Surgical Management of Recurrent MRSA Empyema with Eloesser Flap in a Complex Thoracic Patient: Lessons from Endobronchial Valve Failure

Surgical Management of Recurrent MRSA Empyema with Eloesser Flap in a Complex Thoracic Patient: Lessons from Endobronchial Valve Failure | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Surgical Management of Recurrent MRSA Empyema with Eloesser Flap in a Complex Thoracic Patient: Lessons from Endobronchial Valve Failure Adeesh Parvathaneni^ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6883877/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Chronic empyema with bronchopleural fistula represents a challenging complication in thoracic surgery. We present a case of recurrent methicillin-resistant Staphylococcus aureus (MRSA) empyema due to persistent bronchopleural fistula successfully managed with an Eloesser flap following documented failure of endobronchial valve therapy. Case presentation: A 74-year-old male with a history of left-sided radiation for non-small cell lung cancer, right lower lobectomy, post-operative bronchopleural fistula, and recurrent MRSA empyema presented with worsening respiratory symptoms despite previous interventions including endobronchial valve placement. Direct intraoperative visualization during Eloesser flap creation revealed displacement of both previously placed endobronchial valves, providing unique insights into a specific mechanism of valve failure in chronic empyema. Conclusions: This case demonstrates critical limitations of endobronchial valve therapy in the setting of chronic infection and highlights the continued relevance of the Eloesser flap in modern thoracic surgical practice when newer technologies fail and specifically as a potential salvage procedure. Bronchopleural fistula Chronic empyema Eloesser flap Endobronchial valve MRSA Thoracic surgery Figures Figure 1 Figure 2 Figure 3 Background Bronchopleural fistula (BPF) with associated empyema following lung resection presents a significant challenge for thoracic surgeons [ 1 , 2 ]. Whilst endobronchial valves have emerged as a promising minimally invasive approach to BPF management, there remains a critical gap in the literature regarding their long-term efficacy in the setting of chronic methicillin-resistant Staphylococcus aureus (MRSA) empyema [ 3 , 4 ]. Moreover, limited data exists documenting management strategies following endobronchial valve failure, leaving clinicians without evidence-based guidance when these devices fail. We present the first documented case of direct intraoperative visualization of endobronchial valve displacement during creation of an Eloesser flap in a patient with chronic MRSA empyema. This finding reveals a specific mechanism of failure—physical displacement and dislodgement of the valves in the setting of chronic infection—that has not previously been reported in the literature. Furthermore, this case demonstrates that despite advances in minimally invasive technologies, the classical Eloesser flap remains an essential procedure in the modern thoracic surgeon's armamentarium, particularly in the management of patients who have failed contemporary interventions. The unique aspects of this case include the direct visual documentation of the mechanism of endobronchial valve failure, successful salvage management with an Eloesser flap following valve failure; and demonstration of significant clinical improvement despite multiple comorbidities and failed prior interventions. These findings contribute vital knowledge to guide clinical decision-making in the challenging subset of patients with chronic, refractory bronchopleural fistula and empyema. Case Presentation Written informed consent was obtained from the patient for publication of this case report and accompanying images. A 74-year-old man with a history of left-sided radiation therapy for non-small cell lung cancer presented with worsening cough, dyspnoea, and increased purulent secretions from a right chest tube. His past surgical history was significant for right lower lobectomy complicated by BPF and recurrent MRSA empyema. Notably, the patient had undergone placement of two endobronchial valves 14 months prior to this presentation, a procedure that initially resulted in temporary improvement but ultimately failed to resolve his chronic empyema and air leak. On admission, chest computed tomography demonstrated a large loculated right pleural fluid collection with air-fluid levels consistent with empyema and evidence of a persistent BPF (Fig. 1 ). Despite aggressive medical management including intravenous vancomycin and image-guided drainage, the patient had persistent air leak and incomplete resolution of the empyema collection. The patient underwent redo right thoracotomy, which revealed the unprecedented finding of both endobronchial valves visibly displaced from their original position in the bronchial stump. Strikingly, one valve was completely dislodged into the pleural space, whilst the second remained partially attached but was surrounded by purulent material, explaining the failure of this technology to maintain bronchial closure. This direct visualization of failed endobronchial valves—rarely if ever documented in the literature—provides crucial insights into the limitations of this approach in the setting of chronic infection. An Eloesser flap was created by resecting segments of the 6th and 7th ribs, creating a U-shaped skin