Late-onset post-pneumonectomy empyemal

Thorax, 1977, 32, 149-154

Late-onset post-pneumonectomy empyemalW. F. KERR

From Norfolk and Norwich Hospital, Norwich

Kerr, W. F. (1977). Thorax, 32, 149-154. Late-onset post-pneumonectomy empyema. Nine casesof empyema developing more than three months after pneumonectomy are presented. Diagnosisis difficult; with one exception, all the patients had been ill for at least three weeks and somefor several months before the cause was discovered. In four, the radiological demonstration ofgas in a previously opaque hemithorax led to the diagnosis. One of these had a bronchialfistula, two had oesophageal fistulae, and one had both. The remaining patients had no fistulaeand the diagnoses were not made until empyema necessitatis had developed. Two from thisgroup yielded pure cultures of pneumococci and one a pure culture of Streptococcus viridans.Except for one patient admitted moribund, all were treated in the first instance by rib resectionand open drainage without tubes and all survived. Four of the five without fistulae subsequentlyhad their drainage sinuses successfully closed after the infection of the chest wall had cleared.The belief that a pneumonectomy space normally becomes obliterated is challenged. The

history and mode of onset of some of these cases suggested that infection of the residual fluidwas bloodborne.

Eighty years ago, in 1895, the first man to surviveremoval of a lung was operated on in Glasgowin the Western Infirmary by the Regius Professorof Surgery, Sir William Macewen. The operationwas anything but the formal procedure routinelypractised today. Tuberculosis and superaddedsecondary infection had destroyed the lung andeven, it seems, sealed the bronchus. Macewenevacuated a huge intrapulmonary abscess, dis-sected out the sloughs and remnants of lungadherent to chest wall and mediastinum, and leftthe chest with wide-open drainage (Macewen,1906). Later he dealt so successfully with the in-fected space by thoracoplasty and turning in askin flap that 45 years afterwards, during thesecond world war and at the age of about 70, thepatient was fit for an elective operation for herniawhich he underwent in the hope and expectationof being able to get back to work (Bowman,1942). The first successful pneumonectomy forcancer was also followed by empyema (Grahamand Singer, 1933) and that patient too survived,with a thoracoplasty, for many years.

Today, in the antibiotic era, infection of apneumonectomy space is still an occasional hazardas several recent articles testify (Clagett and

'Based on a paper read to The Society ofThoracic and CardiovascularSurgeons of Great Britain and Ireland: Glasgow, September 1975

Geraci, 1963; Provan, 1971; Adler and Plaut,1972; Holden and Wooler, 1972; Stafford andClagett, 1972; Bhattacharya et al., 1973; Zumbroet al., 1973; Virkkula and Eerola, 1974; Karkolaet al., 1976). Most cases occur early and arerecognised and treated before the patients leavehospital. A late-onset empyema may be arbitrarilydefined as one which first produces symptoms orsigns more than three months after the resectionin a patient whose immediate postoperative coursegave no cause for concern. Almost every reportincludes one or two examples, 26 years being thelongest interval (Stafford and Clagett, 1972), butthe late cases tend to be lost among the muchmore numerous early ones, on which attentionis naturally focused. There seems as a result tobe a widespread belief that once a patient hasrecovered well from the operation and thehemithorax has filled as expected, complicationsin the form of space infections have been avoidedand can be forgotten. The purpose of this paperis to concentrate attention on the late infectionswhich are not so very uncommon.

Cases

The Table summarises the relevant features ofnine cases encountered in the seven years January1968 to December 1974.

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Late-onset post-pneumonectomy empyema

Discussion

All but one of the nine patients were men and allbut one had cancer, the other tuberculosis. Innone had there been anything alarming in theimmediate postoperative course or, looking back,anything that might have given a hint of troublebrewing. The Table indicates how long after theresection each patient remained clinically satis-factory-four months to 13 years-and how longeach was ill before empyema was diagnosed-threeweeks to one year. The patient KS had a shortfebrile illness 15 months after the pneumonectomywhen antituberculosis drugs had been discon-tinued, but he recovered without treatment inunder two weeks and the fluid in his pneu-monectomy space was proved sterile at the time.Another patient (JW) had no premonitory illness;at routine review 22 months after pneu-monectomy, the chest radiograph showed anempty space where previously there had been anopaque hemithorax. It was two years after thatthat he had the first of a series of infections in theother lung indicative of a bronchial fistula notapparent on bronchoscopy.Gas appearing on a chest radiograph that had

previously shown a normal postoperative opacityled to the diagnosis in four cases and all wereeventually proved to have bronchial or oeso-phageal fistulae communicating with the pleuralcavities. One (JW) has already been mentioned.Another (KS) was the patient who fell ill 13 yearsafter pneumonectomy for tuberculosis. After

