Sex differences in surgical treatment of pleural empyema: an exploratory retrospective comparison of video-assisted thoracoscopic surgery and thoracotomy.

BACKGROUND: Pleural empyema is a severe infectious condition that requires timely surgical management. While video-assisted thoracoscopic surgery (VATS) and open thoracotomy are both established treatment modalities, limited data exist regarding sex-specific differences in clinical presentation, intraoperative findings, and outcomes. Previous studies have seldom explored whether biological sex influences local disease extent, such as abscess formation, or short-term perioperative outcomes. METHODS: In this retrospective single-center study, adult patients who underwent surgery for pleural empyema between December 1, 2019, and May 31, 2024, were analyzed. Patients were grouped according surgical approach (VATS or thoracotomy) and stratified by sex. Demographic, clinical, laboratory, and intraoperative data were collected. Comparisons between male and female patients were conducted using Fisher's exact test and unpaired t-tests, with a significance level set to P < 0.05. Postoperative outcomes were assessed until hospital discharge; no long-term follow-up was available. RESULTS: A total of 103 patients were included (73 men, 30 women); 19 underwent VATS and 84 thoracotomy. In the VATS group, no significant sex-related differences were found in age, laboratory values, complications, or intraoperative findings. In the thoracotomy group, a significantly higher rate of intraoperatively detected abscesses was observed in female patients compared to male patients (78.3% vs. 45.9%, P = 0.016). No other statistically significant differences were found between sexes in hemoglobin, leukocyte counts, CRP, ICU admission, or mortality. CONCLUSION: A higher prevalence of intraoperative abscesses was observed in female patients undergoing thoracotomy for pleural empyema, despite a lower burden of systemic comorbidities. Otherwise, outcomes and perioperative parameters were similar between sexes in both surgical groups. These findings are exploratory and hypothesis-generating and should be interpreted with caution. Larger prospective studies with balanced sex representation, standardized staging, and long-term follow-up are warranted to clarify potential sex-related variations in disease manifestation and surgical outcomes. The relatively small female cohort and limited VATS subgroup reduce statistical power and restrict generalizability.