Short and Long-Term Outcomes of Surgical Intervention for Empyema in The Post-Fibrinolytic Era

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Cain, Marc Margolis, John F. Lazar, Hayley R. Henderson, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-547627/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Open window thoracostomy is indicated for patients with bronchopleural fistulae or trapped lung in the setting of empyema refractory to non-surgical interventions. We investigated the role of open window thoracostomy in the era of minimally invasive surgeries, endobronchial valves and fibrinolytic therapy. Methods: A retrospective chart review of all patients who underwent open window thoracostomy at a single institution from 2010-2020 was performed. Indications for the procedure as well as operative details and morbidity and mortality were evaluated to determine patient outcomes for open window thoracostomy. Results: Eighteen patients were identified for the study. The most common indication for open window thoracostomy was post-resectional bronchopleural fistula (n=8). Patient comorbidities were quantified with the Charleston Comorbidity index (n=11 score≥5, 10-year survival ≤21%). Three (16.7%) patients died <30 days post-operatively and 12 (66%) patients were deceased by the study’s end (overall survival 24.0 ± 32.2 months). Mean number of ribs resected were 2.6 ± 1.2 (range 1-6). Patients were managed with negative pressure wound therapy (n=9) or Kerlix packing (n=9). Eleven patients (61.6%) underwent delayed closure (mean time from index surgery to closure 4.8 ± 6.7 months). Conclusions: Our study illustrates the significant comorbidities of patients undergoing open window thoracostomy, the poor outcomes therein, and pitfalls associated with this procedure. We show that negative pressure wound therapy can be utilized as potential way to obliterate the pleural space and manage an open chest in the absence of an airleak; however open window thoracostomy procedures continue to be extremely morbid. Cardiothoracic Surgery Empyema Open Window Thoracostomy Bronchopleural fistula Figures Figure 1 Figure 2 Background Since the inception of pleural fibrinolytic therapy in 2011 for management of empyema and complicated parapneumonic effusions, the incidence of decortication has substantially declined 1 – 4 . Surgical management is considered for empyema when non-surgical therapy – i.e. antibiotics, tube thoracostomy, fibrinolytics -- fails as well as in cases presenting as organized empyema with lung entrapment 5 , 6 . Surgical interventions include video assisted thoracoscopic surgery (VATS) decortication and open thoracotomy with decortication. For unstable patients, Clagett type open-window thoracostomy (OWT) with rib resection and modified Eloesser flap (MEF) with rib resection both with or without negative pressure wound therapy (NPWT) are options, as both operations allow for continuous access to the pleural space for pus evacuation and debridement 6 – 10 , . An OWT is a procedure which may include elements of the Clagett window, EF, or MEF, but fundamentally involves removal of one or more rib segments and circumferentially marsupializing the parietal pleura to the skin (Fig. 1 A,B). In 1935, Eloesser described the original procedure for open chest drainage, with creation of a U-shaped cutaneous flap sutured apically under a resected rib segment (Fig. 1 C) 11 . In 1963, Clagett and Geraci described a new drainage procedure which entailed the removal of one rib segment and suturing the superficial fascia down to the periosteum of the resected rib 7 . The MEF was introduced in 1971 by Symbas et al. with the idea of providing superior empyema decontamination by a dependent drainage system not present in the traditional EF. The MEF is an inverted U-shaped cutaneous flap sutured inferiorly to the diaphragm below a segment of resected rib (Fig. 1 D) 12 . In contrast to the traditional Clagett window and OWT, where the ultimate goal is chest closure after successful empyema treatment, EF and MEFs are historically closed primarily through epithelialization and obliteration of the empyema cavity over time with resolution of the empyema itself 11 – 13 . Thus, current practices of open chest drainage for patients with empyema are best described as an OWT including Clagett windows, MEFs, and EFs. The aim of our study was to review our own practice and compare short and long-term outcomes of OWT for management of empyema, in the era of minimally-invasive surgery, endobronchial valves, and fibrinolytic therapy. Methods We identified all patients who underwent OWT at our institution between 2010 and 2020 by querying International Classification of Disease (ICD) 9 code 510 (empyema), and ICD 10 J86.0 (pyothorax with fistula). These ICD codes was then cross-matched