drainage of the empyema, repeated attempts todemonstrate a bronchial fistula failed but twoyears later an oesophageal fistula was discovered;it showed only when he was examined lying down(Fig. 1). At that time he firmly denied any oeso-phageal symptoms but a few months later clinicalcorroboration was forthcoming.The other two, with gas in their pneumonec-

tomy spaces, were the only patients known tohave recurrent carcinoma. RT, moribund on ad-mission, had obvious tumour in the bronchialstump and adjacent oesophagus, with a fistulainto the pleural cavity from each. The other (MR)first complained of dysphagia some six monthsafter the empyema had been drained and onlythen was the cause of the empyema discovered -a minute oesophageal fistula (Fig. 2). Oesophagealobstruction from mediastinal recurrence ofbronchial carcinoma is common enough butoesophagopleural fistula occurring late seemsto be rather rare. Symes et al. (1972) reportedone case and claimed that it was unique.The five cases which did not have fistulae had

all progressed to empyema necessitatis before theywere recognised. Pneumococci in pure culturewere isolated from two, Strep. viridans from one,and there was no growth from another. In two(HG and RD) the illnesses started during influenzaepidemics. All had had antibiotics at home or inhospital beforehand.

In this series, as in others, delay in diagnosiswas the rule rather than the exception. One causeof difficulty is that late-onset post-pneumonectomy

Fig. 1 KS Barium swallowin recumbent position shows atraction diverticulum of theoesophagus with a fistulabetween it and the pleuralcavity.

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the 'accumulated fluid clots and eventually be-comes a solid fibrotic mass'. In my experience, thefibrous reaction stops short of obliteration andeven after many years encloses a lacuna of clearfluid, a 'target' for circulating bacteria. Figures3 and 4 indicate how much fluid two patientsharboured 33 months and 14 years respectivelyafter pneumonectomy. Once it is generallyrealised that the clinical and radiographic signson the operation side are accounted for in partby fluid, and that that fluid always remains liableto infection, diagnostic aspiration is likely to bemore widely practised when a patient who has hada lung removed falls ill for no apparent reason.Chest aspiration was attempted before the diagnosiswas obvious in only one case in this series (HD),and the procedure was left to an inexperiencedjunior. When a 'dry tap' was reported, the patientwas considered to be suffering from 'carcinoma-tosis', and it was not until the empyema brokethrough the chest wall three months later that thereal cause of the illness was discovered. KS, whocomplained for a year of lassitude, debility, and

Fig. 2 MR Barium swallow showing oesophagealinvolvement in mediastinal recurrence of carcinomaof lung 38 months after pneumonectomy. A thinthread of barium running from the upper third ofthe stricture horizontally to the left indicates thefistula communicating with the empyema cavity.

empyema seldom presents with the classical signsof 'pus somewhere'. Only two of the nine did so(MR and HD); the rest just felt 'out of sorts' andsome did not even have a leucocytosis. Beforethe empyemas declared themselves in unmistak-able terms, the single indication that the pneu-monectomy side was the seat of the trouble wasshift of the tracheal translucency on the chestradiograph back towards the mid-line. Thatoccurred in only one patient and not until hehad been ill for a year, so it hardly qualifies as areliable early sign.Another reason for not suspecting empyema

sooner appears to be a belief that after a timethere is no space to become infected. It is a beliefthat Clagett and Geraci (1963) did nothing todispel when they wrote in the introduction totheir important and widely quoted paper on thetreatment of post-pneumonectomy empyema that

Fig. 3 MR Chest radiograph before drainage ofempyema showing the late accumulation of gas in aside that had previously been completely opaque.Note the size of the space 33 months afterpneumonectomy and three weeks after the acuteonset of fever.

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Fig. 4 KS Chest radiograph after rib resection andopen drainage showing the hemithorax far fromsolid 14 years after pneumonectomy and one yearafter the insidious onset of empyema.

intractable anaemia had in that time every con-ceivable haematological, bacteriological, radio-logical, and biochemical investigation, butaspiration of the chest was not attempted untilthe diagnosis had become plain from the changein radiographic appearances.The source of infection in those patients with-

out fistulae is debatable. Even in very late cases itis not impossible that the organism was liberatedor implanted during the operation and smoulderedaway in bronchial stump or chest wall sutureuntil perhaps a small abscess ruptured into thecavity and infected its contents. On the otherhand, foreign bodies, scar tissue, and isolatedpockets of fluid are well-known 'targets' for cir-culating bacteria, and pneumonectomy providesthem all. It might be significant that both thepneumococcal cases occurred during influenzaepidemics and the streptococcal case after radio-logically confirmed bronchopneumonia. Holdenand Wooler (1972) reported a case of empyemaof the pneumonectomy space that occurred soonafter appendicitis with peritonitis, and the sametype of organism, Bacteroides, was recovered fromthe pleural cavity as had earlier been isolatedfrom the peritoneum. Subphrenic abscess as theroute of infection was ruled out by postmortemexamination. It would seem therefore that blood

