[Differential Treatment Strategy of Pleural Empyema in a Post-Pneumonectomy Cavity].

Introduction: Pleural empyema in a post-pneumonectomy cavity (PEC) occurs with a frequency of 2% -15% and a mortality of more than 10%. It can occur with or without bronchopleural fistula (BPF). The treatment of empyema in the PEC requires a strict algorithm: drainage, bronchoscopy, closure of the fistula, thorough cleaning of the PEC, filling the cavity, thoracoplasty.

Methods: 39 cases with an empyema in the PEC were analysed retrospectively (men: n = 38; women: n = 1; mean age: 60.3 ± 7.6 years). In 32 (82.1%) of the patients, a BPF was detected (right: n = 26, left: n = 6). The average length of stay in hospital was 125 days (22 - 293 days). Cleaning of the PEC was achieved in all surviving patients (n = 23, 65.1%). All patients (n = 39) underwent bronchoscopy with placement of a chest tube for drainage. The BPF was closed in three cases (7.7%) with a stent while in 12 cases (30.8%) a vascularized flap was used. In 14 patients (35.9%) the bronchial stump was either reclosed with sutures or resected. In three cases (7.7%) a re-anastomosis was performed.

Results: The PEC became sterile by regular flushing with antibiotic solution in three patients (7.7%). In 35.9% of the patients (n = 14), aggressive surgical debridement (Weder procedure) was necessary. A thoracic window was applied in 22 patients (56.4%), followed by negative pressure wound therapy (NPWT) and change of dressing every three to four days or a tamponade of the thoracic cavity with simple dressings. In 19 patients (48.7%) the thoracic cavity was sealed with an antibiotic solution. In 5 cases an Alexander thoracoplasty took place.

Conclusions: Pleural empyema after pneumonectomy still poses a serious postoperative complication. A bronchopleural fistula is often detected. Thus, two problems arise at the same time – fistula and infection in the pleural cavity. Through a strict algorithm, both problems can be dealt with in stages. After sealing the fistula, the thoracic cavity is thoroughly cleaned and finally the thorax is closed. Only in a small number of patients (1.3%) in whom these measures remain ineffective (persistent MRSA, aspergillus colonization) should the cavity be obliterated by thoracoplasty.