Open Window Thoracostomy in a Patient With Broncopleural Fistula After Left Pneumonectomy

Introduction

Dr Oscar Clagett described the open window thoracostomy in 1963 for treating postpneumonectomy empyema. This technique is still used in the management of bronchopleural fistula after lung resection. The opening into the chest wall allows repeated drainage, irrigation, and dressing of the cavity, and it lets the wound granulate and close over time. It can also act as a bridge to secondary wound closure with muscle or omental flaps, once the infection of the pleural cavity is under control.

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.

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.