Short and Long-Term Outcomes of Surgical Intervention for Empyema in The Post-Fibrinolytic Era

Background: Open window thoracostomy is indicated for patients with bronchopleural fistulae or trapped lung in the setting of empyema refractory to non-surgical interventions. We investigated the role of open window thoracostomy in the era of minimally invasive surgeries, endobronchial valves and fibrinolytic therapy.Methods: A retrospective chart review of all patients who underwent open window thoracostomy at a single institution from 2010-2020 was performed. Indications for the procedure as well as operative details and morbidity and mortality were evaluated to determine patient outcomes for open window thoracostomy.Results: Eighteen patients were identified for the study. The most common indication for open window thoracostomy was post-resectional bronchopleural fistula (n=8). Patient comorbidities were quantified with the Charleston Comorbidity index (n=11 score≥5, 10-year survival ≤21%). Three (16.7%) patients died <30 days post-operatively and 12 (66%) patients were deceased by the study’s end (overall survival 24.0 ± 32.2 months). Mean number of ribs resected were 2.6 ± 1.2 (range 1-6). Patients were managed with negative pressure wound therapy (n=9) or Kerlix packing (n=9). Eleven patients (61.6%) underwent delayed closure (mean time from index surgery to closure 4.8 ± 6.7 months). Conclusions: Our study illustrates the significant comorbidities of patients undergoing open window thoracostomy, the poor outcomes therein, and pitfalls associated with this procedure. We show that negative pressure wound therapy can be utilized as potential way to obliterate the pleural space and manage an open chest in the absence of an airleak; however open window thoracostomy procedures continue to be extremely morbid.

Successful treatment of refractory empyema using dual sheet covering

Managing thoracic empyema with massive air leakage can be challenging. We present a case with thoracic empyema with multiple bronchopleural fistulae and extensive lung parenchymal necrosis due to drain injury. Emergency surgery was performed for respiratory distress due to massive air leakage. As direct sutures could not be achieved due to extensive parenchymal necrosis, polyglycolic acid and oxidized regenerated cellulose sheets were packed into the lesion. Although open-window thoracostomy was required for bronchopleural fistulae, the stoma closure was achieved via vacuum-assisted closure therapy. The dual sheet coverings contributed to the successful recovery by resolving multiple bronchopleural fistulae.

Is open window thoracostomy the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer?

Summary A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed: Is open window thoracostomy (OWT) the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer? Altogether 442 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Empyema following anatomical lung resection (excluding pneumonectomy) is an uncommon complication but one that remains a challenge to treat effectively. Chest tube thoracostomy and intravenous antibiotics remain the initial steps to management, but evidence is lacking with regard to the best ongoing strategy. Conservative options including chest cavity irrigation, postural drainage and vacuum-assisted closure have been attempted with some success, even in the presence of a broncho-pleural fistula. However, the very limited number of patients on which these various management strategies have been trialled on prevents recommendations and clear guidance being given.

Staged surgery for empyema and lung gangrene caused by pseudoaneurysm after radiofrequency ablation

Lung gangrene is a potentially fatal disease, and primary or staged surgery, depending on the patient’s condition, is reported to be useful. We describe successful management, by staged surgery, of a rare case of empyema and lung gangrene complicating lung radiofrequency ablation. The patient, who was a diabetic with colorectal pulmonary metastases, underwent embolization of a pulmonary artery pseudoaneurysm in the right basal segment that developed after lung radiofrequency ablation. He subsequently developed lung gangrene caused by lung ischaemia, and empyema, necessitating pleural decortication followed by open-window thoracostomy. Subsequently, right basal segmentectomy was performed, with thoracostoma closure. Staged surgery might be beneficial for high-risk patients with empyema and lung gangrene caused by lung ischaemia.

Open window thoracostomy for a chronic calcified pleural empyema in the setting of a closed chest trauma

This case report is a chronic calcified pleural empyema in a patient who suffered a closed chest trauma 30 years ago. The first goal is to demonstrate how the closed chest trauma caused a bronchopleural fistula of the calcified pleural empyema, since the patient began to report continued purulent sputum after his trauma with weight loss and the appearance of an air-fluid level in the chest CT scan (no pleurocutaneous fistula in the clinical examination). The second goal is to reveal the rule and the interest of an open window thoracostomy in the management of chronic calcified pleural empyema, since a decortication remains difficult to perform in cases like this one.

Manual on wound care after open-window thoracostomy

Objective: To produce and validate a manual on wound care after open-window thoracostomy for healthcare professionals. Methods: This is an experience report. Initially, articles in Portuguese, Spanish and English were selected from 2010 to 2018 in the Cochrane, SciELO, LILACS, PubMed and Google Academic databases and search sites for the development of the material. The following descriptors were used: “thoracotomy”, “thoracostomies”, “thoracic cavity”, “pleura”, “pleural cavity”, “injuries and lesions”. After consultation, the text was prepared, followed by illustrations and layout design. The completed manuscript was sent to experts for validation. The content validity index (CVI) was used to validate the manual. Results: The manual developed has thirty-six pages and seven chapters with the following themes: introduction, wound care after open-window thoracostomy, wound cleansing/debridement, dressings, care record, final considerations, and bibliography. Conclusion: It was possible to develop and validate a manual on wound care after open-window thoracostomy for the consultation of health professionals.