to relevant current procedural terminology (CPT) codes including: 32035 (thoracostomy with rib resection), 23036 (thoracostomy with flap drainage), 32220 (release of lung), 32225 (partial release of lung), 32810 (closure chest after drainage), 32905 and 32906 (both revise and repair chest wall). These procedure codes were also cross-referenced to ICD 9 and ICD 10 procedure codes in order to capture additional patients. A retrospective review of all patients undergoing any of the three OWT procedures was performed under an institution-approved IRB protocol. Statistical analysis included modeling survival data using a standard Kaplan Meier curve. Additionally, 10-year survival estimates at the time of the index operation was calculated for each patient using the Charleston Comorbidity Index score; points were given for age at time of surgery (age 50–50, 60–69, 70–79 and ≥ 80 given + 1, 2, 3, and 4 points respectively), history of myocardial infarction, congestive heart failure, peripheral vascular disease, cerebral vascular accident or transient ischemic attack, dementia, chronic obstructive pulmonary disease, connective tissue disease, peptic ulcer disease (all + 1 point), liver disease (+ 1 mild = chronic hepatitis or cirrhosis without portal hypertension; +2 moderate to severe = cirrhosis and portal hypertension without or with variceal bleeding history), diabetes mellitus (none/diet-controlled + 0, uncomplicated + 1, end-organ damage + 2), hemiplegia (+ 2), moderate to severe chronic kidney disease (Cr > 3 mg/dL or status post kidney transplant + 2), solid tumor (localized + 2, metastatic + 6), leukemia (+ 2), lymphoma (+ 2), AIDS (+ 6). Results We identified 18 patients who had undergone an OWT. Their demographics are outlined in Table 1 . Patients ranged in age from 31 to 79. Nine patients (50%) had a history significant for smoking. All but 3 patients had significant pre-existing comorbidities as graded by the Charleston Comorbidity Index (CCI), an estimate of 10-year survival based on individual comorbidities at the time of the index operation. Two of the 3 patients without pre-existing comorbidities as measured by the CCI had a post-traumatic cause of empyema (one occurring in an otherwise healthy 47-year-old male after a gun-shot wound to the chest and the other in a 31-year-old male with cerebral palsy after a gastrostomy-tube was inadvertently tunneled into the pleural space). Of the patients without comorbidities tabulated by CCI, 2 of 3 did not require readmission after their index operation other than for scheduled delayed closure, and they are both still living. The third patient died secondary to complications of his underlying cerebral palsy. The most common comorbidities among our patient population were metastatic cancer (n = 7) and hypertension/coronary artery disease, which is not factored into CCI (n = 7). Another common comorbidity was COPD or reactive airway disease (n = 4). Table 1 Demographic characteristics of OWT cohort Cohort Demographics, N = 18 Patient age at procedure (years), M ± SD Patient age range 59.44 ± 14.67 31–79 Gender, n (%) Male 11 (61.1) Female 7 (38.9) Ethnicity/Race, n (%) Non-Hispanic, Caucasian 9 (50.0) Black, African American 4 (22.2) Asian 1 (5.6) Hispanic 1 (5.6) Other, Unknown 3 (16.6) Smoking History, n (%) Yes 9 (50.0) No 9 (50.0) Comorbidities, n Cancer, metastatic 7 Cancer, local 2 COPD or Reactive Airway disease 4 HTN/CAD 7 Organ transplant 1 HIV/AIDs 1 CVA/stroke 2 Cerebral Palsy 1 None 2 Charleston Comorbidity Index Score Predicted 10 year survival 0 (n = 3) 98% 1 (n = 1) 96% 3 (n = 2) 77% 5 (n = 3) 21% 6 (n = 4) 2% 8 (n = 1) 0% 9 (n = 3) 0% 12 (n = 1) 0% Indication for OWT, n (%) Post-resectional BPF 8 (44.4) Post-pneumonectomy 5 Post-lobectomy 3 Parapneumonic Empyema 5 (27.8) Esophageal Related 1 (5.6) Subdiaphragmatic Abscess 1 (5.6) Post-traumatic BPF 2 (11.1) Operative details of the procedures are listed in Table 2 . The most common indication for OWT was a post-resectional BPF (44% with n = 3 post-lobectomy and n = 5 post-pneumonectomy). Mean number of ribs resected were 2.6 with a range notable for 1–6 ribs. NPWT was utilized 50% of the time, with Kerlix packing used in patients who did not undergo NPWT. NPWT was primarily used for patients who only had trapped lung, and had no underlying airleak as that would not allow the negative-pressure device to hold suction. The was no trend for NPWT vs Kerlix over time, and 6 of 9 NPWT therapy patients were successfully closed by the end of the study. One patient was lost to follow up and two were deceased prior to closure. Eleven of 18 patients (61.1%) underwent delayed closure, with the most common means of closure being a latissimus dorsi pedicled flap (6 of 11 closed patients). Six patients were not closed as they died in the interim and in one