Modified thoracostomy window as a surgical treatment for chronic pleuropulmonary infections

Introduction

Pleuropulmonary infections remain a significant global health concern, consistently ranking among the top 10 leading causes of death worldwide, with reported mortality rates reaching 40% (1,2). Amongst these, empyema, and in particular chronic empyema, is complicated in its management, not only because of the clinical state of patients but also because of its associated complications (3). Several treatment strategies have been used to prevent chronic empyema, such as administering antibiotics, tube thoracostomy, or intrapleural fibrinolytics, such as tissue plasminogen activator (tPA) (4).

Despite these efforts, up to 30% of empyema patients require surgical intervention (5). These include pleural drainage +/− decortication +/− lung resection, and as a last resort or for medically unfit patients, procedures such as the Clagett pleural window or Eloesser flap may be performed (6-8). These procedures involve creating a permanent opening in the chest wall to enable long-term drainage (9). Though these procedures can be lifesaving, they often result in prolonged dressing changes, persistent soiling, and a reduced quality of life (10).

Consequently, modifications to the technique have been proposed to achieve similar outcomes while significantly improving aesthetics, pain management, quality of life, and morbidity. For this reason, we decided to review our experience with classic and modified pleural window techniques, focusing on the length of hospital stay, overall survival, and window closure. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-238/rc) (11).

Methods

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of the National Institute of Respiratory Diseases (No. C81-24). We conducted a retrospective cohort study, selecting patients from January 2012 to June 2023 in whom an open-window thoracostomy was done. The ethics committee waived consent for data extraction, as the reproduction of the study’s findings posed minimal risk and did not affect or compromise patient rights or well-being. Furthermore, all data were reported in aggregate form to maintain confidentiality. We included the following cases: patients ≥18 years of age operated through a conventional or modified thoracostomy window. Patients with incomplete relevant data in their files were excluded from our study. Patients who underwent conventional window thoracostomy served as the control group, while those treated with a modified technique comprised the study group.

Chronic empyema was defined as empyema persisting for ≥3 months, characterized by pleural thickening and signs of lung entrapment on computed tomography (CT). The early window was defined as window creation within four months of diagnosis. Patients were assigned to either the conventional or modified window technique based on the period of admission. Those admitted between 2012 and 2018 underwent the conventional technique, whereas those admitted between 2019 and 2023 were treated with the modified approach.

Patients underwent window creation after demonstrating unfavorable outcomes following medical or surgical treatment (i.e., antibiotic therapy, chest tube placement, decortication, or fistula closure) or if their clinical condition rendered them unfit for decortication.

Surgical technique

Modified Eloesser procedure

Patients were positioned in a lateral decubitus with the involved chest up. The empyema cavity was located either by a previously placed drainage tube or through thoracocentesis. A U-shaped skin flap was created over the cavity, measuring 5–10 cm at its base, with a length spanning two to three ribs. The soft tissue covering the chest wall over the abscessed cavity is then surgically removed, completing the unroofing of the empyema cavity. The U-shaped skin flap is then reflected onto the most dependent area of the abscessed cavity and sutured to the cavity’s floor. The edges of the skin are then marsupialized, attaching them to the surrounding soft tissue (Figure 1). The postoperative care of the cavity included once-a-day cleaning of the cavity and packing until surgical closing was planned.

Figure 1 Creation of a conventional thoracostomy. (A,B) Conventional thoracostomy; (C) remodeling with a wound protector.

Modified thoracostomy window

Patients were positioned in the lateral decubitus position. The side depended on the location where the thoracostomy was to be carried out. Before the incision, a chest CT was reviewed to determine the lowest point of the patient’s thoracic cavity. Once determined, a 4 cm resection of one costal arch (usually at the level of the 5th or 6th costal arch) was made. This opening was kept patent, with its edges protected by an Alexis retractor. This protector allows the introduction of ring forceps and gauze for wound care, reducing patient discomfort and protecting the edges of the wound. The protector was cleaned daily as part of the care for the thoracostomy window (Figure 2). One month after creating the window, the soft tissue retractor was replaced with a smaller one.

Figure 2 Creation of a modified thoracostomy, evolution, and healing over time. (A) Modified thoracostomy window at the 5th intercostal space; (B) resection of 4 cm of the rib arch; (C,D) placement of a soft tissue retractor to maintain the window permeable and to protect the wound during healing; (E) spontaneous closure of the window.

