Empyema is a collection of pus in the cavity between the lung and the membrane that surrounds it (pleural space). Caused by an infection that spreads from the lung and leads to an accumulation of pus in the pleural space, the infected fluid can build up to a quantity of a pint or more, which puts pressure on the lungs, causing shortness of breath and pain. Risk factors include recent lung conditions like bacterial pneumonia, lung abscess, thoracic surgery, trauma or injury to the chest.

1. EMPYEMA

2. Directed by
DR.Karar .A.Ali
kararbenign@gmail.com

3. •

4. • The bacteria traditionally associated with parapneumonic
empyema are Streptococcus pneumonia, Streptococcus pyogenes,
Staphylococcus aureus, and, more recently, Streptococcus anginosus
(formerly Streptococcus milleri). Anaerobes
have been identified as sole or coexisting pathogens in
25% to 76% of cases. A recent review of the NIS database
between 1996 and 2008 characterized the changing epidemiology of
parapneumonic empyema in community
hospitals across the United States. The largest increase
in relative incidence of empyema occurred in young
adults. The most serious cases of empyema were associated with
staphylococcal infections. For patients older
than 40 years, staphylococcal empyema had a significantly higher in-
hospital mortality rate than those associated with other pathogens.

5. • The incidence of pneumococcal empyema has
remained relatively stable in both children and adults.
Infant vaccination with a seven-valent pneumococcal
conjugate vaccine (PCV7) started in 2000.11-14 Studies
documented significant reductions in the incidence of
pneumonia hospitalizations after the introduction of this
vaccine
The introduction of a 13-valent pneumococcal
conjugate vaccine in 2010 in the United States may
provide protection against several pneumococcal
serotypes commonly associated with empyema

6. • Some studies using molecular techniques have suggested that
a significant percentage of culture-negative
empyema may be caused by pneumococci, mainly serotype
1.19-23 Although recent studies suggest Streptococcus
anginosus may be a leading cause of empyema,24-26 it can
be difficult to distinguish between streptococcal species.
Mixed bacterial infections are found in some parapneumonic
empyemas.

7. • PATHOGENESIS
Classically, the development of empyema occurs in three
clinical stages:
• the exudative stage,
• the fibrinopurulent stage, and
• the organizing stage.

8. • When initially presented
with an infectious organism, the pleura responds with
edema formation, and exudation of proteins and
neutrophils into the pleural space. Inflammatory cytokines
result in increased pleural mesothelial and capillary cells
permeability, resulting in an effusion. Activated by bacteria,
mesothelial cells act as phagocytes and trigger an
inflammatory cascade with the release of chemokines,
cytokines, oxidants, and proteases. Polymorphonuclear
cells are recruited.1

9. • Early in the exudative stage, bacterial growth may be
minimal, and the exudate may be sterile. The rapidity of
progression depends on the type and virulence of the
organism, host defenses, and initiation of antibiotic
treatment. Staphylococcal pneumonias are almost always
associated with pleural effusions. With uncomplicated
parapneumonic effusions, the pleural fluid has a pH
greater than 7.20, relatively normal glucose levels, and
lactate dehydrogenase (LDH) levels that, although elevated,
are typically less than 3 times the upper limit of
normal. Most patients with uncomplicated parapneumonic
effusions respond to antibiotics alone

10. • Untreated exudative effusions may develop into fibrinopurulent effusions or complex
parapneumonic effusions. The fibrinopurulent stage represents the deposition
of fibrin on visceral and parietal pleural membranes and
the formation of loculations. Ongoing phagocytosis and
cell lysis result in pleural fluid with a pH less than 7.20,
LDH levels more than 3 times normal, and low glucose.
A complex parapneumonic effusion develops into a pleural
empyema when the concentration of leukocytes becomes
sufficient to form frank pus. Empyema fluid consists of
fibrin, cellular debris, and viable or dead bacteria. As
fibrin is deposited into the pleural space, lymphatic channels may become occluded,
further increasing the amount
of pleural fluid. The fibrin strands result in loculations of
the pleural space, which prevent drainage of the pleural
fluid using a single needle or tube.30 This stage is more
likely to result in a positive Gram stain and/or positive
bacterial cultures. This stage of pleural effusion requires
catheter drainage and often surgical drainage

