Postpneumonectomy empyema: drainage by spontaneous oesophagopleural fistula.

Abstract

Oesophagopleural fistula after pneumonectomy is not as uncommon as the 49 previously published cases might suggest. Nevertheless, it presents a diffidlt therapeutic problem. Direct surgical repair of the fistula is the treatment of choice'-7 as the mortality rate approaches 100% in patients who are not fit for surgery. This report describes the case of a patient who survived without surgical treatment as the fistula provided effective drainage of the empyema space. Case reportIn 1978 a 70 year old man underwent right pneumonectomy for a squamous cell carcinoma. His early recovery was uneventful but 10 days after operation he developed a bronchopleural fistula, which was followed shortly by empyema in the pneumonectomy space. The main microorganism cultured from the pleural fluid was Escherichia coli. The empyema was treated by tube drainage and antibiotics for six months, by the end of which the fistula had closed, and then by drainage and irrigation for a further two years. In January 1981, when the pleural fluid was sterile on culture, the chest tube was finally removed.Four weeks later the patient consulted his private physician because of malaise and gastric symptoms. Gastrograffin swallow showed an oesophagopleural fistula situated at the lowest point of the empyema space, by which the empyema had obviously been discharged (fig 1). Chest radiographs confirmed a drop in the level of the pleural fluid, although the patient was still without a chest tube. Since his general condition did not allow a surgical attempt at direct closure of the fistula we tried unsuccessfully to close it by the oesophagoscopic application of fibrin glue. Subsequently the patient's condition improved spontaneously, though he was still without a chest tube. When a normal diet was restored his health continued to improve and he was discharged.Two years later he is alive and in excellent health. Chest radiographs show that the pneumonectomy space is well drained and has shrunk to about one quarter of its original size. The oesophagopleural fistula remains in its original position but can only be demonstrated with the patient in