Invited Commentary

Abstract

We are more familiar with the management of post-pneumonectomy empyema than with post-lobectomy or post-segmentectomy empyema. The latter has not been addressed well in thoracic surgical literature, and the authors should be commended for bringing a new contribution to an uncommon problem. Although the number of patients is small, the material and methods are correctly described, and the results are clearly expressed. The late occurrence of empyema in this series [1Massera F. Robustellini M. Della Pona C. Rossi G. Rizzi A. Rocco G. Open window thoracostomy for pleural empyema complicating partial lung resection.Ann Thorac Surg. 2009; 87: 869-874Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] is bothersome. Empyema developed in 12 of 19 patients (63%) at more than 3 months after pulmonary resection, and it is wondered if this is because of missed or delayed diagnosis, indolence of organism, or residual or recurrent tumor at the stump [1Massera F. Robustellini M. Della Pona C. Rossi G. Rizzi A. Rocco G. Open window thoracostomy for pleural empyema complicating partial lung resection.Ann Thorac Surg. 2009; 87: 869-874Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]. The authors believe the reason for delayed occurrence is probably due to hematogenous spread of bacteria to the pleura or from other parts of the body. In dealing with post-pulmonary resection empyema, two problems must be considered: (1) the treatment of infection, and (2) the obliteration of the infected space. To treat infection, drainage must be established. Chest tube drainage should be considered in early cases. The authors suggested that early performance of open window thoracostomy, in their hands, was more effective and instrumental in early eradication of infection. It was a significant predictor of healing, whereas prolonged chest tube drainage failed to control the infection in “late onset empyema,” especially in patients with an entrapped lung, and we are in total agreement. In regard to obliteration of the residual space, certain principles should be considered at the time of initial pulmonary resection that hopefully may cut down on the incidence of postoperative empyema. Measures such as the application of a pleural tent, phrenic nerve crush, or institution of pneumoperitoneum are good examples. The authors expressed their opinion regarding bronchopleural fistula as a cause of persistence of drainage. If bronchopleural fistula persists, the intrathoracic interposition of muscle flaps will help with obliteration of the residual space. In the absence of bronchopleural fistula, the use of the Clagett procedure with antibiotic irrigation was effective in their hands. At our institution, we use the transaxillary approach for the Eloesser flap, in which no muscles need to be cut, and therefore it is cosmetically attractive. In regard to muscle flaps for the obliteration of the space we use the serratus anterior, the latissimus dorsi, and occasionally the pectoralis major muscle for post-upper lobectomy empyema and the omentum for post-lower lobectomy empyema and intercostal muscle to buttress the closure of a bronchopleural fistula. Open Window Thoracostomy for Pleural Empyema Complicating Partial Lung ResectionThe Annals of Thoracic SurgeryVol. 87Issue 3PreviewAlthough an open-window thoracostomy (OWT) represents the ideal method for drainage of postpneumonectomy empyema, several controversies exist concerning its application to pleural empyema complicating pulmonary resections less than pneumonectomy. Full-Text PDF