11. • The third and final phase is the organizing phase. This
stage is characterized by the influx of fibroblasts and the
formation of a thick, fibrous pleural peel along with
continued maturation of dense septations. Both the visceral
and the parietal pleura may become severely thickened
with significant fluid remaining in the pleural space.
During this stage of disease, simple drainage of the fluid
may be possible, but the thick peel prevents reexpansion
of the underlying lung. Failure of the “trapped” lung to
reexpand will not allow for improved aeration of the lung
or any improvement in breathing. The residual space
quickly refills with infected fluid

12. •

13. • Chest x-ray
demonstrates
multiple air fluid
levels in the lower
part of the right
hemithorax. This is
associated with
patchy areas of
consolidation,
possibly with areas
of cavitation. The
left side is
unremarkable

14. • CT demonstrates
a large sub-
pulmonic
collection with
consolidation of
the compressed
lung above.

15. •

16. •
VATS decortication in pleural empyema stage
II. a) Pre-operative CT of the thorax; b–d)
operative views with multiple intrapleural
loculations. 1: lung; 2: chest wall; 3: sub-
pulmonary fibrin collection.

17. • Radiographic features
• Plain radiograph
• Can resemble a pleural effusion and can mimic a peripheral
pulmonary abscess, although a number of features usually
enable distinction between the two (see empyema vs lung
abscess) 3. Pleural fluid is typically unilateral or markedly
asymmetric 4. Generally, empyemas form an obtuse angle
with the chest wall, and due to their lenticular shape are
much larger in one projection (e.g. frontal) compared to the
orthogonal projection (e.g. lateral) 3. The lenticular shape
(biconvex) is also suggestive of the diagnosis, as
transudative/sterile pleural effusions tend to be crescentic
in shape (i.e. concave towards the lung, see empyema vs
pleural effusion).

18. •

19. • Distinguishing between an empyema and a
peripherally located pulmonary abscess is
essential.
• Lung abscesses are usually managed with
prolonged antibiotics and physiotherapy with
postural drainage whereas an empyema usually
requires percutaneous or surgical drainage.

20. • Radiographic features
• Plain radiograph
• shape
– abscess is usually (but not always) round in all
projections
– an abscess may form an acute angle with the costal
surface / chest wall
– empyema is usually (but not always) lentiform

21. • CT
• relationship to adjacent bronchi/vessels
– abscesses will abruptly interrupt the bronchovascular structures
– empyema will usually distort and compress adjacent lung
• split pleura sign
– thickening and separation of visceral and parietal pleura is a sign of empyema
• wall
– abscesses have thick irregular walls
– empyema are usually smoother
• angle with pleura
– abscesses usually have an acute angle (claw sign)
– empyema tends to have obtuse angles
• pleural enhancement
– empyemas tend to show more pleural enhancement.
• edema or hazyness of extrapleural fat - tends to occur with empyema

23. •

24. •

25. • CT
• Typically appears as a fluid density collection in the pleural
space, sometimes with locules of gas. They form obtuse
angles with the adjacent lung, which is displaced and
compressed. The pleura is thickened due to fibrin
deposition and in-growth of vessels with enhancement. At
the margins of the empyema, the pleura can be seen
dividing into parietal and visceral layers, the so-called split
pleura sign, which is the most sensitive and specific sign on
CT, and is helpful in distinguishing an empyema from a
peripheral lung abscess (see: empyema vs lung abscess) 2-
3. The inner walls of the empyema are smooth. There may
be increased density and haziness of the extrapleural and
extrathoracic fat