flap, and suturing the skin edges to the pleura to establish a permanent drainage window (Fig. 2 ). Post-operative CT imaging confirmed resolution of the empyema and appropriate positioning of the Eloesser flap with significant improvement in the pleural space abnormality (Fig. 3 ). Despite several postoperative complications including transient delirium, acute kidney injury, and Candida superinfection of the wound, all of which resolved with appropriate management, the patient showed marked clinical improvement. From the patient's perspective, whilst he reported significant improvement in his respiratory symptoms and overall quality of life following the procedure, he expressed that he had not fully comprehended the extent of chest cavity exposure that would result from the Eloesser flap. The patient acknowledged that despite preoperative counseling, he had not understood the nature of the permanent "sucking chest wound" and the intensive wound care requirements post-operatively. He found the appearance of the open chest cavity and the maintenance care initially distressing and confronting. This highlights the importance of enhanced preoperative education with visual aids and detailed wound care demonstrations for patients undergoing this procedure to ensure they are truly informed about the significant anatomical changes and long-term care requirements. At 3-month follow-up, the Eloesser window showed evidence of granulation tissue with minimal drainage, and repeat cultures were negative for bacterial and fungal growth. Most significantly, the patient reported dramatic improvement in respiratory symptoms and quality of life, confirming the efficacy of this approach when more contemporary interventions had failed. Discussion and Conclusions This case offers several novel and clinically significant insights. First and foremost, it provides rare direct visual documentation of endobronchial valve failure in the setting of chronic empyema. The finding of valve displacement and dislodgement suggests that chronic infection, inflammation, and repeated coughing may compromise the seating and function of these devices over time. This observation carries significant implications for patient selection and long-term planning when considering endobronchial approaches to BPF. Second, this case demonstrates the critical importance of maintaining proficiency with classical surgical techniques even as newer technologies emerge. While the trend toward minimally invasive management is appropriate, this case shows that there remains a distinct subset of patients for whom more definitive approaches like the Eloesser flap are not merely alternatives but necessities. The dramatic improvement in our patient's clinical status following this procedure—after the failure of more contemporary interventions—underscores this point. Finally, the successful management of a patient with significant comorbidities and multiple failed prior interventions highlights the continued relevance of the Eloesser flap as more than just a historical footnote in thoracic surgery. Rather, it represents an essential tool that should remain in the active armamentarium of modern thoracic surgeons facing complex cases of chronic empyema. In conclusion, this case provides unique documentation of endobronchial valve failure in chronic MRSA empyema and demonstrates the continued efficacy of the Eloesser flap in the modern era. The direct visualization of displaced valves contributes valuable knowledge regarding the limitations of this technology and may help guide appropriate patient selection for various BPF management strategies. Thoracic surgeons should maintain proficiency with classical techniques like the Eloesser flap, as these approaches remain essential when contemporary interventions fail in complex cases. Abbreviations BPF Bronchopleural fistula MRSA Methicillin-resistant Staphylococcus aureus Declarations Consent for publication Written informed consent was obtained from the patient for publication of this case report and accompanying images. The consent form is attached Funding No funding was received for this case report. Author Contribution A.P. Prepared, wrote, and gathered all of the information pertaining to this manuscript and reviewed it. Acknowledgement I acknowledge the patient who provided their data and information to present this case report as well as the Saint Luke's Staff that helped make this possible and who gave this person a chance at life! Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. References Cerfolio RJ. The incidence, etiology, and prevention of postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg. 2001;13(1):3–7. Puskas JD, Mathisen DJ, Grillo HC, Wain JC, Wright CD, Moncure AC. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg. 1995;109(5):989–95. Travaline JM, McKenna RJ, De Giacomo T, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest. 2009;136(2):355–60. Firlinger I, Stubenberger E, Müller MR, Burghuber OC, Valipour A. Endoscopic one-way valve implantation in patients with prolonged air leak and the use of digital air leak monitoring. Ann Thorac Surg. 2013;95(4):1243–9. Garner O, Iardino A, Ramirez A, Ahmed Y. Role of modified Eloesser flap in the treatment of bronchopleural fistula caused by pulmonary coccidioidomycosis. BMJ Case Rep. 2018;2018. 10.1136/bcr-2017-223717 . PMID: 29351943; PMCID: PMC5775779. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Dec, 2025 Reviews received at journal 23 Nov, 2025 Reviews received at journal 31 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers invited by journal 11 Aug, 2025 Editor assigned by journal 14 Jun, 2025 Submission checks completed at journal 14 Jun, 2025 First submitted to journal 12 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6883877","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":501875940,"identity":"566695a5-a76b-431b-ab9b-3504d35c5b58","order_by":0,"name":"Adeesh Parvathaneni^","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYBCDBAhZwcDABxFgJqTDAKrljAEDG2laGNuI0MI/u/nZZ56aP3lAxrEHD+f9SWxjP3vwAUOFdWIDDi0Sd44Zz+Y5ZlAMZKQbJG4zSGzjyUs2YDiTjlMLw40EY8YZbAaJDTdyzCTAWhiADMa2wzi1yN9I/8w4459B4vwb+d8kEucAtfC/Mf/B+A+3FoMbOcYMH9sMEjfcyGGTSGwAapHIMWNgbMCtxfDOmWKGj33GiRtvpJlJJBwzNm6TeGMMZKQb49Iid7t9M0PCN7nEeTeSn0n+qJGT7efPMfzwocZaFqf3JbCKJuBSjlvLKBgFo2AUjAIkAADGb1vTkvDG0wAAAABJRU5ErkJggg==","orcid":"","institution":"Tulane University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Adeesh","middleName":"","lastName":"Parvathaneni^","suffix":""}],"badges":[],"createdAt":"2025-06-13 02:08:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6883877/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6883877/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89399434,"identity":"e246dbf1-a46d-4142-8682-8b9ecc62b2cc","added_by":"auto","created_at":"2025-08-19 14:02:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":169434,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative chest computed tomography showing a large loculated right pleural fluid collection with air-fluid levels consistent with empyema and evidence of a persistent bronchopleural fistula.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6883877/v1/71e48adeae88197cb95e3f0e.png"},{"id":89397316,"identity":"bedca6cc-3721-4293-b8db-ee83842c2f3d","added_by":"auto","created_at":"2025-08-19 13:46:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3583519,"visible":true,"origin":"","legend":"\u003cp\u003eOperative photograph demonstrating the Eloesser flap and the surgical field, showing inflamed tissues and evidence of chronic infection within the thoracic cavity as well as some remnants of bronchopleural valves\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6883877/v1/ead1b103bebf1d47fc7c0646.png"},{"id":89397313,"identity":"fe6e5ac7-25f1-4942-9d3a-f8b2b3596e67","added_by":"auto","created_at":"2025-08-19 13:46:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":190570,"visible":true,"origin":"","legend":"\u003cp\u003ePost-operative CT scan showing resolution of the empyema and the Eloesser flap repair with significant reduction in pleural space abnormality.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6883877/v1/5a40338078c418e7babe5ae5.png"},{"id":89399444,"identity":"d70b71b2-fc29-454b-b8cd-cc02e4a74052","added_by":"auto","created_at":"2025-08-19 14:02:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6213647,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6883877/v1/54da2620-5293-4337-a9af-ac8008d146a0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Management of Recurrent MRSA Empyema with Eloesser Flap in a Complex Thoracic Patient: Lessons from Endobronchial Valve Failure","fulltext":[{"header":"Background","content":"\u003cp\u003eBronchopleural fistula (BPF) with associated empyema following lung resection presents a significant challenge for thoracic surgeons [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Whilst endobronchial valves have emerged as a promising minimally invasive approach to BPF management, there remains a critical gap in the literature regarding their long-term efficacy in the setting of chronic methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (MRSA) empyema [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, limited data exists documenting management strategies following endobronchial valve failure, leaving clinicians without evidence-based guidance when these devices fail.\u003c/p\u003e\u003cp\u003eWe present the first documented case of direct intraoperative visualization of endobronchial valve displacement during creation of an Eloesser flap in a patient with chronic MRSA empyema. This finding reveals a specific mechanism of failure\u0026mdash;physical displacement and dislodgement of the valves in the setting of chronic infection\u0026mdash;that has not previously been reported in the literature. Furthermore, this case demonstrates that despite advances in minimally invasive technologies, the classical Eloesser flap remains an essential procedure in the modern thoracic surgeon's armamentarium, particularly in the management of patients who have failed contemporary interventions.\u003c/p\u003e\u003cp\u003eThe unique aspects of this case include the direct visual documentation of the mechanism of endobronchial valve failure, successful salvage management with an Eloesser flap following valve failure; and demonstration of significant clinical improvement despite multiple comorbidities and failed prior interventions. These findings contribute vital knowledge to guide clinical decision-making in the challenging subset of patients with chronic, refractory bronchopleural fistula and empyema.