Management of late postpneumonectomy empyema and bronchopleural fistula

Postpneumonectomy empyema occurs in 5% of pneumonectomy patients, more commonly with completion pneumonectomy, right pneumonectomy, operations for sepsis, mediastinal lymph node dissections, and in patients requiring postoperative mechanical ventilation. BPF is identified in over 80% of patients at presentation. Optimal management includes prevention by minimizing perioperative sepsis, meticulous bronchial closure, and the use of vascularized flaps to reinforce the bronchial stump. Management of the developed complication requires flexible bronchoscopy, drainage of the empyema space initially by closed tube drainage, and later by open thoracostomy, appropriate therapy of the underlying infection, and identification and correction of systemic risk factors. Surgical interventions to obliterate the residual empyema space are successful in 80% of cases. Closure of BPF occurs spontaneously in one third of cases, but can be achieved in 86% of cases with aggressive surgical interventions involving reclosure of the bronchial stump and transposition of vascularized flaps. The mortality of postpneumonectomy empyema, with or without BPF, ranges from 23% to 50%. The mortality for surgical intervention is 10%. In the absence of debilitating systemic illness, such as metastatic lung cancer, aggressive surgical intervention is the optimal method of management for postpneumonectomy empyema with an associated bronchopleural fistula.