26. •

27. • DIAGNOSIS: CLINICAL SIGNS AND
SYMPTOMS, FLUID ANALYSIS, AND
RADIOLOGIC APPEARANCE
The clinical presentation may vary depending on the
underlying bacterial cause. Patients with aerobic infections tend to be more
acutely ill with an initial presentation similar to that of pneumonia. This can be
followed
by a nonresolving picture with pleuritic chest pain, fever
spikes, and failure to improve after receiving appropriate
antibiotic therapy. Immunocompromised patients, older
adults, and those with anaerobic infections may have a
more indolent course and may experience weight loss,
cough, fever, and anemia.25 The pleural effusions are generally evident on
upright chest radiographs. Lateral decubitus films are useful in determining
whether the fluid is
free flowing and amenable to complete percutaneous
drainage.

28. • The presence of leukocytosis, radiographic evidence
of a pleural effusion, and the presence of purulent fluid
on thoracentesis are classic findings of empyema. Signs
or symptoms of infection, history of malignancy, or associated
medical diseases such as cardiac failure or kidney
or liver disease can be helpful in determining the cause
of an effusion.

29. • Ultrasound can detect loculations and can determine
an appropriate site for thoracentesis. A computed axial
tomographic (CAT) scan can determine the size and
the location of the effusion and provides information
regarding associated underlying parenchymal and pleural
abnormalities. A CAT scan with intravenous contrast can
further characterize the empyema, suggesting loculations
or a thickened pleura or rind. Inspection of the lung-fluid
interface may suggest entrapped lung and may reveal an
underlying parenchymal process such as an abscess or
tumor. The appearance of the effusion and fluid-lung
interface can give indications as to the need for operative
intervention

30. •

31. •

32. •

33. • Thoracentesis is useful in determining the cause of an
effusion. Pleural fluid evaluation should include a cytologic
evaluation, pH level, gram stain and culture, cell count, and
total protein, glucose, and LDH levels. Effusions are classified as
exudative or transudative based on
protein and LDH levels. Exudate effusions will have a
pleural fluid protein/serum protein level higher than 0.5
and a pleural fluid LDH/serum LDH level higher than
0.6. The presence of an increased white blood cell count
in the pleural fluid, particularly with a preponderance of
neutrophils, may indicate pleural infection. Low pleural
fluid glucose and a pH less than 7.20 are indicators of
active pleural infection and the need for pleural
drainage

34. •

35. •

36. •

37. •

38. • TREATMENT
Initial antibiotic coverage of patients with parapneumonic effusions is generally dictated
by treatment guidelines for pneumonia and may be modified according to
blood and pleural fluid microbial cultures and sensitivities. Empiric anaerobic antibiotic
coverage may be initiated although anaerobes are much less likely to be
cultured. Patients with nosocomial empyema need adequate gram-negative coverage.
Vancomycin may be
added for suspected methicillin-resistant infection.
Reported bacteriology of pleural sepsis varies significantly between community acquired
and nosocomial
infections.30 Early appropriate antibiotic therapy represents the cornerstone of therapy
for pneumonia and parapneumonic effusion. Minimal size free-flowing effusions
may be observed without a diagnostic aspiration because
the risk of a complicated course is remote. All other freeflowing effusions should be
aspirated for diagnostic
purposes

39. • Uncomplicated parapneumonic, exudative effusions
that are of small volume, free flowing without loculations,
with a negative Gram stain, pH greater than 7.20, and
negative cultures are usually inflammatory in nature.
Most of these resolve with antibiotic treatment of the
underlying pneumonia and can be observed without
formal drainage.1 Early drainage of pleural fluid becomes
necessary when a parapneumonic effusion advances
beyond the exudative stage to the fibrinopurulent stage
and becomes a complicated parapneumonic effusion.
Indications for immediate drainage are large effusions
(larger than half the hemithorax), effusions with loculations, pH less
than 7.20, positive Gram stain or culture,
and low glucose levels. The presence of frank pus on
aspiration is also an indication for immediate and complete drainage

