Pneumonectomy Complicated by Bronchopleural Fistula and Empyema

Abstract

Thoracic empyema with or without an associated bronchopleural fistula (BPF) is one of the most common complications after a pneumonectomy. We discuss the case of a 72-year-old gentleman with stage III poorly differentiated squamous cell carcinoma of the lung, who underwent right thoracoscopic pneumonectomy and mediastinal lymphadenectomy. Postoperatively, he developed a BPF and empyema with quinolone-resistant Pseudomonas aeruginosa. Subsequently, he underwent a right thoracoscopic drainage and debridement of the chest cavity followed by repair of the BPF with omental pouch. He was then treated with intravenous tigecycline and meropenem for 20 days with gradual clinical improvement. We discuss the pathophysiology of empyema, microorganisms involved, and the role of appropriate antibiotic therapy. We also describe various preoperative and intraoperative strategies to prevent the development of empyema and how both medical and surgical interventions play an important role in the management of these patients.B ronchopleural fistulas (BPFs) and empyemas are serious complications in patients after pneumonectomy. There is a 5% to 10% incidence of empyema within the first 4 weeks of lung resection, with 80% of cases associated with BPF. 1 Risk factors include age older than 60 years, diabetes, poor nutritional status, underlying lung disease, preoperative radiation or chemotherapy, prolonged mechanical ventilation, right-sided procedures, long bronchial stump (>25 mm), carcinoma at the bronchial margin, and a disrupted bronchial blood supply. 2 Early antibiotic therapy in combination with irrigation and drainage of the pleural space is imperative to decrease morbidity and mortality. In addition, closure with either omental flap or extrathoracic skeletal muscle is necessary to prevent recurrence in those cases complicated by BPF. Despite these interventions, the mortality rate after pneumonectomy for BPF and empyema is 10% to 20%. 3 We describe a case of a 72-year-old gentleman with non-small cell lung cancer who underwent right pneumonectomy and mediastinal lymphadenectomy that was complicated by BPF and empyema by multidrug-resistant Pseudomonas aeruginosa. CASE REPORTA 72-year-old gentleman with longstanding chronic obstructive pulmonary disease and newly diagnosed stage III poorly differentiated squamous cell carcinoma of the lung underwent a complete right thoracoscopic pneumonectomy with mediastinal lymphadenectomy. His postoperative course was complicated by respiratory failure secondary to inability to clear secretions, and a tracheostomy tube was placed. He also developed aspiration pneumonia and was treated with intravenous (IV) piperacillin/ tazobactam and metronidazole. While it is now well known that there is no need for double anaerobic coverage, this was not appreciated at the time of this patient's illness. 4 He continued to improve clinically, his tracheostomy tube was removed, and he was discharged home with oral amoxicillin/clavulanic acid and metronidazole after 12 days in the hospital.One month later...