patient, closure status is unknown as they were lost to follow up. In 1 patient who was closed 109 days after the index operation, BPF with empyema recurred within 2 months of closure and was managed with repeat thoracotomy and MEF creation. During the closure there were no signs of ongoing infection; though there was some fibrinous material debrided. Table 2 Short and long-term outcomes of OWT cohort Cohort Outcomes, N = 18 Ribs resected (number), M ± SD; range 2.6 ± 1.2; 1–6 NPWT utilized, n (%) 9 (50.0) Kerlix packing, n (%) 9 (50.0) Delayed Closure, n (%) Yes 11 (61.1) Latissimus dorsi pedicled flap 6 † Pectoralis major pedicled flap 1 Free flap 2 Reapproximation of surrounding tissue 2 No, due to death 6 (33.3) Unknown, lost to follow up 1 (5.6) Time from index surgery to closure, M ± SD (months); range 4.8 ± 6.7; 3 days – 22.2 months Patient Deceased, n (%) Yes, total 12 (66.6) Yes, within 30 days post-operatively 3 - N = 2 Respiratory failure, sepsis - N = 1 Acute MI Yes, within 90 days post-operatively 1 - Tracheoinnominate fistula, hemorrhage, sepsis Yes, > 90 days post-op 9 No 6 (33.3) Major post-operative complication (within 90 days), n(%) Recurrent infection after closure 1 (5.6) DVT 1 (5.6) Pulmonary Embolism 1 (5.6) Stroke 1 (5.6) MI 1 (5.6) OR take-back 2 (11.1) - POD1: Hemorrhage - POD 7: Subcutaneous emphysema Readmission Yes, total 7 (38.9) Yes, within 30 days 3 - N = 1 scheduled closure - N = 1 fall, altered mental status - N = 1 dyspnea Yes, within 90 days 4 - N = 2 scheduled closure - N = 1 aspiration pneumonia - N = 1 bleeding from OWT No 6 (33.3) Not applicable, death on primary admission 5 (27.8) Overall Survival (months), M ± SD 24.0 ± 32.2 † 1 patient re-opened for recurrent infection and repeat OWT/Eloesser flaps At the end of the review period, 12 patients (66.6%) were deceased, with 3 (16.7%) patients dying within 30 days postoperatively with the following etiologies: respiratory failure/sepsis, respiratory failure/BPF, and acute myocardial infarction (MI). One patient died within 90 days due to tracheoinnominate fistula. A significant long-term complication was recurrent infection after closure (1 or 5.6% of patients). Additionally, 2 patients required OR takeback within 30 days, one for hemorrhage and the other for subcutaneous emphysema resulting in respiratory failure requiring intubation and chest tube placement in the contralateral pleural space to the OWT site. Total readmissions within 90 days included 7 patients (38.9%); though 5 patients (27.8%) had died on admission for index surgery. The mean overall survival was 24 months. Our Kaplan Meier curve shows the probability of survival after OWT to 1 month is 88% and 30% at 30 months (Fig. 2 ). Discussion No literature has been published in the last 10 years looking at outcomes of OWT. Our study illustrates the often-significant comorbidities of patients undergoing OWT in the modern era as well as the associated poor outcomes for patients and pitfalls that continue to be associated with this morbid procedure. There were two previous major studies published on this subject prior to the era of widespread use of fibrinolytic therapy. The first is a study by Thourani et al. in 2003 which examined 78 patients from 1975–2001 who received strictly MEFs for empyema thoracis 14 . The second is a study by Reyes et al. in 2010 which looked at 78 patients who underwent OWT from 1998–200815. However, our cohort is distinct from both of theirs for multiple reasons. Compared to Reyes’ study which found a 6% 30-day mortality and Thourani’s study which found a 5% 30-day mortality, our study demonstrates a 12% 30-day mortality predicted by a Kaplan-Meyer curve or 16.7% based on raw data (n = 3 of 18 deceased at 30 days, Fig. 2 ). Our increased mortality and smaller cohort are in part explained by the advent of fibrinolytics and endobronchial valves, and improved conservative interventions for empyema management. Given these advances, fewer patients go to the operating room for OWT as their index case, and often those who do undergo OWT have either failed or were not candidates for less-invasive surgical interventions. The First and Second Multicenter Intrapleural Sepsis Trial (MIST I, MIST II) in 2005 and 2011 respectively (after the publication of the aforementioned studies) revolutionized care for the patient with empyema through the intrapleural use of fibrinolytics. First streptokinase was trialed, which compared to placebo did not improve mortality (MIST I), followed by combined tPA and DNAase (MIST II), which was shown to reduce the frequency of surgical referral and the duration of the hospital stay 1 , 16 . Additionally, in current practice decortication with same day closure (either VATS or via open thoracotomy) are considered the procedures of choice before OWT as they are known