Management of Parapneumonic Effusions

Annotation for Point H

In the event of a dense fibrous peel that precludes clearance via VATS, a limited lateral muscle-sparing thoracotomy (‘‘mini thoracotomy’’) is performed to accomplish decortication (Fig. 6). Transecting the posterior rib facilitates exposure of the fibrous cavity. Advanced empyemas often require scalpel incision to free the lung for reexpansion; inspection of the lung with periodic reinflation should be done to avoid extensive pulmonary parenchymal air leaks. In the unusual case of a chronic empyema, a standard posterolateral thoracotomy is required. Often, the safest approach is to develop an extrapleural plane and directly enter the empyema cavity before any further thoracic dissection is done. After these extensive decortications, the thorax is drained with three relatively large chest tubes (28F), and the most inferior tube is usually an angled tube positioned in the posterior dependent recess of the chest. Occasionally, these tubes are simply transected to provide external drainage for outpatient management of extended processes. Treatment of an advanced process caused by a necrotic infected lung with associated major air leaks in a severely immunocompromised patient warrants open thoracic drainage. The Eloesser flap, thoracic cavity marsupialization via segmental rib resection and suturing the skin to the underlying parietal surface (Fig. 7), has been the standard for these complicated cases.62 But recently, simple open drainage with suturing the skin margin to the chest wall, thoracostoma, and the application of a vacuum-assisted wound closure have been popularized.63-65 Ultimately, some of these wounds will heal by secondary intention, and the remaining can be closed with thoracomyoplasty.66,67