Empyema following pulmonary resection. What is difficult management?

รศ.นพ. ธีรวิทย์ พนัธุ์ชยัเพชร

Post lung resection empyema

• Post lobectomy 0.01-2.00%

• Post-pneumonectomy 2-16%

Rt>Lt., mortality 10%

• Residual space & air-leakage

Empyema thoracis

Stage I Exudative or acute phase (1-2 wk.) low viscosity, low

cellular, early angioblastic & fibroblastic proliferation

Stage II Fibrinopurulent or transitional phase (2-3wk.) more

turbid, PMN, fibrin deposit & loculation

Stage III Organizing or chronic phase (>3 wk) pleural peel with

ingrowth of capillaries, fibroblasts & collagen fibers

The American Thoracic Society(1962)

Empyema Thoracis without BPF

Antibiotics, General supports

Drainage: (frank pus, pH<7.2, +bacteria)

catheter drainage,closed tube thoracostomy

? Intrapleural fibrinolytic drug

Surgical drainage: (loculation)

limited thoracotomy(rib resection), VATS

Definitive treatment:

Filling of space & Closure(decortication) VATS?

Sterilization & Closure

Permanent drainage(open window thoracostomy

Collapse(Thoracoplasty)

Empyema with BPF

Tube drainage, Antibiotics, General supports

Fistula closure:

small: spontaneous closure endobronchial procedures

Large & late: reclosure(direct or indirect)

permanent drainage

rotation flaps(muscle transposition)

collapse(thoracoplasty)

JAPI • VOL. 52 • JUNE 2004

ชายไทยอาย ุ59ปี ไอน า้หนกัลดมา 1 เดือน FOB biopsy poorly diff. carcinoma

Operation RUL lobectomy, sleeve resection of RPA, node dissection..21/11/2554 Discharge..24/11/2554

Postop. Diagnosis : squamous cell carcinoma stage T2b N0 = 1B

Adjuvant CMT 27/12/2554

ไข้ไอหนาวสัน่เสมหะเหลือง 23/1/2555 Diagnosis: lung abscess with empyema thoracis

Operation: Rethoracotomy partial rib resection, debridement of RML & closed

drainage..24/1/2555

Intermittent irrigation with diluted Betadine solution … ..Open window thoracostomy

Debridement & additional rib resection &Eloesser flap 16/2/2555

ตค 2555 Minor airleak

30/4/2555

มค 2556 no BPF

Assessment of empyema in the postop. patient

Is this a postoperative infection?

• Is this acute or chronic?

• Is there a bronchopleural fistula?

• Is there adequate drainage?

• Is there a space problem?

Drainage procedures

• Chest tube

• Rib resection

• Clagett window/Eloesser flap

Airspace filling procedures

• Thoracoscoplasty

• Fill space with muscle and omentum

BPF after surgery

• Early reoperation

• Transpericardial approach to close fistula

• Muscle flap over fistula

Thoracoplasty

Post pulmonary resection empyema

Chest tube drainage & antibiotics

No BPF BPF

improve worse

Remove chest tube

Do clagett window/Eloesser flap for drainage or

Space filling procedure

Close fistula omentoplasty/myoplasty 2 wk after tube drainage Clagett if needed

ผูห้ญิงอาย ุ75ปี มีอาการไอเป็นเลือด FOB biopsy …adenocarcinoma

Operation LUL lobectomy, node dissection 26/2/2009 Massive hemothorax at recovery room..Rethoracotomy blood clot evacuation,

27/2/2009 28/2/2009

2/3/2009 10/3/2009

เบ่ืออาหารไขสู้งหนาวสั่น 1 เดือนหลงัผา่ตดั thoracentesis bloody pleural fluid culture …Pseudomonas

ICD …bloody fluid 1000cc

Postpneumonectomy empyema

Post-pneumonectomy empyema

No BPF BPF Antibiotics & chest tube drainage

Convert to open drainage after 2 wk. Early postop.(1 wk.) Late(>1wk.)

Chest tube drainage Reoperation close BPF & muscle or omental flap

Clagett window

Clagett window &

Muscle or omental flap

If persistent airleak Consider

Trans-sternal/transpericardial Bronchial stapler

Muscle flap interposition

Postpneumonectomy empyema

• Open v/s minimally invasive surgery (171 papers) • Minimally invasive surgery : chest tube drainage + or - chemical irrigation VATS debridement • Open surgery : open debridement, open window thoracostomy (OWT) thoracomyoplasty • Open approach is superior: empyema recurrence rate, mortality and reintervention rate

Zahid et al. What is the best treatment of postpneumonectomy empyema. Interactive CardioVascular and Thoracic Surgery 12 (2011) 260–264