Open pleural drainage is an uncommon modality in the current area of appropriate antibiotic coverage and multiple means of closed pleural drainage. Open drainage is usually reserved for very ill patients for whom a thoracoscopy or thoracotomy would be too morbid. In its extreme form, open pleural drainage results in a thoracoplasty by removing ribs from the chest wall, which brings the chest wall to the lung and achieves obliteration of an empty space.
In the preantibiotic era, pleural infections were a challenging entity, with many complications and difficult management. At that time, open pleural drainage was an important treatment of chronic empyemas. Because of advances in medical technology, including radiographic imaging and antibiotics, today most pleural infections are successfully treated with closed suction drainage or video-assisted thoracoscopy. However, given the historical importance of this operation, this article will review its indications and techniques.
Open drainage has been described dating back to the time of Hippocrates. The chest cavity and the pleural space present a greater challenge to drain empyemas than infections of the abdomen. Because of the rigid structure of the chest wall, infections are more difficult to eradicate. Moreover, a space problem can occur when the lung is trapped and no pleural-to-pleural apposition can be reached. This sometimes requires open pleural drainage or additional measures, such as the interposition of healthy, well-perfused tissue (eg, muscle flaps, omentum).
Thoracic and extrathoracic (ie, abdominal) procedures and complications can lead to a pleural empyema. Thoracic procedures include postresectional (lobectomy, lung biopsy, pneumonectomy) and esophageal disease (perforation, esophageal surgery with complications). Moreover, pulmonary infections without prior resection can lead to an empyema of the pleural space with possible need for closed or open drainage. In addition, surgery in the abdomen can lead to pleural effusions with subsequent seeding of bacteria and an empyema. Examples include perforated intra-abdominal viscus, duodenal ulcer, diverticulum of the colon, appendicitis, and other causes of peritonitis.
Several factors promote the progression of pleural effusions into a pleural empyema, as follows:
Improper or delayed use of antibiotics
Delay in diagnosis
Inadequate initial drainage with residual fluid collections
Foreign body in the pleural space
Presence of a bronchopleural fistula
Adequate drainage and obliteration of the pleural space has been outlined by Dr. Samuel Robinson as the 2 basic principles of managing chronic empyema since 1915.  He suggested a technique of open drainage and partial obliteration of the pleural cavity with muscle, which probably influenced some of the subsequent procedures of chest drainage. In 1935, Dr. Leo Eloesser described a technique of open drainage without extensive thoracoplasty that became known as the Eloesser flap.  The flap was designed to act as tubeless one-way valve to drain chronic pleural effusions without the need of indwelling catheters.
In 1963, Clagget and Geraci described a procedure for the treatment of postpneumonectomy empyema, now known as the Clagget procedure. It consists of the resection of a posterolateral lower ribs and formation of an open window in the lateral aspect of the chest to allow continuous drainage and irrigation of the cavity with antibiotic solutions.  In the final step, when the chest cavity showed signs of granulation tissue, it was filled with antibiotic solution and closed. Dr. Clagget's partners at the Mayo Clinic have since then modified this procedure to address the issue of a stump leak. Since then, due to recent advances in antibiotic therapy and early recognition of infectious processes, these operations are rarely used nowadays, and no major procedural modifications have been described for open chest drainage.
Most patients presenting with pleural space infections initially undergo less invasive procedures, such as repeat aspiration thoracentesis, radiographic-guided catheters, and tube thoracostomy.  In the case of failure of those less invasive modalities, or in the presence of multiloculated chronic collections and entrapped lung, surgical decortication is indicated.
However, some patients are debilitated enough to undergo an extensive surgical procedure. Open pleural drainage remains an alternative approach in this particular setting.
The main current indications for open chest drainage are as follows:
Patients who failed an initial approach with closed suction drainage and have a low physiologic reserve to tolerate more aggressive surgical interventions, such as decortication
Patients who need a period of medical rehabilitation or correction of nutritional abnormalities prior to more radical and definitive procedures
Anticipation of long-term drainage
Contraindications include the following:
No proper adherence of surrounding lung tissue to the chest wall, which could lead to complications of open pneumothorax
Patients with good functional status who otherwise could tolerate a more invasive and definitive treatment, such as a surgical decortication
Closed drainage with escalating invasiveness ranging from needle thoracentesis, 12-F pigtail placement, tube thoracostomy, to video-assisted thoracoscopy are preferred to open drainage. However, open pleural drainage may be indicated for very ill patients or, more commonly, patients with postpneumonectomy empyema with or without bronchopleural fistula. In the latter, the open drainage is the first step in a staged, definitive closure.
Computed tomography scans and chest radiographs prior to the procedure are recommended to better define the extent of disease, determine the presence of loculations, and assess the site of incision. It is helpful to review the computed tomography scan not only in axial, but also in sagittal and coronal views, to get a better orientation on where to place the incision.
Patient Education/Informed Consent
Some patients live with thoracic window for years or for the rest of their lives. They need to understand the importance of daily dressing changes and adjusting their lifestyle for this new routine. Good family support is also important because many spouses actively participate in the management of these patients.
A major thoracotomy tray with various-sized rib spreaders should be available. In addition, periosteal elevators, such as the Matson, Coryllos, and Alexander, and various-sized rib cutters should be available.
Monitoring & Follow-up
The wound must be regularly inspected to ensure adequate drainage of the pleural space. Thoracic window obliteration should also be observed.
Open chest drainage is usually well tolerated by patients. The main complications include failure to create the one-way valve, which leads to pneumothorax, and premature closure of the window, leading to inadequate empyema drainage. Irritation of the surrounding skin also may be a source of pain or discomfort for the patient.
The procedure for an Eloesser flap originally consisted of making a U-shaped skin incision, 2 inches wide by 2.5 inches long. A segment of rib over the most dependent portion of the infected pleural space was removed, then the skin flaps were sutured to the pleura and the remaining edges of skin were sutured together. As a result, the one-way valve provided drainage of purulent material and air and prevented the formation of pneumothorax. However, the only aspect of the original technique that still applies today is the concept of draining an empyema cavity with an epithelialized stoma. 
Different skin incisions have been described, including U-shaped, inverted U-shaped, and H-shaped.  No matter the type of incision chosen, it needs to be long enough to provide adequate drainage, prevent premature closure, and facilitate dressing changes. Suturing the skin flaps to the parietal pleural edge will “marsupialize” the open drainage site. Over time, the infected pleural space will be replaced by epithelialized tissue and the thoracic window will slowly obliterate, leaving only an indentation on the chest wall.