to have superior outcomes 17 , 18 . Furthermore in both Reyes’ and Thourani’s study the primary indication for OWT was for parapneumonic empyema, whereas in our study it was postoperative BPF 14 . This is likely explained by current practice of management of patients with parapneumonic empyema with the aforementioned conservative modalities. The wide-use of endobronchial valves has also changed the management of persistent airleaks, albeit only in sterile fields 19 . Furthermore, our study supports the recent work of Nayak et al. 2020, which analyzed the epidemiology and trends in management of thoracic empyema from 1996-2015 20 . Like our study, Nayak et al. used the Charleston Comorbidity Index to analyze morbidity and mortality risk in their population. They observed an increased incidence over time of thoracic empyema in patients aged 50–70 and postulated that this trend both reflects a change in the etiology of empyema from risk factors affecting a younger or more at risk population (IV drug use, Tuberculosis) as well as the greater presence of risk factors such as COPD and diabetes – both independent risk factors for empyema development – in the aging population 21 . Our study likewise had older patients (an average age of 59.44) with significant comorbidities as measured according to the CCI, supporting the changing epidemiological trends reported in Nayak et al 20 . There are several limitations to our study. First, the cohort of OWT patients (n = 18) in this study is limited by its small size. However, it still provides a valuable illustration of the various etiologies for which OWT is still indicated, most notably for trapped lung that cannot be expanded via VATS or open decortication or post-resectional dead space which is a nidus for infection in the setting of BPF. Additionally, our study further illustrates – similarly to past studies 9 , 10 , 22 -- that NPWT can be utilized as potential way to obliterate the pleural space and manage an open chest in absence of an airleak, as this method ultimately led to successful closure in six of nine patients with NPWT. In our study, most patients who underwent OWT were debilitated at baseline and poor surgical candidates irrespective of their underlying severe pleural space infection as evidenced by their high Charleston Comorbidity Score’s (n = 13 with a score ≥ 5 indicating 21% 10 year survival or less) (Table 1 ). A particularly undesirable, yet possible outcome of empyema management with OWT is premature window closure leading to recurrent infection, as seen in one patient in our cohort (Table 2 ). This patient was significantly immunocompromised at the time of closure given his underlying stage IV non-small cell lung cancer, which likely increased his risk of recurrent infection. Cases such as this illustrates the need to be wary of the possibility of recurrent or ongoing sub-clinical infection in patients who seem otherwise well and ready for closure. This is particularly poignant for immunocompromised patients who may not mount a clinical, symptomatic response (fever, leukocytosis) to ongoing infection. While there is no consensus as to when to close OWT patients, particular care should be taken in the immunocompromised patient to give enough time to truly decontaminate the space and ensure that colonization of the pleural space has decreased to < 10 5 colonies/hpf. Conclusions Patients that undergo OWT are a sick population at baseline, and the poor outcomes associated with OWT in current practice are unsurprising as patients receiving this operation are either too sick for other interventions or are out of other treatment options. A pitfall to avoid in management of OWT patients is early closure of the window to avoid the dire effects of reinfection. Further studies are needed to compare fibrinolytics versus all surgical interventions for empyema, albeit the results can be expected to be better for the former cohort of patients. Abbreviations Video assisted thoracoscopic surgery (VATS), Open window thoracostomy (OWT), Eloesser flap (EF), Modified Eloesser flap (MEF), negative pressure wound therapy (NPWT), Charleston Comorbidity Index (CCI), Bronchopleural fistula (BPF) Declarations Ethics approval and consent to participate: Not applicable; IRB approved study Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: None. Authors' contributions: CJC and PGK acquired, analyzed, and interpreted the patient data on patients undergoing the regional block. CJC, MM, JFL, HRH, MEH, SM, and PGK interpreted the data, substantially revised the manuscript, and were major contributors in writing the manuscript. All authors read and approved the final manuscript. Acknowledgements: The illustrations were done by author CC. References Rahman NM, Phil D, Maskell NA, et al. Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection. The New England Journal of Medicine . Published online 2011:9. Oyetunji TA, Dorman RM, Svetanoff WJ, et al. Declining frequency of thoracoscopic decortication for empyema — redefining failure after fibrinolysis. 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Published online January. 2021;3:7. doi: https://doi.org/10.1007/s11748-020-01554-5 . Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 04 Jun, 2021 Review # 1 received at journal 03 Jun, 2021 Review # 2 received at journal 02 Jun, 2021 Reviewer # 2 agreed at journal 22 May, 2021 Reviews received at journal 22 May, 2021 Reviewers invited by journal 22 May, 2021 Reviewer # 1 agreed at journal 21 May, 2021 Editor assigned by journal 21 May, 2021 Submission checks completed at journal 20 May, 2021 Editor invited by journal 20 May, 2021 First submitted to journal 20 May, 2021 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. 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Cain","email":"","orcid":"","institution":"Medstar Georgetown University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Caitlin","middleName":"J.","lastName":"Cain","suffix":""},{"id":28687356,"identity":"cb06abe4-3223-4f7c-bdb7-94911a70f3a0","order_by":1,"name":"Marc Margolis","email":"","orcid":"","institution":"Medstar Georgetown University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Marc","middleName":"","lastName":"Margolis","suffix":""},{"id":28687357,"identity":"47cb2b31-3193-4d57-b201-215926d2b44b","order_by":2,"name":"John F. Lazar","email":"","orcid":"","institution":"Medstar Georgetown University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"John","middleName":"F.","lastName":"Lazar","suffix":""},{"id":28687358,"identity":"bf8203b1-fb49-4be7-b5af-86d9e094f954","order_by":3,"name":"Hayley R. Henderson","email":"","orcid":"","institution":"Medstar Georgetown University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hayley","middleName":"R.","lastName":"Henderson","suffix":""},{"id":28687359,"identity":"a1ab69ab-6196-42e0-879a-77051a8c1dc2","order_by":4,"name":"Margaret E. Hamm","email":"","orcid":"","institution":"Medstar Georgetown University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Margaret","middleName":"E.","lastName":"Hamm","suffix":""},{"id":28687360,"identity":"545e2084-50aa-4805-8f1d-4d4f400a2e52","order_by":5,"name":"Stefanie C Malouf","email":"","orcid":"","institution":"Medstar Georgetown University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Stefanie","middleName":"C","lastName":"Malouf","suffix":""},{"id":28687361,"identity":"69fed8cb-dc1f-442b-8f19-9073ed105d77","order_by":6,"name":"Puja Gaur Khaitan","email":"data:image/png;base64,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","orcid":"","institution":"MedStar Georgetown University Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Puja","middleName":"Gaur","lastName":"Khaitan","suffix":""}],"badges":[],"createdAt":"2021-05-21 11:15:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-547627/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-547627/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":9627326,"identity":"f4f61f67-1314-48b7-ab2a-8a5001200e80","added_by":"auto","created_at":"2021-05-26 19:57:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":28723,"visible":true,"origin":"","legend":"A – OWT part I with rib segments removed showing underlying lung parenchyma; B – OWT part II showing skin sutured circumferentially to parietal pleura (marsupialization) \nC – Eloesser flap (adapted from original sketch by Dr. Eloesser)11, D – Modified Eloesser flap with numbers 1, 2, 3, 4 corresponding to cutaneous flap, removed rib segment, lung parenchyma, and diaphragm respectively \n","description":"","filename":"OnlineFIGURE1300dpi.png","url":"https://assets-eu.researchsquare.com/files/rs-547627/v1/2007d0e82c6f171a97c7efd5.png"},{"id":9627327,"identity":"6c7377c5-972c-410d-ba41-c7ba9a299987","added_by":"auto","created_at":"2021-05-26 19:57:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":11269,"visible":true,"origin":"","legend":"Kaplan Meier curve modeling survival probability for OWT cohort ","description":"","filename":"OnlineFIGURE2300dpi.png","url":"https://assets-eu.researchsquare.com/files/rs-547627/v1/44275221d62173b8139ac0fd.png"},{"id":13695215,"identity":"353b3961-8f00-40e8-8227-1dbf69191a8e","added_by":"auto","created_at":"2021-09-17 12:56:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":334909,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-547627/v1/a868574a-1aa6-4ca9-bdaf-04b1098845a2.