What is the best treatment of postpneumonectomy empyema?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether an open surgical approach is superior to minimally invasive surgery in patients with postpneumonectomy empyema (PPE). Overall 171 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that open surgical approaches are superior to minimally invasive surgery in terms of empyema recurrence rate, mortality and reintervention rate. Minimally invasive surgery includes chest tube drainage with or without chemical irrigation and video-assisted thoracoscopic surgery debridement. Whereas open surgery includes open debridement, open window thoracostomy (OWT) and thoracomyoplasty. To allow for an accurate comparison, success of an intervention was defined as prevention of empyema recurrence. Two studies reported surgical outcomes of patients treated with minimally invasive treatment options. They found high mortality rates (17.1%) and low success rates (31%) in patients treated by chest tube drainage with chemical irrigation. Five studies treated PPE using a combination of minimally invasive and open surgical approaches and reported a high reintervention rate of 3.5 (range 3-5) and an empyema recurrence rate of 13.3%. Higher success rates (6.7 vs. 95%), lower mortality rates (33 vs. 0%) and shorter hospital stay (47.5 vs. 17.6 days) were all noted with thoracomyoplasty compared to chest tube drainage therapy. Five studies managed PPE using OWT or thoracomyoplasty. The time between empyema diagnosis to resolution (3 vs. 38 months) was much shorter with immediate OWT than with delayed OWT therapy. The Clagett procedure resulted in a mean hospital stay of 12.9 days, an operative mortality rate of 7.1% and an overall success rate of 81%. Thoracomyoplasty led to a mean hospital stay of 34 days with a mortality rate of 6%. The shorter hospital stay, lower empyema recurrence rates and lower mortality rates may make open surgical approaches a more effective treatment option to minimally invasive options.