40. • Options for drainage include serial
thoracenteses, tube
thoracostomy (with or without intrapleural
fibrinolytics),
thoracoscopic drainage, thoracotomy and
drainage
(decortication), and chronic open drainage.
• Choice of
drainage is dependent on the viscosity of the pleural fluid;
location, volume, and extent of loculations; and the
general condition of the patient

41. • In theory, in the absence of loculations, either thoracentesis or tube
thoracostomy should adequately
drain any fluid. With significant ongoing infection and
inflammation, however, continued production of fluid
will occur, requiring repeat thoracentesis.
Serial thoracenteses are generally not recommended. Using
such strategy, one study showed that the average patient
required 7.7 aspirates with an average hospital stay of 31
days.31 Tube thoracostomy is generally performed with a
size 24 to 32 Fr chest tube placed in a dependent area
(usually the posterior costophrenic recess). If pleural
infection is confirmed and all fluid is drained, then the
tube is generally left in place until drainage is very low,
typically less than 30 to 40 mL/day.

42. • Complicated parapneumonic effusions and empyema
are characterized by a procoagulant state within the
pleural space, which results in the progressive
development of dense layers of fibrin and loculations,
as discussed earlier. These complex loculated
effusions are
unlikely to be adequately drained with simple tube
thoracostomy. In an attempt to aid drainage of
loculated
areas of empyema, instillation of fibrinolytic agents via
the chest tube has been proposed as a means of
avoiding
operation

43. • Intrapleural instillation of fibrinolytic agents can
theoretically dissolve fibrinous clots and adhesions and
prevent
pleural loculations. The use of fibrinolytic agents is
appealing because the most common reason for failure of
pleural drainage among patients with an appropriately
positioned catheter is occlusion of the catheter by viscous
fibrin-rich fluid and/or debris, or partitioning of the
pleural space with fibrin bands that loculate pleural fluid
and prevent it from reaching the chest tube. Side effects
with fibrinolytics are minimal with rare reports of fever
and bleeding.

44. • Streptokinase, urokinase, and tissue plasminogen
activator have all been instilled via chest tube. Streptokinase is
usually administered as 250,000 IU in 100 to
200 mL saline daily for up to 7 days. Urokinase is usually
administered as 100,000 to 200,000 IU in 100 mL
saline daily up to 3 days. Tissue plasminogen activator is
administered as 10 to 25 mg twice daily up to 3 days.
Drains are typically clamped for several hours following the
administration of the fibrinolytic. Tissue
plasminogen activator, a recombinant agent, provides
fibrinolytic activity without the risk of antigenic-based
reactions that can be seen with repeated administration
of streptokinase

45. • Tuncozgur and colleagues34 looked at fibrinolytic
versus saline instillation via chest tube in 49 patients.
They found a significantly lower decortication rate (60%
vs. 29%) and shorter duration of hospitalization (14 vs.
21 days) with the addition of intrapleural fibrinolysis as
well as a greater volume of chest tube drainage (1.8 liters
vs. 0.8 liters). It should be noted, however, that even a
14-day hospital stay is considerably longer than what is
expected following an expeditious video-assisted thoracic
surgery (VATS) decortication. A single-center randomized placebo-
controlled study by Diacon and colleagues32
reported that intrapleural streptokinase resulted in faster
resolution of infection, reduced need for surgery (13.6%
vs. 45.5%), and improved outcomes in patients with
complex parapneumonic effusions and empyema.

