Chapter 109: Surgical Approaches for Chronic Empyema and Bronchopleural Fistula

INTRODUCTION

Empyema and bronchopleural fistula (BPF) are distinct yet intimately related entities. They may occur together or independently, and they share similar etiologies. Managing these entities 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 b.c., when 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 19th century that significant work on the subject was presented.

In 1843, Trousseau 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 20th 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 U.S. Army Empyema Commission made a major advance in the treatment of early empyema when they recommended closed-tube drainage. This strategy decreased the mortality rate dramatically from 30% to 4.3%.³

In 1935, Eloesser described an open thoracotomy technique that would permit skin and soft tissue to behave as a valve to allow lung expansion.⁴ In 1963, Clagett and Geraci introduced open window drainage for 6 to 8 weeks, followed by empyema cavity obliteration with antibiotic solution and window closure.⁵ Today, the Clagett window remains useful for the treatment of chronic empyema in its modified form. Muscle flap closure of BPF and the postresectional space has become increasingly popular.^6,7 Over the past decade, video-assisted thoracoscopy and fibrinolytic therapy have played increasingly important roles in empyema management.^8–10

EMPYEMA

Empyema is defined as an infected pleural fluid collection, evidenced either by purulent fluid or the presence of bacterial organisms (Fig. 109-1). In the modern era, nontuberculotic bacterial pneumonia is the leading cause of empyema, with nearly 5% of the 1.2 million annual cases of pneumonia worldwide complicated with an empyema.^11,12 Approximately 50% of empyemas are caused by bacterial infection. Postresectional causes account for 25% of empyemas and an additional 8% to 11% are caused by extension of an intraabdominal process.

Clinical Presentation

The presenting signs and symptoms of empyema can be nonspecific and depend on the patient’s immune status and virulence of the infectious agent. The most common symptoms are shortness of breath and ...