Treatment of postpneumonectomy empyema with debridement followed by continuous antibiotic irrigation

BACKGROUND: The goal of this study was to determine the efficacy of treating postpneumonectomy empyema (PPE) with debridement followed by continuous antibiotic irrigation for pneumonectomy space sterilization. STUDY DESIGN: All patients presenting with PPE were evaluated. Patients with bronchopleural fistula (BPF) underwent thoracotomy for fistula closure and debridement. Patients without BPF underwent video-assisted thoracic surgery debridement. All patients then underwent intraoperative placement of an 8-F irrigation catheter and a 36-F drainage catheter. Two weeks of continuous antibiotic irrigation, as determined by cultures, were followed by collection of chest cultures on 3 consecutive days. If cultures returned negative, antibiotic was instilled into the chest and all catheters were removed. If cultures were positive, another 2 weeks of irrigation were reinitiated, adjusting the antimicrobial agent based on culture results. This regimen was repeated until three consecutive negative cultures were obtained. RESULTS: Over a 5-year period, 8 consecutive patients with PPE were evaluated. Two had BPE Mean age was 56 years. Median time to empyema after pneumonectomy was 20 days (range 12 to 497 days). Mean irrigation duration was 40 days (range 18 to 72 days) and mean followup was 580 days (range 75 to 1,666 days). There was no treatment-associated morbidity or mortality No patients experienced empyema recurrence during followup. CONCLUSIONS: PPE can be successfully treated with thoracic debridement followed by continuous antibiotic irrigation. This method avoids the morbidity of rib resection or thoracic cavity reduction procedures. Closure of BPF, if present, is a prerequisite. Debridement can be performed by video-assisted thoracic surgery in patients without fistula.