The following criteria were used to remove the retractor and allow for closure in both procedures: Negative cultures, absence of inflammatory response indicators, appropriate granulation tissue, and evidence of >75% cavity occupation in radiography or tomography (Figure 3).

Figure 3 Coronal CT follow-up of a patient with modified thoracostomy showing complete lung inflation. CT, computed tomography.

Statistical analysis

Categorical variables were represented as frequencies with percentages (%), while continuous data were presented as the variable mean and standard deviation (SD) or median and interquartile range (IQR) when data were skewed. Data distribution was ascertained by the Kolmogorov-Smirnov test. For bivariate analysis, data were compared with Student’s t-test for variables with a normal distribution or Mann-Whitney U, Chi-squared, and Fisher’s exact tests for non-parametric data. Statistical analysis was conducted using SPSS version 25.0 (SPSS Inc., Chicago, IL, USA). We took into account a P value <0.05 to define statistical significance.

Results

We conducted a total of 58 thoracostomies from 2012–2023. The median for follow-up was 521 days (IQR, 429–1,019 days). Of these, 32 patients (55%) underwent a conventional window thoracostomy, while 26 patients (45%) were treated with our modified technique. Baseline characteristics are summarized in Table 1. The mean age of our patients was 46±17 years, with a predominance of male patients (81%). Comorbidities included diabetes mellitus in 21 patients (36%), a history of Mycobacterium tuberculosis (MbTb) infection in 14 patients (24%), human immunodeficiency virus (HIV) infection in 2 patients (3.4%), and other complications in 19% of the patients (n=11). When comparing baseline characteristics between the two techniques, although we observed slight variations, these differences were non-significant, owing to a homogeneous distribution between our groups.

Indications for window creation included mostly chronic empyema (n=47, 81%), which was associated with lung resection in 9 (16%), bronchopleural fistula (BPF) in 7 (12%), and necrotizing pneumonia in 11 (19%). In all of the patients with BPF, this occurred following lung resection. The distribution of etiologies based on the window technique is detailed in Table 2. In nine patients (16%), an initial thoracostomy window was performed as the first intervention. For the remaining patients, the median number of procedures before creating a thoracostomy window was 2 (IQR, 1–3). Before window creation, 20 patients (34%) underwent decortication, nine patients (16%) had a chest tube placed for drainage, and fistula closure was attempted in 3 patients with BPF.

Postoperative microbiological findings revealed MbTb infection in 23 patients (40%), Pseudomonas aeruginosa in 13 patients (22%), and Escherichia coli in 10 patients (17%). Polymicrobial infections were identified in 13 patients (22%), while no microbiological findings were observed in 8 patients (14%) (Figure 2). Window creation resolved the underlying infectious process in 84% of cases (n=49). By the last follow-up, 24 patients (49%) had achieved window closure, with a median time to closure of 267 days (range, 172–488 days). Among these, 14 patients (29%) underwent surgical closure, while 10 patients (20%) experienced spontaneous closure. Notably, of the nine patients who received an early window, 5 (56%) achieved closure.

Nine patients were lost to follow-up. Overall, there was a 19% mortality in our study (n=11). Of the patients that died, 5 (45%) were from the conventional thoracostomy group, while 6 (55%) were from the modified technique group, 9 of them died of septic shock (82%). In the remaining two patients, the causes of death were postoperative bleeding in one and acute myocardial infarction in the other.

Postoperative outcomes between conventional and modified thoracostomy

Comparing postoperative outcomes between the conventional and modified techniques revealed significant differences. These are presented in Table 3. The modified technique was associated with shorter operative times (62 vs. 121 minutes; P<0.001) and lower blood loss (78 vs. 245 mL; P=0.001). Similarly, the length of hospitalization (time from thoracostomy to patient discharge) was markedly reduced in the modified technique group (9 vs. 40 days; P=0.005). Resolution of the underlying infectious process was achieved in 84% (n=27) of the patients treated with a conventional window thoracostomy and 85% (n=22) in the modified thoracostomy (P=0.98). When evaluating the type of closure between techniques, we observed a highly heterogeneous distribution (P<0.001). Surgical closure predominantly occurred in the conventional group (93%, n=13), with only one patient (7%) requiring surgical closure in the modified group. Conversely, spontaneous closure was exclusive to the modified group (n=10).