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\u003cp\u003eA 74-year-old man with a history of left-sided radiation therapy for non-small cell lung cancer presented with worsening cough, dyspnoea, and increased purulent secretions from a right chest tube. His past surgical history was significant for right lower lobectomy complicated by BPF and recurrent MRSA empyema. Notably, the patient had undergone placement of two endobronchial valves 14 months prior to this presentation, a procedure that initially resulted in temporary improvement but ultimately failed to resolve his chronic empyema and air leak.\u003c/p\u003e\u003cp\u003eOn admission, chest computed tomography demonstrated a large loculated right pleural fluid collection with air-fluid levels consistent with empyema and evidence of a persistent BPF (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Despite aggressive medical management including intravenous vancomycin and image-guided drainage, the patient had persistent air leak and incomplete resolution of the empyema collection.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient underwent redo right thoracotomy, which revealed the unprecedented finding of both endobronchial valves visibly displaced from their original position in the bronchial stump. Strikingly, one valve was completely dislodged into the pleural space, whilst the second remained partially attached but was surrounded by purulent material, explaining the failure of this technology to maintain bronchial closure. This direct visualization of failed endobronchial valves—rarely if ever documented in the literature—provides crucial insights into the limitations of this approach in the setting of chronic infection.\u003c/p\u003e\u003cp\u003eAn Eloesser flap was created by resecting segments of the 6th and 7th ribs, creating a U-shaped skin flap, and suturing the skin edges to the pleura to establish a permanent drainage window (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Post-operative CT imaging confirmed resolution of the empyema and appropriate positioning of the Eloesser flap with significant improvement in the pleural space abnormality (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Despite several postoperative complications including transient delirium, acute kidney injury, and Candida superinfection of the wound, all of which resolved with appropriate management, the patient showed marked clinical improvement.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFrom the patient's perspective, whilst he reported significant improvement in his respiratory symptoms and overall quality of life following the procedure, he expressed that he had not fully comprehended the extent of chest cavity exposure that would result from the Eloesser flap. The patient acknowledged that despite preoperative counseling, he had not understood the nature of the permanent \"sucking chest wound\" and the intensive wound care requirements post-operatively. He found the appearance of the open chest cavity and the maintenance care initially distressing and confronting. This highlights the importance of enhanced preoperative education with visual aids and detailed wound care demonstrations for patients undergoing this procedure to ensure they are truly informed about the significant anatomical changes and long-term care requirements.\u003c/p\u003e\u003cp\u003eAt 3-month follow-up, the Eloesser window showed evidence of granulation tissue with minimal drainage, and repeat cultures were negative for bacterial and fungal growth. Most significantly, the patient reported dramatic improvement in respiratory symptoms and quality of life, confirming the efficacy of this approach when more contemporary interventions had failed.\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThis case offers several novel and clinically significant insights. First and foremost, it provides rare direct visual documentation of endobronchial valve failure in the setting of chronic empyema. The finding of valve displacement and dislodgement suggests that chronic infection, inflammation, and repeated coughing may compromise the seating and function of these devices over time. This observation carries significant implications for patient selection and long-term planning when considering endobronchial approaches to BPF.\u003c/p\u003e\u003cp\u003eSecond, this case demonstrates the critical importance of maintaining proficiency with classical surgical techniques even as newer technologies emerge. While the trend toward minimally invasive management is appropriate, this case shows that there remains a distinct subset of patients for whom more definitive approaches like the Eloesser flap are not merely alternatives but necessities. The dramatic improvement in our patient's clinical status following this procedure—after the failure of more contemporary interventions—underscores this point.\u003c/p\u003e\u003cp\u003eFinally, the successful management of a patient with significant comorbidities and multiple failed prior interventions highlights the continued relevance of the Eloesser flap as more than just a historical footnote in thoracic surgery. Rather, it represents an essential tool that should remain in the active armamentarium of modern thoracic surgeons facing complex cases of chronic empyema.\u003c/p\u003e\u003cp\u003eIn conclusion, this case provides unique documentation of endobronchial valve failure in chronic MRSA empyema and demonstrates the continued efficacy of the Eloesser flap in the modern era. The direct visualization of displaced valves contributes valuable knowledge regarding the limitations of this technology and may help guide appropriate patient selection for various BPF management strategies. Thoracic surgeons should maintain proficiency with classical techniques like the Eloesser flap, as these approaches remain essential when contemporary interventions fail in complex cases.