Postresection Empyema

The management of post-resection empyema is shown in Table 13.3.

This is much more common after pneumonectomy than after lobectomy. If a post-resection empyema occurs, one must consider if there is a bronchopleural fistula present. If there is no bronchopleural fistula present, then chest tube drainage is employed and 2 weeks later it is converted to open drainage.

In the case of post-pneumonectomy empyema, the protocol is a little bit different. Chest tube drainage is employed for 2 weeks and then converted to open drainage under fluoroscopic guidance. If the mediastinum is frozen under fluoro-scopic guidance then it is safe to do a Clagett window for good drainage of the post-pneumonectomy empyema. If, however, the mediastinum seems to shift towards the side of the empyema after a pneumonectomy, then it is not yet safe to do a Clagett window, and the chest tube is placed back to closed drainage. There should not be suction applied at this point, lest the mediastinum be further shifted to the empyema side.

For post-resection empyema other than pneumonectomy and if there is no bronchopleural fistula present, chest tube drainage with conversion to open drainage may be all that is necessary. However, if there is persistent sepsis or evidence of problems, then a Clagett window may be necessary for better drainage, and a myoplasty/omentoplasty may be necessary to obliterate the dead space. Thoraco-plasty may be warranted for post-resection empyema, particularly in the event that this is status post pneumonectomy. If there is a bronchopleural fistula present, then the protocol changes. If this is an early empyema and bronchopleural fistula, i.e. within 6 days postoperatively, chest tube drainage is indicated followed by immediate reoperation to repair the technical error. The plan is to go into the old incision, fix the bronchus and place a pleural flap or intercostal muscle flap over the repair. For late post-pneumonectomy empyema with bronchopleural fistula, again chest tube drainage is the initial procedure. A Clagett window is then performed early on to drain the empyema, and a simultaneous muscle flap procedure may be done. This should probably be done within a week after placement of the chest tube. If there is still persistent air leak despite the Clagett window and muscle flap procedure, then much later another attempt at repair of the bronchial stump can be done. If this was a pneumonectomy, then transsternal stapling of the bronchial stump may be indicated. The reason for doing a transsternal approach to the mainstem bronchus is that it permits access to virgin territory not affected by the empyema. The location of the carina after performing a median sternotomy is in the region just to the right of the ascending aorta, just to the left of the superior

Table 13.3. Postresection empyema

Bronchopleural Fistula
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