Current state of management of post-pneumonectomy empyema: a narrative review
Year: 2026
Type: review
Abstract: Background and Objective: Pneumonectomy operations have been performed for around 100 years with post-pneumonectomy empyema (PPE) as a feared complication. Unlike an isolated empyema, these cases are most often associated with a bronchopleural fistula (BPF) that causes ongoing contamination of the surgical space and contralateral lung with subsequent respiratory failure and severe sepsis. The objective of this narrative review is to outline the wide range of treatment options that range from conservative management to more extensive surgical procedures, while also proposing a treatment algorithm. Methods: Two reviewers (A.P.K. and A.A.) queried PubMed, MEDLINE, and the Cochrane Library since inception for meta-analyses, retrospective, cohort studies, case series, and case reports. Disagreements between the two reviewers were resolved through discussion and consensus. Exclusion criteria included non-English articles. Key Content and Findings: First reports of BPF were managed with open window thoracostomy (OWT), which eventually evolved into the two-stage "Modified Clagett Procedure". Alternative surgical approaches described included trans-sternal and contralateral intra-thoracic approach for left-sided fistulas with short stumps to avoid repair in an infected field. More recently, endoscopic approaches have been described with variable success rates but are worth exploring for small fistulas to avoid the morbid surgical approach and poor surgical candidates as a salvage technique. Conclusions: Although there is limited data given the scarcity of this disease, current evidence shows that PPE with associated BPF located in a small (<6-8 mm) healthy stump can be successfully managed endoscopically, whereas surgical approach may be the better strategy for larger fistulas. Further evaluation of specific endoscopic techniques is necessary to further refine the treatment algorithm.
Source: Journal of Thoracic Disease
Authors: Alla P. Kozubenko, Abbas Abbas
Institution: Yale University
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7223881800