spread is a distinct possibility as a cause of late-onset post-pneumonectomy empyema.The primary treatment of all cases except that

of the moribund man was open drainage withouta tube, as advocated by Clagett and Geraci (1963)and Stafford and Clagett (1972). Nothing more isplanned for the patient with the non-malignantbronchial fistula (JW), now too old and feeblefor major surgery. The woman with tumour re-currence in the mediastinum and an enlargingoesophageal fistula had the discharge from herchest reduced to tolerable quantities by a palliativesubcutaneous colon bypass of the oesophagus, andshe died of tracheal obstruction six months later.The man with the non-malignant oesophagealfistula has had a similar oesophageal bypass opera-tion and has been able to return to sedentarywork.Four of the five patients who did not have

fistulae had their sinuses closed at varying in-tervals after the establishment of open drainage,following precisely the procedure described byClagett and Geraci (1963). One of these (HD)died of myocardial infarction a year later. Thefluid in his chest was proved sterile a monthbefore death. Two (HG and JEi) are alive andwell at five and seven years respectively afterclosure of their sinuses, and the fourth (RD) hassurvived eight years without recurrence ofempyema or bronchial carcinoma but is far fromwell with heart disease and carcinoma of theprostate. The one patient without a fistula whohas not had his sinus closed (AN) has manytimes refused offers of further surgery. The scantdischarge from his chest and the daily dressinginconvenience him so little that he considersanother operation not worth while.

Conclusions

Late-onset post-pneumonectomy empyema is aninfrequent cause of refractory illness in patientswho have had uncomplicated pneumonectomiesand one that is liable to be overlooked. Thediagnosis can be confirmed or excluded byaspiration of the residual pocket of fluid. Per-manent open drainage without a tube is a con-venient, comfortable, and satisfactory way oftreating patients with fistulae; thoracoplasty is notnecessary. A patient without a fistula may havethe drainage sinus closed, once the chest wallinfection has settled, with excellent prospects ofa good long-term result.

I am grateful to the several chest physicians whoreferred these cases, to Mr. B. A. Ross for per-

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mission to include a case treated by him, and toMr. P. L. C. Dove, Department of MedicalIllustration, The Ipswich Hospital for theilluistrations.

References

Adler, R.H. and Plaut. M. E. (1972). Post-pneumo-nectomy empyema. Surgery. 71, 210-214.

Bhattacharya, S. K., Polk, J. W., and Bailey, A. H.(1973). Management of postpneumonectomyempyema: a report of 20 patients and review oftreatment methods. American Surgeon, 39, 264-268.

Bowman, A. K. (1942). The Life and Teaching of SirWilliam Macewen, p. 344. William Hodge, London.

Clagett, 0. T. and Geraci, J. E. (1963). A procedurefor the management of postpneumonectomyempyema. Journal of Thoracic and CardiovascularSurgery. 45, 141-145.

Graham, E. A. and Singer. J. J. (1933). Successfulremoval of an entire lung for carcinoma of thebronchus. Journal of the A merican MedicalA4ssociation. 101, 1371-1374.

Holden. M. P. and Wooler, G. H. (1972). Pus some-where, pus nowhere else, pus above the dia-phragm: postpneumonectomy empyema necessitatis.American Journal of Surgery, 124, 669-670.

Karkola, P., Kairaluoma, M. I., and Larmi, T. K. I.(1976). Postpneumonectomy empyema in pulmonary

W. F. Kerr

carcinoma patients: Treatment with antibioticirrigation and closed-chest drainage. Journal ofThoracic and Cardiovascular Surgery, 72, 319-322.

Macewen, W. (1906). Some points in the surgery efthe lung. British Medical Journal, 2, 1-7.

Provan, J. L. (1971). The management of post-pneumonectomy empyema. Journal of Thoracicand Cardiovascular Surgery, 61, 107-109.

Stafford, E. G. and Clagett, 0. T. (1972). Post-pneumonectomy empyema: neomycin instillationand definitive closure. Journal of Thoracic andCardiovascular Surgery, 63, 771-775.

Symes, J. M., Page, A. J. F., and Flavell, G. (1972).Esophagopleural fistula: a late complication afterpneumonectomy. Journal of Thoracic and Cardio-vascular Surgery, 63, 783-786.

Virkkula, L. and Eerola, S. (1974). Treatment ofpostpneumonectomy empyema. ScandinavianJournial of Thoracic and Cardiovascular Surgery, 8,133-137.

Zumbro, G. L.. Jr., Treasure, R., Geiger, J. P., andGreen, D. C. (1973). Empyema after pneu-monectomy. Annals of Thoracic Surgery, 15, 615-621.

Requests for reprints to: W. F. Kerr, FRCS, Con-sultant Thoracic Surgeon. Norfolk and NorwichHospital. St. Stephen's Road, Norwich, NorfolkNRI 3SR.



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Late-onset post-pneumonectomy empyemal