Early and delayed post-pneumonectomy empyemas: Microbiology, management and prognosis

Introduction: Post-pneumonectomy empyema (PPE) is the most severe complication of pneumonectomy. Microbiology and its impact on management and prognosis have rarely been reported Methods: We retrospectively reviewed the files of a series of 37 consecutive patients with PPE over a 10-year period with a special focus on microbiology, means used to treat empyema, and prognosis. Results: PPE occurred within 14 days of pneumonectomy in 17 cases (early PPE) and after postoperative day 16 in 20 patients (delayed PPE). PPE was monomicrobial in 57% of cases. The most frequent pathogens were Staphylococcus sp.and Streptococcus sp. Polymicrobial empyema was more frequent in patients with early PPE than delayed PPE (65% vs 25%; p=0.02). Video-assisted thoracoscopic approach for cavity lavage was performed in 22 patients without broncho-pleural fistulae (BPF), associated with antimicrobial therapy and drainage, and was successful in 13 cases (59%). Seventeen patients (46%) underwent an open window thoracostomy. Overall 90-day post empyema mortality was 19%, with 6 deaths due to empyema in the early PPE group (35%), versus one (5%) in the delayed PPE group (p=0.02). Conclusion: We distinguished 2 different PPE presentations: An early occurrence, mostly with polymicrobial cultures, including Gram-negative bacterias, and associated with a high mortality rate. By contrast, delayed PPEs were mostly monomicrobial with Gram-positive bacterias and associated with a better prognosis. VATS approach was successful in the majority of cases without BPF, even if some patients required secondary thoracostomy. PPE was associated with an excess of mortality especially when occurring in the early course after pneumonectomy. This article is protected by copyright. All rights reserved.