CLEARING THE CAVITY: A CASE OF POSTPNEUMONECTOMY EMPYEMA

Abstract

SESSION TITLE: Surgery cases SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/07/2018 04:45 PM - 05:45 PM INTRODUCTION: Post-pneumonectomy Empyema (PPE), is a rare but dangerous complication. Hypothesized to be the result of microbial infection via Bronchopleural fistula (BPF) vs. direct muco-cutaneous infection. Management of this pathology varies from debridement and antibiotics to thoracoplasty. Presented is a case of PPE in a patient who underwent pneumonectomy for the treatment of metastatic colorectal cancer. CASE PRESENTATION: A 53-year-old male with prior history of metastatic colorectal cancer treated with chemotherapy and managed surgically with right pneumonectomy four years prior presented to the emergency department with five days of worsening right sided chest pain, cough, fevers, and chills. On physical exam the patient was noted to have a right chest wall palpable mass with crepitation. A computed tomography angiogram of the chest was performed showing worsening accumulation of fluid in the prior known post-surgical hydropneumothorax. Additionally, new extension of air into the surrounding soft tissue was observed, a condition called pneumothorax neccesitans (Image 1). Antibiotics were started and a surgical chest tube was placed which drained foul-smelling purulent brown fluid. Polymicrobial cultures grew methicillin-resistant staphylococcus aureus, streptococcus anginosus, streptococcus mitus, bacteroides caccae, and fusobacterium species. Video assisted thorascopic surgery (VATS) was converted to thoracotomy with creation of Eloesser flap. While irrigating the hemithorax with saline copious bubbles were seen indicating a BPF. Post-operative course complicated by pseudomonal wound infection being treated with levaquin. DISCUSSION: PPE occurs in 2%-16%(1) of post-pneumonectomy patients. Although it is rare, mortality has been reported as high as 72%(2) and management can often be complicated. The majority of PPE are due to microbial infection via BPF. The presence of BPF in patients with PPE has been documented to be 80%-100%. Other theories include direct microbial invasion of the wound. Monomicrobial infections are more common than polymicrobial, with staphylococcus and streptococcus being the most frequent culprits. A 2015 expert consensus statement published by the European Association of Cardiothoracic Surgeons suggests that for simple PPE without fistulae, conservative management can be performed with pleural space irrigation, fenestration or VATS debridement alongside antibiotics. During VATS the surgeon has the opportunity to identify an underlying BPF for closure. In the case of BPF presence or complicated PPE intervention may require more invasive techniques such as thoracoplasty. (3) CONCLUSIONS: With a high mortality rate and complex management, PPE should be addressed swiftly and with cardiothoracic involvement at time of diagnosis. Drainage and antibiotics are the cornerstones to management but many cases require more expert invasive surgical intervention. Reference #1: Stern, Jean-Baptiste, Ludovic Fournel, Benjamin Wyplosz, Philippe Girard, Malik Al Nakib, Dominique Gossot, and Agathe Seguin-Givelet. "Early and delayed post-pneumonectomy empyemas: Microbiology, management and prognosis." The clinical respiratory journal (2017). Reference #2: Jadczuk, Eugeniusz. "Postpneumonectomy empyema." European journal of cardio-thoracic surgery 14, no. 2 (1998): 123-126. Reference #3: Scarci, Marco, Udo Abah, Piergiorgio Solli, Aravinda Page, David Waller, Paul Van Schil, Franca Melfi et al. "EACTS expert consensus statement for surgical management of pleural empyema." European journal of cardio-thoracic surgery 48, no. 5 (2015): 642-653. DISCLOSURES: No relevant relationships by Elizabeth Awerbuch, source=Web Response No relevant relationships by Anupam Gupta, source=Web Response no disclosure on file for Terence McGarry; No relevant relationships by Michael Megally, source=Web Response