107: Surgical Approaches for Chronic Empyema and for Management of Chronic Bronchopleural Fistula

Introduction

Empyema and bronchopleural fistula (BPF) are two distinct yet intimately related entities. They may occur together or independently, and they share similar etiologies. The management of each process has proved, over several centuries, to be a daunting task that requires sound clinical judgment and a resilient patient.

Hippocrates provided the first clinical description of empyema approximately 2400 years ago. In 229 bc he described the clinical presentation and physical examination findings in patients with empyema. Hippocrates is also credited with the first drainage procedure for empyema. This entailed partial rib resection, drainage, and daily packing.¹ Despite Hippocrates' detailing of the clinical presentation, natural history, and treatment of empyema, it was not until the nineteenth century that significant work on the subject was presented.

In 1843, Trosseau advanced thoracentesis for the treatment of empyema. French surgeon Sedillot described thoracotomy and empyema drainage. More extensive procedures, including thoracoplasty and decortication, were introduced by Estlander (1879) and Fowler (1893), respectively.² At the start of the twentieth century, most treatment strategies for acute empyema involved early rib resection and open drainage. Mortality rates with this approach averaged 30%. Graham and Bell, of the United States Army Empyema Commission, made a major advance in the treatment of early empyema. They recommended closed-tube drainage to manage early empyema. This strategy decreased the mortality rate from 30% to 4.3%.³

In 1935, Eloesser⁴ described an open thoracotomy technique that would permit skin and soft tissue to behave as a valve to allow lung expansion. In 1963, Clagett and Geraci⁵ introduced open window drainage for 6 to 8 weeks, followed by empyema cavity obliteration with antibiotic solution and window closure. The Clagett window remains useful in the treatment of chronic empyema. Muscle flap closure of BPF and the postresectional space has become increasingly popular.^6,7 Video-assisted thoracoscopy and fibrinolytic therapy also have roles in the management of empyema.^8,9

Empyema

Empyema is defined as a purulent pleural collection (Fig. 107-1). Causes include bacterial pneumonia, tuberculosis, postresectional, posttraumatic, and intra-abdominal processes. Approximately 50% of empyemas are caused by bacterial infection. Postresectional causes account for 25%, and an additional 8% to 11% are caused by extension of an intra-abdominal process.¹⁰

Clinical Presentation

The presenting signs and symptoms of empyema are nonspecific. The most common symptoms are shortness of breath and fever. Patients also may complain of cough and chest pain. Sputum production may or may not be present. These symptoms are also present in patients with pneumonia. Empyema should be considered when a patient manifests these symptoms after a prolonged respiratory illness or a lung resection. Laboratory analysis is also relatively nonspecific ...