46. • Davies and colleagues35 compared fibrinolysis versus saline
control in
the second to fifth hospital day in 24 patients with tube
thoracostomy for empyema. These investigators looked
at volume of drainage and improvement in chest
radiographs. Fibrinolytics caused an increased rate of fluid
drainage and greater improvement on chest radiograph.
No bleeding complications were seen. Three patients in
the control group and none in the fibrinolytic group
required surgical drainage

47. •

48. •

49. • Surgical drainage via thoracoscopy is indicated in
patients who fail chest tube drainage, in patients whose
lung does not reexpand following either thoracentesis or tube
thoracostomy, or as the initial treatment in patients
who, based on chest computed tomography (CT) appearance, are
unlikely to be effectively treated with a chest
tube. These include patients with very loculated effusions, patients
with thick pus, or with a thick pleural rind
on CT scan. Loculations can be broken down, thick
pleural fluid and debris completely evacuated, the pleural
space can be extensively lavaged, and chest tubes can be
carefully placed. Several small retrospective and nonblinded prospective
studies suggest that thoracoscopy is
superior to tube thoracostomy with fibrinolytics, with the
need for thoracotomy halved

50. • In the only prospective randomized controlled trial of
fibrinolytic therapy versus thoracoscopy for empyema,
Wait and coworkers41 randomly assigned 20 patients with
complicated multiloculated parapneumonic empyema to
streptokinase (250,000 IU daily for 3 days) via tube
thoracostomy or immediate thoracoscopic drainage.
Thoracoscopy had a higher treatment success rate (91% vs.
44%), lower duration of chest tube drainage (5.8 vs. 9.8
days), and a shorter hospital stay (8.7 vs. 12.8 days). This
study supports the preferred approach of primary thoracoscopic
drainage in patients presenting with loculated
collections, provided that they are suitable candidates for
surgical intervention.

51. • Often in the chronic organizing phase of empyema, a
thick fibrous peel builds up on the visceral pleura that
restricts lung mechanics and prevents lung reexpansion,
even after fluid drainage. The procedure allows for excision
of all the fibrous tissue from the pleura to permit
lung reexpansion.42 Decortication relies on lung elasticity
to fill the cavity. Failure of reexpansion of the lung in the
acute phase may result when there is densely consolidated
lung that does not fully reexpand after drainage of fluid,
even with decortication. Lung constriction after empyema
can reduce lung perfusion by 20% to 25% on the involved
side

52. • The pulmonary function of patients who undergo
decortication can increase significantly. Decortication
can improve lung perfusion and improve vital capacity
from 62% up to 80% and the forced expiratory volume
after 1 second (FEV1) from 50% to 69%. Nonetheless,
decortication remains a procedure with significant morbidity and a reported
mortality rate of up to 10%.42 Some
investigators have suggested that pleural thickening may
resolve over time and recommend deferring decortication for up to 6 months,
but this opinion is in the minority.43 In patients suffering from overwhelming
sepsis,
pleural drainage by tube thoracostomy or expeditious
VATS is the immediate goal. Decortication may then be
performed at a later date when the patient is stable.
Delayed decortication is advised if there remains significant restriction of the
affected lung and if the patient is
a good operative risk.

53. • For patients in whom sepsis cannot be controlled
acutely with thoracoscopic drainage and in whom
decortication is not appropriate, window
thoracostomy may be
performed. Open thoracostomy may be the
procedure of
choice if there is a permanent supply of causative
organisms as a result of a bronchopleural fistula or if
there is a
space issue such as in a postpneumonectomy
empyema

57. •

59. •

60. •

61. • Case Report
• A 66-year-old man was referred to the authors’ department
due to a bronchopleural fistula of the main bronchus. The
fistula occurred three months after a left pneumonectomy
that he underwent in another center for a pulmonary
adenocarcinoma. The patient reported fever, dyspnea, and
cough with mucopurulent sputum. Chest radiography
demonstrated a drop in the air-fluid level and a computed
tomography scan showed a fistulous communication that
was confirmed by bronchoscopy. Parenteral antibiotic
therapy was imposed. A pleural drainage (18 Fr) was
positioned and repeated irrigations with betadine solutions
were performed without benefit. Surgical indication for a
left thoracostomy was thus given.

