-assisted thoracoscopic decortication. Ann Thorac Surg, 2010, 89(1): 220-225.
32. Waller DA, Renggajan A. Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema. Ann Thorac Surg, 2001, 71(6): 1813-1816.
33. Cardillo G, Carleo F, Carbone L, et al. Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication. Eur J Cardiothorac Surg, 2009, 36(6): 914-918.
34. Melloni G, Carretta A, Ciriaco P, et al. Decortication for chronic parapneumonic empyema: results of a prospective study. World J Surg, 2004, 28(5): 488-493.
35. Reichert M, Posentrup B, Hecker A, et al. Thoracotomy versus video-assisted thoracoscopic surgery (VATS) in stage III empyema-an analysis of 217 consecutive patients. Surg Endosc, 2018, 32(6): 2664-2675.
36. Shin JA, Chang YS, Kim TH, et al. Surgical decortication as the first-line treatment for pleural empyema. J Thorac Cardiovasc Surg, 2013, 145(4): 933-939. e1.
37. Chen B, Zhang J, Ye Z, et al. Outcomes of video-assisted thoracic surgical decortication in 274 patients with tuberculous empyema. Ann Thorac Cardiovasc Surg, 2015, 21(3): 223-228.
38. Shahin Y, Duffy J, Beggs D, et al. Surgical management of primary empyema of the pleural cavity: outcome of 81 patients. Interact Cardiovasc Thorac Surg, 2010, 10(4): 565-567.
39. Akiba T, Morikawa T, Yamasaki S, et al. Utility of three-dimensional computed tomography in thoracoscopic surgery for empyema. Surg Today, 2014, 44(6): 1153-1158.
40. Bagheri R, Tavassoli A, Haghi SZ, et al. The role of thoracoscopic debridement in the treatment of parapneumonic empyema. Asian Cardiovasc Thorac Ann, 2013, 21(4): 443-446.
41. Mier JM, Cortés-Julián G, Berrios-Mejía J, et al. Beneficios del drenaje torácico digital en pleurodecorticación por empiema. Estudio prospectivo, comparativo aleatorizado. Cir Cir, 2017, 85(6): 522-525.
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43. Ng T, Ryder BA, Maziak DE, et al. Treatment of postpneumonectomy empyema with debridement followed by continuous antibiotic irrigation. J Am Coll Surg, 2008, 206(6): 1178-1183.
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Latest ArticlesExpert consensus on a stepwise strategy for the surgical management of empyema based on pathological staging (2026 edition)

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