The use of open window thoracostomy in the management of post-pneumonectomy pleural empyema after gun-shot

Lung gun-shot injury is a life-threatening condition requiring immediate surgical intervention – sometimes even total pneumonectomy. Pneumonectomy is a procedure associated with high mortality and morbidity, and poses a high risk of post-surgical complications, such as right-sided heart failure, ARDS, pneumonia or bronchopleural fistula (BPF) [1]. Among numerous possible complications, postpneumonectomy empyema (PPE) is one of the most serious. We present the case of a patient who has undergone multiple surgical interventions in the past 50 years as a result of PPE and bronchopleural fistula BPF.
In 1970, an 18-year-old male soldier was shot during military training and right-sided pneumonectomy had to be performed (Figures 1, 2). After the appearance of postpneumonectomy empyema, two drainages were applied and empyema was rinsed with chloramine solution. In addition, antibiotic therapy (4 cycles) was applied, with positive outcomes. After a few years the recurrence of PPE was observed due to development of bronchopleural fistula in the bronchial stump. Consequently, it was necessary to perform bronchoplasty. At the time of the recurrence bronchoscopy had confirmed it. Before that, the bronchoscopy did not reveal any fistula. The bronchial stump was sutured using the Klinkenberg technique – continuous non-absorbable suture, double overcast. It was effective until recurrence of the fistula in 2009. As a result, partial thoracoplasty was performed with fenestration (in the form of open window thoracostomy). Four upper right ribs were removed, which resulted in a partially collapsed chest. The initial attempt of fenestration closure was ineffective due to local infection with Pseudomonas. Additionally, foam was appearing from the patient’s unclosed anastomosis of the bronchial stump during coughing. On 28 May 2017, the patient was admitted to the Department of Thoracic Surgery and Transplantation with discharge from the wound during coughing. Hospitalization had to be postponed as a result of circulatory insufficiency with cardiac arrhythmia. Due to the patient’s deteriorating condition, myoplasties were carried out. The first myoplasty (17 July 2017) was performed after cardiac improvement and involved the use of a dermatomuscular patch (5 × 12 cm) made of the pectoralis major muscle. The patch was stitched to the walls of the fistula channel. Povidone-iodine was used for perfusion of the fistula. The second procedure (16 April 2018) included a...


View full text...