Finally, when comparing the time to closure between techniques, no significant difference was observed. However, the conventional group demonstrated longer intervals (median, 329 days; IQR, 223–1,007 days) compared to the modified group (median, 219 days; IQR, 154–417 days). A similar pattern was noted when evaluating closure within three timeframes: less than 6 months, 6–12 months, and more than 1 year. Although the difference was not statistically significant, a higher proportion of patients achieved closure within 6 months in the modified thoracostomy group (21%) compared to the conventional group (6.5%).

Discussion

Despite advances in the surgical and medical management of pleuropulmonary infections, chronic empyema and its complications remain challenging conditions for physicians. Most pleural space infections can be treated with closed thoracostomy drainage, antibiotics, fibrinolytics, or decortication. However, up to 30% of patients fail first-line therapies, which is reflected in our study, where patients underwent a median of two interventions before window creation (3,5). In such cases, a thoracostomy window is a viable option, particularly for patients who are too ill for decortication, those with incomplete lung expansion, and especially those with BPF (3).

Our study compared the postoperative outcomes of patients subjected to a modified Eloesser flap thoracostomy window vs. our modified thoracostomy window technique. With our study, we aimed to provide a surgical alternative that would prove effective in treating empyema and decrease the impact of living with a large hole in the chest. For both treatment groups, we demonstrated the feasibility of the technique in achieving resolution of the infectious process and closure of the window. However, our results may tend towards improved outcomes for patients subjected to our modified technique.

Regarding comorbidities, we observed that 82.7% of the included patients had, most frequently, type 2 diabetes mellitus, hypertension, MbTb, and HIV infection. These findings share similarities with the reports by Sosa et al., who reported that patients who presented with parapneumonic effusions had a history of diabetes, arterial hypertension, obesity, and lung cancer as comorbidities associated with the effusion (12). Although there are slight differences in our findings, these may be because we only included patients who required an open-window thoracostomy, which has been historically associated with immunosuppressive states and sequelae from MbTb infection (10). Furthermore, the higher incidence of MbTb infection in our patient cohort may account for the relatively young age group observed, which is likely related to an underlying state of immunocompromise.

In line with the latter, most of our patients had a positive culture for MbTb, owing to a high prevalence of this entity as a causative agent for empyema in our population. As described by Eloesser and further portrayed in the study by García-Yuste et al., half of the empyema cases were associated with MbTb infection (9,13). Globally, it is estimated that the prevalence of MbTb reaches 10.8 million people, with 5% of those cases in endemic areas being accounted for by pleural tuberculosis (14,15). Prevalence of MbTb varies among geographical regions. In 2023, MbTb infected over 28,000 patients and was the cause of death in more than 2,000 of these in Mexico. Worldwide, extrapulmonary MbTb affects up to 22% of infected patients, and it has been reported to be present in 9% and 29% of patients with empyema in studies conducted in the United Kingdom and India, respectively (16-18). These high rates of MbTb in studies may be associated with a high rate of comorbidities and a large number of patients with inadequate disease control or relapses. In past decades, pleural empyema was often associated with pulmonary tuberculosis. However, the prevalence of tuberculosis has decreased in many parts of the world. Still, a high incidence has remained in Latin American countries, where drug-resistant tuberculosis is a considerable problem (19).

Surprisingly enough, we encountered a positive culture in 88% of the patients in our study, which contrasts with the rates of 33% (20) and 64% (21) reported in the literature. The discrepancy between our positive culture results and those reported in these studies may be attributable to pre-hospital antibiotic use, as noted by one of the authors, and the high quality of our institution’s microbiology department (22). Additionally, we observed variations between the pathogens we most commonly encountered and those reported in the literature, likely due to regional differences. Notably, in the study by Tantraworasin et al., Pseudomonas aeruginosa was the most frequently isolated microorganism in patients with recurrent empyema, which aligns with our findings (20). This correlation may be attributable to factors such as prior medical interventions, the chronic nature of their clinical condition, or prolonged hospitalization, which may increase the risk of nosocomial infections (19,23).

