Pleural space irrigation and modified clagett procedure for the treatment of early postpneumonectomy empyema

Abstract

Objective: The incidence of postpneumonectomy empyema is 5% to 10%. Approximately half of postpneumonectomy empyemas occur within 4 weeks of pneumonectomy. A bronchopleural fistula is found in more than 80% of the patients. The classic treatment of postpneumonectomy empyema includes parenteral antibiotics, drainage of the pleural space, removal of necrotic tissue, and open pleural packing for many weeks followed by obliteration of the empyema space with antibiotic fluid or muscle. This approach results in prolonged hospitalization, repeated operations, and significant morbidity. As a possible means of decreasing morbidity with the classic treatment of postpneumonectomy empyema, we studied the use of pleural space irrigation in these patients. Method: In a 5-year period, we treated 22 patients with early postpneumonectomy empyema. All patients had a bronchopleural fistula. All patients underwent emergency drainage of the pleural space followed by thoracotomy, debridement of necrotic tissue, closure of the bronchial stump with absorbable monofilament suture, and pleural space irrigation. After a negative Gram stain from the pleural fluid, the pleural space was filled with 2 L of debridement antibiotic solution (DAB solution) (gentamicin 80 mg/L, neomycin 500 mg/L, and polymyxin B 100 mg/L), and the irrigation and drainage catheters were removed. Results: Twenty patients had negative Gram stains on day 9, and 2 patients had a negative Gram stain on day 16. The mean duration of hospitalization was 12.9 ± 3.4 days. There was no recurrence of empyema or a bronchopleural fistula. Conclusions: Pleural space irrigation followed by obliteration of the pleural space with an antibiotic solution required one surgical procedure and resulted in significantly shorter hospitalization and decreased morbidity in patients with early postpneumonectomy empyema. (J Thorac Cardiovasc Surg 1998;116:943-8)