Pleural space irrigation and modified Clagett procedure for the treatment of early postpneumonectomy empyema

Objective: The incidence of postpneumonectomy empyema is 5 % to 10 %. Appro ximately half of postpneumonectomy empyemas occur within 4 weeks of pneumon ectomy. A bronchopleural fistula is found in more than 80% of the patients. The classic treatment of postpneumonectomy empyema includes parenteral ant ibiotics, drainage of the pleural space, removal of necrotic tissue, and op en pleural packing for many weeks followed by obliteration of the empyema s pace with antibiotic fluid or muscle. This approach results in prolonged ho spitalization, repeated operations, and significant morbidity, As a possibl e means of decreasing morbidity with the classic treatment of postpneumonec tomy empyema, we studied the use of pleural space irrigation in these patie nts. Method: In a 5-year period, we treated 22 patients with early postpneu monectomy empyema, All patients had a bronchopleural fistula, All patients underwent emergency drainage of the pleural space followed by thoracotomy, debridement of necrotic tissue, closure of the bronchial stump with absorba ble monofilament suture, and pleural space irrigation. After a negative Gra m stain from the pleural fluid, the pleural space was filled with 2 L of de bridement antibiotic solution (DAB solution) (gentamicin 80 mg/L, neomycin 500 mg/L, and polymyxin B 100 mg/L), and the irrigation and drainage cathet ers were removed. Results: Twenty patients had negative Gram stains on day 9, and 2 patients had a negative Gram stain on day 16, The mean duration of hospitalization was 12.9 +/- 3.4 days. There was no recurrence of empyema or a bronchopleural fistula. Conclusions: Pleural space irrigation followed by obliteration of the pleural space with an antibiotic solution required one surgical procedure and resulted in significantly shorter hospitalizatio n and decreased morbidity in patients with early postpneumonectomy empyema.