62. • Surgical Procedure
• Under general anesthesia, the patient was placed in the standard right lateral decubitus
position.
• An “H-shaped” skin incision was made in the fourth intercostal space, and subcutaneous
tissues were dissected to reach the muscular layer. Latissimus dorsi and pectoralis major
muscles were identified and spared. The third rib was isolated and cut. The thickened
parietal pleura was digitally opened. The pleural cavity appeared full of purulent
material, and the bronchopleural fistula was clearly visible. The fourth and second ribs
were then isolated and removed to enlarge the thoracostomy and to create an easy-to-
pack drainage cavity. The pleural cavity was then deeply cleaned and debrided, and the
purulent material was removed. Washings with saline solution and betadine were
performed. Finally, the skin flaps were sutured directly to the parietal pleura with
interrupted absorbable sutures anchored to the ribs stumps. This served to epithelialize
the thoracostomy borders and maintain the patency of the window, improving the
healing. The margins were sutured. After that, the bronchial fistula was covered with a
sponge, and betadine-soaked gauzes were plugged into the pleural cavity. The cavity was
thus packed, and the wound was dressed. During the hospital stay, the patient
underwent daily dressing changes to ensure the sterilization of the cavity and to
eradicate the local sepsis.

63. • Bronchial stump closure with staples had a protective effect
against BPF compared with suture closure.
Factors not affecting the incidence of PPE or BPF were
gender, age, smoking history, associated cardiovascular
disease, corticosteroid use, chronic renal failure, diabetes
mellitus, hematologic disease, cirrhosis, nonpulmonary
malignancy, body mass index, weight loss, stage,
preoperative chemotherapy or radiation therapy,
preoperative
percentage of predicted total lung capacity and residual
volume, PaO2, and PaCO2, extended resection, and
duration of postoperative mechanical ventilation

64. • The signs and symptoms of postpneumonectomy
empyema initially consist of low-grade fever, malaise, and
leukocytosis. The appearance of air in the pleural fluid
after pneumonectomy is nondiagnostic; however, a drop
in the air-fluid level is strongly suggestive of a BPF even
in the absence of other symptoms. Computed tomography can be helpful in
demonstrating the size and location
of loculated air-fluid pockets. It may also show reversal
of the normal concavity of the mediastinal margin with
increased thickening of the residual parietal pleura.50,51
Air in continuity with the bronchial stump may raise
suspicion of a BPF but is not diagnostic. Bronchoscopy
should be performed if the diagnosis of empyema is suspected after pulmonary
resection. The bronchial stump
should be thoroughly inspected for a small BPF. Similarly, the contralateral
airway should be inspected and
sputum collected for cultures.

65. • Staphylococcus aureus and
Pseudomonas aeruginosa are the organisms most frequently
involved.49 In patients with suspected early empyema who
have no evidence of a fistula, systemic antibiotics and
observation may be the most appropriate management
option. In cases of confirmed postpneumonectomy empyema, however,
treatment follows the well-established
rules of managing any abscess.49 These management rules
include adequate pleural drainage, appropriate parenteral
antibiotics, removal of necrotic tissue, and obliteration of
residual space. Obliteration of the empyema space can be
accomplished by transposition of viable tissue such as
omentum or skeletal muscle; this can be performed as a
primary procedure to manage an empyema space or as
a staged procedure some months after an open
thoracostomy.

69. • Treatment
When the patient presents acutely with clinical features
of a BPF, contralateral pneumonitis, and respiratory distress, initial
management begins with emergency chest
tube drainage of the cavity to control infection and stop contralateral
spillage. The patient should be positioned
in the lateral decubitus position with the pneumonectomy side down
until adequate drainage of the pleural
space is achieved. Simultaneously, respiratory support is
provided as clinically needed. When a large BPF is
present and mechanical ventilation is required, a doublelumen
endotracheal tube or a straight, long single-lumen
tube is used to ventilate the remaining lung and bypass
the fistula.