Traditionally, empyema has been categorized into exudative, fibrinopurulent, and organized phases. More invasive strategies are usually implemented for patients in or beyond the fibrinopurulent stage (24,25). For these patients, window creation might be a suitable treatment, particularly for those patients with empyema associated with BPF or after lung resection (25,26). Notably, our study also included patients with necrotizing pneumonia-associated empyema who showed favorable outcomes after window creation. This condition presents a significant treatment challenge because of its torpid evolution associated with a higher rate of complications, as the infectious process leads to the destruction of both parenchyma and pulmonary vessels, hindering intravenous antibiotic delivery and reducing their effectiveness in reaching the infected tissue; also, patients affected with this entity are characterized to have comorbidities such as neutropenia, leucopenia, diabetes mellitus, and alcoholism that worsen the course of the disease (27,28).

Even though management guidelines are scarce, most authors recommend aggressive antibiotic therapy and decortication in the presence of associated empyema and lobectomy when associated with important lung destruction (24,28). In line with these approaches, we demonstrated the feasibility of window creation as a treatment strategy for empyema associated with necrotizing pneumonia. However, it is important to note that this was applied to a limited number of patients.

Even though open procedures are rarely carried out in developed countries, these may be life-saving for patients who have failed less invasive therapies or are at a more advanced stage of the disease that requires more radical treatment strategies. Such is the case for open window thoracostomy, which has been shown to be feasible not only in our study but in multiple reports in the literature (1,23-25). Two simultaneous goals of the thoracostomy flap, as it was initially described, were to allow passive drainage of the infected pleural space and the creation of a one-way valve that would allow egress of fluid from the chest cavity without the return of air to facilitate expansion of the remaining lung parenchyma to fill the thoracic space (10). Thus, allowing for a resolution of chronic infectious processes and decreasing mortality. Nevertheless, cosmetic problems and functional status may be impacted by a conventional thoracostomy.

Although there is no consensus regarding the optimal timing for window closure, various factors have been explored that may favor early closure. For instance, Massera et al. identified that the late onset of empyema following pneumonectomy, as well as earlier window creation, were significantly associated with successful early closure (25). Notably, in this series, surgical intervention was used to achieve window closure in all conventional cases. Patients who did not undergo window closure had a poor functional status, refused further treatment, were cachectic, or had tumor recurrence. The thoracostomy window technique described in our study aimed to address these limitations by reducing surgical times and hospitalization, thus decreasing complications associated with both of these. Additionally, window closure was achieved via secondary intention in almost all patients managed through this procedure, minimizing the need for additional interventions and attempting to reduce the long-term impact of window creation.

Our observed mortality rate of 19% is higher than the 5–10% reported in the literature (1,21). This difference may be attributable to several factors. Firstly, our hospital is a tertiary-level center to which complicated cases are referred, usually after a considerable time after diagnosis, in addition to the complexity of treating chronic pleuropulmonary infections. Nonetheless, the overall cause of death (sepsis) was consistent with the findings reported in short- to mid-term follow-up studies.

Our study had several limitations. Given the retrospective nature of the analysis, our study is subject to bias from data extraction. Furthermore, the small sample size warrants a cautious interpretation of the results. Additional studies are required to determine the true benefits of the technique described in this study and its impact on quality of life and postoperative pain outcomes, in addition to longer follow-up periods.

Conclusions

The present study compared the postoperative results between the conventional thoracic window and a modified technique in patients with chronic empyema and other complex pleuropulmonary pathologies. The findings demonstrate that the modified technique was associated with shorter operative times, less blood loss, and a significant reduction in hospital stay without compromising the resolution of the infectious process. Furthermore, the rate of spontaneous closure was exclusive to the group that underwent the modified technique, suggesting a potential advantage in terms of recovery and a lesser need for additional surgical interventions. However, the observed mortality was high in both groups, highlighting the severity of the underlying condition and the need to identify criteria for performing these pleural windows earlier.

The modified technique presented in this study offers a viable alternative in the management of chronic pleural infections; however, a study with a larger number of patients and with a longer follow-up is required to evaluate the true impact of its outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-238/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-238/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-238/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-238/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of the National Institute of Respiratory Diseases (No. C81-24). The ethics committee waived consent for data extraction, as the reproduction of the study’s findings posed minimal risk and did not affect or compromise patient rights or well-being. Furthermore, all data were reported in aggregate form to maintain confidentiality.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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