Open Pleural Drainage Technique

Updated: Feb 19, 2020
  • Author: Doraid Jarrar, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Technique

Approach Considerations

Thoracic and extrathoracic (ie, abdominal) procedures and complications can lead to a pleural empyema. Thoracic causes include the following:

  • Postresectional factors (eg, after  lobectomy, [8] lung biopsy, or  pneumonectomy [9] )
  • Esophageal disease (eg, perforation or complications of esophageal surgery)

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 the following:

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
  • Malnourishment
  • Foreign body in the pleural space
  • Presence of a bronchopleural fistula

The chest cavity and the pleural space present a greater challenge to the drainage of empyemas than the abdomen does. Because of the rigid structure of the chest wall, infections within the thorax 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 necessitates open pleural drainage or additional measures, such as the interposition of healthy, well-perfused tissue (eg, muscle flaps or omentum).

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Open Drainage of Pleural Space

In 1915, Robinson identified adequate drainage and obliteration of the pleural space as the two basic principles of managing chronic empyema. [10] 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, Eloesser described a technique of open drainage without extensive thoracoplasty, which became known as the Eloesser flap. [11] The flap was designed to act as tubeless one-way valve to drain chronic pleural effusions without the need of indwelling catheters.

In 1963, Clagett and Geraci described a procedure for the treatment of postpneumonectomy empyema, now known as the Clagett procedure. [12] 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. Clagett's partners at the Mayo Clinic subsequently modified this procedure to address the issue of a stump leak.

In current practice, as a consequence of advances in antibiotic therapy and early recognition of infectious processes, these operations are rarely used. No major procedural modifications have been described for open chest drainage.

The procedure for an Eloesser flap originally consisted of making a U-shaped skin incision that was 2 in. (5 cm) wide by 2.5 in. (6.25 cm) long. A segment of rib over the most dependent portion of the infected pleural space was removed, and the skin flaps were then sutured to the pleura and the remaining edges of skin sutured together. As a result, the one-way valve provided drainage of purulent material and air and prevented the formation of pneumothorax.

The only aspect of the original technique that still applies today, however, is the concept of draining an empyema cavity with an epithelialized stoma. [13]

Different skin incisions have been described, including U-shaped, inverted U-shaped, and H-shaped. [13] Whichever type is chosen, the incision must 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. [14]

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Complications

Open chest drainage is usually well tolerated by patients. The main complications include the following:

  • Failure to create the one-way valve, which leads to pneumothorax
  • Premature closure of the window, which leads to inadequate empyema drainage

Irritation of the surrounding skin also may be a source of pain or discomfort for the patient.

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