PURPOSE: Hippocrates was credited with the first drainage of an empyema. As medical therapy evolved and surgical techniques improved, indications for open window thoracostomy have gradually diminished. However, open window thoracostomy still has a role in the management of empyema. We reviewed our recent experience to determine: 1) the current indications and timing of surgery and 2) the survival of patients undergoing open window thoracostomy.
METHODS: From January 1, 1998 to January 1, 2008, a total of 78 patients underwent open window thoracostomy, 72 (95%) of which had long-term follow-up. Chart review was performed after Institutional Review Board approval.
RESULTS: Patients were predominantly male (66%) with a median age of 60.5 years. Median time from initial diagnosis to open window thoracostomy was 70 days (range 1 to 720 days). The primary indication for surgery was empyema in 76 patients (95%). Rarer indications in one patient each (1.3%) included tuberculous fibrothorax, recurrent hemothorax and persistent apical space. Causes of empyema was post-pneumonectony in 25 (32%), post-pneumonic in 14 (18%), post-lobectomy in 9 (11%) and post- complications of other chest surgeries in 6 (7.6%). A bronchopleural fistula was present in 28 patients (36%). 66 of 78 patients (85%) had at least one prior thoracic operation before open window thoracostomy. Kaplan-Meier survival (Figure 1) was 94%, 82%, 74% and 60% at 1month, 6 months, 1 year and 5 years respectively with an in-hospital mortality of 10.2% (n=8). Infection was controlled in all 76 patients (97.5%). The thoracostomy was successfully closed in 14 patients (18%) with a median time to closure of 12 months.
CONCLUSION: Open window thoracostomy effectively treats empyema with or without bronchopleural fistula when other thoracic surgery procedures have failed. Perioperative mortality in this debilitated patient population is acceptable. It continues to be an important surgical option in the thoracic surgeon's treatment of complex pleural disease.
CLINICAL IMPLICATIONS: The open window thoracostomy remains a reliable operative strategy which still holds a place in a thoracic surgical practice.
DISCLOSURE: Karl Reyes, No Financial Disclosure Information; No Product/Research Disclosure Information