70. • The ventilation of these patients can be
extremely challenging. If the fistula occurs in the perioperative
period (i.e., within the first month or so), repeat
thoracotomy and attempted closure of the stump with
muscle flap reinforcement and drainage of the pleural
space are recommended. After this time, scarring and
granulation tissue prevent the precise placement of bronchial
stump sutures. Other treatment options include
thoracoplasty,52-54 open pleural drainage,55-57 and
transsternal, transpericardial closure of the fistula.58-60 If
bronchoscopy reveals a long main bronchus stump (i.e.,
>1 cm), then transsternal, transpericardial closure with a
thoracoabdominal (TA) stapler may be a good option.

71. • Rarely, carinal resections have been used for treatment
of a pneumonectomy stump BPF.61 Clagett and Geraci
in 196362 showed that post-pneumonectomy empyema
could be successfully treated by open pleural drainage,
frequent wet-to-dry dressing changes, and, when the
thorax was clean, secondary chest wall closure with
obliteration of the pleural cavity with an antibiotic solution.
Failure was most often due to a persistent or recurrent
fistula.60 Because of this, the original Clagett technique
is modified when a BPF is present to include transposition
of a well-vascularized muscle to cover the stump at
the time of open drainage to prevent further ischemia and
necrosis.63

72. • Our preference is intrathoracic transposition
of extrathoracic skeletal muscle.63-67 Usually, the serratus
anterior muscle is intact despite a previous thoracotomy.
Other available muscles include the pectoralis major, the
cephalic portion of the previously transected latissimus
dorsi, and the rectus abdominis. The advantages of using
these muscles include adequate bulk, an axial blood
supply, and the muscle’s availability in the same visceral
cavity. Transposition of the latissimus dorsi and pectoralis
major muscles results in minimal cosmetic or functional
abnormality; transposition of the serratus anterior muscle,
however, may result in scapular winging.

73. • CONCLUSIONS
Patients with pneumonia and associated pleural effusion
should initially be evaluated with thoracentesis. Presence
of loculations or pleural fluid analysis showing bacteria
on Gram stain or culture, low glucose or low pH, and
frank pus are all indications for immediate drainage.
Nonloculated parapneumonic effusion and empyema
may be adequately treated with tube thoracoscopy, but
loculated effusions, or those inadequately drained with a
chest tube, are best treated with thoracoscopic drainage.
The fundamental principles of therapy are to remove
infection and allow for lung reexpansion to obliterate
dead space. If visceral scarring results in lung entrapment,
then decortication is required. With recent advances in

74. • VATS technology and skills, most decortications can be
performed using minimally invasive techniques. Open
decortication is usually reserved for patients with severe
scarring after remote pleural empyema. If a significant
pleural space exists and decortication is not possible, then
the options are thoracoplasty, muscle flap transposition,
or open window drainage

75. • BPF is a communication between the pleural space and the bronchial
tree or lung parenchyma resulting in air leak in the chest tubes. It might
be divided into alveolopleural fistula (APF) or bronchopleural fistula
(BPF). An APF is a communication between the pulmonary parenchyma
distal to a segmental bronchus and the pleural space, while a BPF is a
communication between a main stem, lobar, or segmental bronchus and
the pleural space. The term BPF is used for any air leak which failed to
heal conservatively and progressed to chronicity. Chronic BPF is a serious
complication of several pulmonary and postoperative conditions, as it
carries a high morbidity and mortality and is associated with prolonged
hospital stay and thus high resource consumption. The treatment of BPF
includes control of infection, pleural space drainage, surgical
interventions and bronchoscopic interventions. Till date surgical
intervention has been the main stay of management of chronic BPF

76. • Modified silicone stent for the treatment of post-
surgical bronchopleural fistula: a clinical
observation of 17 cases

77. • Background
• Bronchopleural fistula is a rare but life-threatening event
with limited therapeutic options. We aimed to investigate
the efficacy and safety of the modified silicone stent in
patients with post-surgical bronchopleural fistula.
• Methods
• Between March 2016 and April 2020, we retrospectively
reviewed the records of 17 patients with bronchopleural
fistula and who underwent bronchoscopic placement of the
Y-shaped silicone stent. The rate of initial success, clinical
success and clinical cure, and complications were analyzed.

