Predictors of successful closure of open window thoracostomy for postpneumonectomy empyema

Although the open window thoracostomy (OWT) represents the ideal method for drainage of postpneumonectomy empyema (PPE), several controversies exist concerning its closure.

Between January 1993 and December 2003, an OWT was created in 31 patients (29 male and 2 female) with PPE. The median age was 61 years (range, 32 to 76). In 26 patients (84%) a bronchial stump fistula developed. The OWT closure was correlated with characteristics of PPE and the timing of OWT.

In 15 patients (48%), the OWT could be closed by obliteration of pleural cavity with antibiotic solution (3 patients) or intrathoracic muscle transposition (12 patients). A successful closure was observed in 13 of the 15 patients (87%). All patients closed by Clagett's procedure remained empyema free. Recurrent cancer (n = 4), poor functional status (n = 3), refusal of further operation (n = 2), and persistent tuberculous empyema (n = 2) were common causes of failure of OWT closure. Univariate analysis revealed that the timing of empyema development after surgery (p = 0.02) and the timing of OWT (p = 0.03) were significant predictors of thoracostomy closure.

Late onset of PPE and immediate OWT creation are significant predictors of OWT closure. Smaller dimensions of the pleural cavity appeared to increase the likelihood of closure. When the pleural cavity shows healthy granulation tissue and no bronchopleural fistula, the Clagett's procedure is safe and effective to obliterate the pleural cavity. Obliteration by muscle flap transposition can be reserved for patients with persistent or recurrent bronchopleural fistula.