Re: What is the best treatment of postpneumonectomy empyema?

We have read with interest the report by Zahid and colleagues on open surgical approaches as primary treatment of postpneumonectomy empyema [1].

Empyema of the pleural cavity is a serious complication of pneumonectomy. Its incidence ranges from 2% to 15% and its mortality is superior to 10% [2]. When no bronchopleural fistula is present the management of empyema is controversial. All authors admit treatment must be done urgently. However, many different techniques have been described. Some surgeons use a relatively low invasive approach, such as simple drainage followed by cyclical irrigation [3], rethoracotomy [1] or open-window thoracostomy [2].

There is no universally appropriate treatment and management depends upon the patient’s general condition and the presence of associated fistulas. In the absence of bronchopleural fistula, aggressive surgery is a questionable option because of its high morbidity and because it does not totally prevent recurrences. A similar reasoning has recently been held for empyema thoracis leading some surgeons to prefer a thoracoscopic approach as primary choice [4]. Indeed, thoracoscopy makes it possible to remove most of the false membranes and debris and to wash the cavity under direct visual control. For this reason, we do not agree with the authors about the analysis of thoracoscopic group and drainage group as the same subset. In a randomized trial comparing chest tube pleural drainage plus streptokinase and video-assisted thoracic surgery (VATS), Wait and associates demonstrated that there were considerably less recurrences in the VATS group and hospital stays were also substantially shorter [5].

Finally, we consider urgent thoracotomy as primary choice only in cases of bronchopleural fistula for closure of the fistula, lavage, and drainage of the pleural space or in case of late postpneumonectomy empyema. For all other conditions we believe that VATS, when technically feasible, could represent the safest procedure in postpneumonectomy empyema.

References