Treatment Optimization of Post-pneumonectomy Pleural Empyema.

INTRODUCTION: Pleural empyema after pneumonectomy still poses a serious postoperative complication. A bronchopleural fistula is often detected. Despite various therapeutic options developed during the last five decades it remains a major surgical challenge. RESULTS: There is no widely accepted treatment for post-pneumonectomy pleural empyema (PPE) and the management depends mostly on the presence or absence of broncho-pleural fistula (BPF) and the patient's general condition. In the absence of BPF, the role of surgery is still not clear because of its high morbidity and impossibility to prevent recurrences. In the earlier period, the definitive treatment consisted of open window thoracostomy followed by obliteration of the pleural cavity with antibiotic solution at the time of chest wall closure. Subsequently, the proposed different methods and modifications improved the outcome. There is an association between hospital volume and operative mortality after the lung resection. Hospital volume and the surgeon's specialty have more influence on the outcome than the individual surgeon's volume. CONCLUSIONS: Treatment management of PPE should be individualized. Definitive treatment options comprise aggressive surgery that is not possible in quite a high proportion of impaired patients. Hospital volume, surgeon's volume and surgeon's specialty may influence the prognosis.

Epidemiology, Etiology and Prevention of Postpneumonectomy Pleural Empyema.

BACKGROUND: Pleural empyema after pneumonectomy still poses a serious postoperative complication. A broncho-pleural fistula is often detected. Despite various therapeutic options developed over the last five decades it remains a major surgical challenge. MATERIALS AND METHODS: A literature search in MEDLINE database was carried out (accessed through PubMed), by using a combination of the following key-words and MeSH terms: pneumonectomy, postoperative, complications, broncho-pleural fistula, empyema, prevention. The following areas of intervention were identified: epidemiology, etiology, prevention. RESULTS: Pleural empyema in a post-pneumonectomy cavity occurs in up to 16% of patients with a mortality of more than 10%. It is associated with broncho-pleural fistula in up to 80% of them, usually in the early postoperative months. Operative mortality could reach 50% in case of broncho-pleural fistula. Unfavourable prognostic factors are: benign disease, COPD, right-sided surgery, neoadjuvant and adjuvant therapy, time of chest tube removal, long bronchial stump and mechanical ventilation. Bronchial stump protection with vascularised flaps is of utmost importance in the prevention of complications. CONCLUSION: Postpneumonectomy pleural empyema is a common complication with high mortality. The existing evidence confirms the role of bronchopleural fistula prevention in the prevention of life-threatening complications.