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBPF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBronchopleural fistula\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMethicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images. The consent form is attached\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNo funding was received for this case report.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.P. Prepared, wrote, and gathered all of the information pertaining to this manuscript and reviewed it.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eI acknowledge the patient who provided their data and information to present this case report as well as the Saint Luke's Staff that helped make this possible and who gave this person a chance at life!\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\u003cp\u003eCompeting interests\u003c/p\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCerfolio RJ. The incidence, etiology, and prevention of postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg. 2001;13(1):3\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePuskas JD, Mathisen DJ, Grillo HC, Wain JC, Wright CD, Moncure AC. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg. 1995;109(5):989\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTravaline JM, McKenna RJ, De Giacomo T, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest. 2009;136(2):355\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFirlinger I, Stubenberger E, M\u0026uuml;ller MR, Burghuber OC, Valipour A. Endoscopic one-way valve implantation in patients with prolonged air leak and the use of digital air leak monitoring. Ann Thorac Surg. 2013;95(4):1243\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGarner O, Iardino A, Ramirez A, Ahmed Y. Role of modified Eloesser flap in the treatment of bronchopleural fistula caused by pulmonary coccidioidomycosis. BMJ Case Rep. 2018;2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bcr-2017-223717\u003c/span\u003e\u003cspan address=\"10.1136/bcr-2017-223717\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 29351943; PMCID: PMC5775779.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bronchopleural fistula, Chronic empyema, Eloesser flap, Endobronchial valve, MRSA, Thoracic surgery","lastPublishedDoi":"10.21203/rs.3.rs-6883877/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6883877/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Chronic empyema with bronchopleural fistula represents a challenging complication in thoracic surgery. We present a case of recurrent methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (MRSA) empyema due to persistent bronchopleural fistula successfully managed with an Eloesser flap following documented failure of endobronchial valve therapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e A 74-year-old male with a history of left-sided radiation for non-small cell lung cancer, right lower lobectomy, post-operative bronchopleural fistula, and recurrent MRSA empyema presented with worsening respiratory symptoms despite previous interventions including endobronchial valve placement. Direct intraoperative visualization during Eloesser flap creation revealed displacement of both previously placed endobronchial valves, providing unique insights into a specific mechanism of valve failure in chronic empyema.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This case demonstrates critical limitations of endobronchial valve therapy in the setting of chronic infection and highlights the continued relevance of the Eloesser flap in modern thoracic surgical practice when newer technologies fail and specifically as a potential salvage procedure.\u003c/p\u003e","manuscriptTitle":"Surgical Management of Recurrent MRSA Empyema with Eloesser Flap in a Complex Thoracic Patient: Lessons from Endobronchial Valve Failure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 13:46:37","doi":"10.21203/rs.3.rs-6883877/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-25T22:07:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-23T12:26:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-01T02:34:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64687809368260846634575633107582528312","date":"2025-08-19T18:46:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211313866373854110230450743226712247567","date":"2025-08-13T19:21:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163595885173062440482669325285652782489","date":"2025-08-13T17:16:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-11T16:23:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-14T05:23:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-14T05:22:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-06-13T02:06:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"167a6aae-5ac0-412c-ad60-0a6c44627b3a","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-06T10:08:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-19 13:46:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6883877","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6883877","identity":"rs-6883877","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}