78. • Results
• Stent placement was successful in 16 patients in the first attempt (initial
success rate: 94.1%). The median follow-up time was 107 (range, 5–431)
days. All patients achieved amelioration of respiratory symptoms. The
clinical success rate was 76.5%. Of the 14 patients with empyema, the
daily drainage was progressively decreased in 11 patients, and empyema
completely disappeared in six patients. Seven stents were removed
during follow-up: four (26.7%) for the cure of fistula, two for severe
proliferation of granulomatous tissue and one for stent dislocation. No
severe adverse events (i.e. massive hemoptysis, suture dehiscence) took
place. Seven patients died (due to progression of malignancy,
uncontrolled infection, myocardial infarction and left heart failure).
• Conclusions
• The modified silicone stent may be an effective and safe option for
patients with post-surgical bronchopleural fistula patients in whom
conventional therapy is contraindicated.

79. •

80. • Illustration of the modified silicone stent. a The
modified silicone stent consists of the main
branch, the lateral branch and the occluded
branch; b the stent rings are sutured to the main
branch and the lateral branch of silicone stent; c
the stent ring is sutured to the occluded branch

82. • The bronchoscopic view of
the stent placement in a
representative case. Patient
5 is a 72-year-old male with
BPF. a Bronchoscopic image
of fistula in the left main
bronchus and the drainage
tube could be seen from
the fistula (arrow); b the
straight stent segment is
used to measure the
diameter of the left main
bronchus; c bronchoscopic
image of the carina, left
main bronchus and right
main bronchus after
stenting; d the inner
surface of the occluded
branch

83. • The coronal computer
tomography image of
patient 5 in different
time. a The fistula in the
left main bronchus
(arrow) and the drainage
tube (arrow head) is
placed in the left thoracic
cavity; b the occluded
branch of the stent can
be seen in the left main
bronchus (arrow) and
the drainage tube (arrow
head) is still in the left
thoracic cavity; c the
residual pleural space
diminishes over time; d
the residual pleural
space disappears during
follow-up

85. Background: Bronchopleural fistula (BPF) is a communication between
the pleural space and the bronchial tree or lung paren-
chyma resulting in air leak in the chest tubes. Chronic BPF is a serious
complication of several pulmonary and postoperative
conditions, as it carries a high morbidity and mortality and is
associated with prolonged hospital stay and thus high resource
consumption. Till date surgical intervention has been the main stay of
management of chronic BPF.
This study was carried out to assess the efficacy of surgical closure of
the chronic BPF using vascularized tissue transfer into the
pleural cavity.

86. Patients and methods: 28 patients were operated upon primarily
due to chronic BPF with or without empyema. All patients were
selected and subjected to surgical intervention using vascularized
tissue transfer into the pleural cavity. The vascularized tissues had
been used were: Intercostal muscle flap, Latissmus dorsi muscle
transposition, Omental flap, and Pericardial pad of fat.
Results: The mean hospital stay postoperatively was 4 ± 1 day.
There was immediate or early stoppage of air leak after the
intervention in all patients. No patient had prolonged
postoperative air leak (5 days). One patient required negative
suction for 2
days to help stoppage of the leak. No patient required instillation
of sealants through the tubes.

87. •

92. • The
standard
thoracot
omy
incision
along the
sixth rib

96. • A) Pedicled intercostal muscle flap, IMF (B) ruptured
pulmonary sarcoidosis cyst before closure with IMF (C)
completely dissected and
• isolated right sided latismus dorsi muscle, LDM, with
preservation of its vascular pedicle (D) longitudinal skin
incision along the anterior border
• of LDM (E) operative view for the anatomy of pericardial
pad of fat (F) omental flap passed through the foramin of
Morgagni to be directed
• toward the pleural cavity.