eMedicine Specialties > Plastic Surgery > Chest

Empyema and Bronchopleural Fistula: Treatment

Author: Jeffrey J Rentz, MD, Fellow in Surgical Research, Wound Healing and Tissue Engineering Lab, Brigham and Women's Hospital
Coauthor(s): William G Austen Jr, MD, Assistant Professor, Department of Surgery, Harvard Medical School; Consulting Staff, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital; Suresh Koneru, MD, Clinical Assistant Professor, Department of Plastic and Reconstructive Surgery, University of Texas Health Science Center at San Antonio
Contributor Information and Disclosures

Updated: Jun 15, 2006

Treatment

Medical Therapy

Medical therapy alone may benefit acute empyema following drainage of a pneumonic abscess yet is not effective in the treatment of empyema because of bronchopleural fistula or chronic empyema. The empyema cavity must be aggressively drained early and appropriate antibiotic therapy initiated for successful medical therapy. If the empyema cavity cannot be adequately drained by tube thoracostomy, open drainage in preparation for flap surgery will be required.

Surgical Therapy

Treatment of a bronchopleural fistula depends on several factors. Acute fistulae (1-7 d postoperatively) should be repaired and drained promptly. Care must be taken to protect the contralateral lung from contamination. The fistula should be debrided of necrotic or inflammatory material. If able, repair should be performed with monofilament suture or stapled anastomosis. Often, repair becomes too technically difficult due to the degree of inflammation present. Repair may be reinforced with a local flap of pleura, pericardium, or mediastinal fatty tissue. In addition, a muscle or omental flap sutured over the fistula with monofilament suture may be used to reinforce the repair. Treatment of chronic fistulae requires a staged approach.

During the first stage, drain the empyema and allow the underlying lung to expand maximally. Drainage may be performed by tube thoracostomy, thoracoscopy, or open thoracostomy. The next stage involves debridement or decortication of the empyema cavity and placement of vascularized tissue to cover the infected area as well as obliteration of dead space. Debridement of all epithelialized and granulating surfaces must be performed. This decortication may become quite tedious and may be accompanied by heavy blood loss.

Prior to flap reconstruction of the thoracic cavity, adequately drain the cavity and ensure it is free of gross infection. Several flap options are available when treating an empyema cavity following bronchopleural fistula as outlined above. Evaluate the simplest and closest flaps, such as the pleura or intercostal muscle flap, first. One option is omental flap coverage, usually based on the right gastroepiploic artery. The omentum can be harvested laparoscopically or via laparotomy and passed through the diaphragm into the chest cavity. This flap provides well-vascularized tissue to cover the bronchus or esophagus yet does not usually contain enough bulk to fill the dead space of the empyema cavity.

Other flap options are the serratus anterior or the latissimus dorsi muscles based on the thoracodorsal vessels. These muscles have the advantage of being easily accessible at the site of the thoracotomy wound. The latissimus also is advantageous, as it is a large-volume muscle that can fill the residual cavity. Passage into the chest may necessitate partial resection of the sixth or seventh ribs. The disadvantage of either of these muscles is that they may have been transected at thoracotomy.

More distant muscle flap options include the rectus abdominis based on the superior epigastric vessels and the pectoralis major based on the thoracoacromial vessels. Both of these muscles are large enough the fill the empyema cavity and usually are preserved at thoracotomy. Free tissue transfer using contralateral latissimus, pectoralis, or de-epithelialized transverse rectus abdominus myocutaneous (TRAM) flap also has been described for use when local flaps are not available.

It is imperative that all residual space be filled with muscle or omentum to decrease the risk of recurrent empyema. If the entire cavity cannot be filled, it may be partially obliterated by removing portions of overlying ribs. The chest cavity also should be thoroughly drained postoperatively via chest tubes. Multiple large bore (32-36 Fr) tubes are often required. Patients prefer softer tubes, since they may remain in place for weeks. One of the tubes should sit on the diaphragm and go into the posterior sulcus to collect dependent drainage. After a week, the tubes can be gradually removed by 2 centimeters at a time and resecured. The inflammation in the pleural space is vigorous and usually prevents the lung from collapsing in several days, but prudence requires follow-up with chest radiography.

Preoperative Details

Preoperative evaluation should involve a thorough history and physical examination. A chest radiograph usually is adequate to visualize the process. However, a CT scan of the chest is reasonable to assess for drainage catheters and to plan an operative strategy. Assess nutritional status preoperatively and correct deficiencies prior to definitive flap reconstruction.

Intraoperative Details

Intraoperatively, fill the cavity with water and have the anesthesiologist manually inflate the lungs to a pressure of 35-40 cm water. This may identify the fistula. Make attempts to seal this fistula. Debride devitalized or marginal tissue. Stapled closures or hand-sewn closures with monofilament suture should be done; base the choice on the surgeon's preference and comfort. Biologic sealants may be helpful.

Aggressive debridement and decortication of all epithelialized and granulating surfaces should be undertaken.

Ensure all of the empyema cavity has been filled with vascularized tissue prior to closing the chest and drain all cavities postoperatively. Consider that the tubes will likely remain in place for a long time and that they will be backed out gradually every other day when they come out. Take care to drain the most dependent areas in the supine and upright positions.

Postoperative Details

Adequately drain all cavities postoperatively for at least 7-10 days. If a patient is using a ventilator, keep the pressures as low as possible and extubate the patient as quickly as it is safe to do so. As mentioned above, the tubes may be removed gradually once the lung is stuck against the parietal pleura. Maintain appropriate antibiotics based on intraoperative and preoperative cultures. Patients commonly decompensate after the initial drainage procedure. Be prepared for this situation, and keep it under consideration when deciding when to proceed with definitive closure. The patient should be followed closely as recurrence of the bronchopleural fistula or empyema cavity is possible. In the event of a recurrence, the basic principles of drainage, coverage, and obliteration of the cavity should be reinstituted.

Complications

Observe patients closely postoperatively as recurrence of the fistula and empyema is possible. Many patients deteriorate in the first day or two after debridement and drainage. If the cavity is well-drained and the antibiotics are appropriate, patients readily improve within a few days. If they continue to worsen, consider a repeat CT scan to look for more undrained infection. The most common complication in the most series is persistence of the cavity. If residual cavity is present it may be eliminated with further muscle flap coverage.

• Search for CME/CE on This Topic »