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eShort and Long-Term Outcomes of Surgical Intervention for Empyema in The Post-Fibrinolytic Era\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eSince the inception of pleural fibrinolytic therapy in 2011 for management of empyema and complicated parapneumonic effusions, the incidence of decortication has substantially declined\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Surgical management is considered for empyema when non-surgical therapy \u0026ndash; i.e. antibiotics, tube thoracostomy, fibrinolytics -- fails as well as in cases presenting as organized empyema with lung entrapment\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Surgical interventions include video assisted thoracoscopic surgery (VATS) decortication and open thoracotomy with decortication. For unstable patients, Clagett type open-window thoracostomy (OWT) with rib resection and modified Eloesser flap (MEF) with rib resection both with or without negative pressure wound therapy (NPWT) are options, as both operations allow for continuous access to the pleural space for pus evacuation and debridement\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAn OWT is a procedure which may include elements of the Clagett window, EF, or MEF, but fundamentally involves removal of one or more rib segments and circumferentially marsupializing the parietal pleura to the skin (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA,B). In 1935, Eloesser described the original procedure for open chest drainage, with creation of a U-shaped cutaneous flap sutured apically under a resected rib segment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC)\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In 1963, Clagett and Geraci described a new drainage procedure which entailed the removal of one rib segment and suturing the superficial fascia down to the periosteum of the resected rib\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The MEF was introduced in 1971 by Symbas et al. with the idea of providing superior empyema decontamination by a dependent drainage system not present in the traditional EF. The MEF is an inverted U-shaped cutaneous flap sutured inferiorly to the diaphragm below a segment of resected rib (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD)\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In contrast to the traditional Clagett window and OWT, where the ultimate goal is chest closure after successful empyema treatment, EF and MEFs are historically closed primarily through epithelialization and obliteration of the empyema cavity over time with resolution of the empyema itself\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThus, current practices of open chest drainage for patients with empyema are best described as an OWT including Clagett windows, MEFs, and EFs. The aim of our study was to review our own practice and compare short and long-term outcomes of OWT for management of empyema, in the era of minimally-invasive surgery, endobronchial valves, and fibrinolytic therapy.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eWe identified all patients who underwent OWT at our institution between 2010 and 2020 by querying International Classification of Disease (ICD) 9 code 510 (empyema), and ICD 10 J86.0 (pyothorax with fistula). These ICD codes was then cross-matched to relevant current procedural terminology (CPT) codes including: 32035 (thoracostomy with rib resection), 23036 (thoracostomy with flap drainage), 32220 (release of lung), 32225 (partial release of lung), 32810 (closure chest after drainage), 32905 and 32906 (both revise and repair chest wall). These procedure codes were also cross-referenced to ICD 9 and ICD 10 procedure codes in order to capture additional patients.\u003c/p\u003e \u003cp\u003eA retrospective review of all patients undergoing any of the three OWT procedures was performed under an institution-approved IRB protocol. Statistical analysis included modeling survival data using a standard Kaplan Meier curve. Additionally, 10-year survival estimates at the time of the index operation was calculated for each patient using the Charleston Comorbidity Index score; points were given for age at time of surgery (age 50\u0026ndash;50, 60\u0026ndash;69, 70\u0026ndash;79 and \u0026ge;\u0026thinsp;80 given\u0026thinsp;+\u0026thinsp;1, 2, 3, and 4 points respectively), history of myocardial infarction, congestive heart failure, peripheral vascular disease, cerebral vascular accident or transient ischemic attack, dementia, chronic obstructive pulmonary disease, connective tissue disease, peptic ulcer disease (all +\u0026thinsp;1 point), liver disease (+\u0026thinsp;1 mild\u0026thinsp;=\u0026thinsp;chronic hepatitis or cirrhosis without portal hypertension; +2 moderate to severe\u0026thinsp;=\u0026thinsp;cirrhosis and portal hypertension without or with variceal bleeding history), diabetes mellitus (none/diet-controlled\u0026thinsp;+\u0026thinsp;0, uncomplicated\u0026thinsp;+\u0026thinsp;1, end-organ damage\u0026thinsp;+\u0026thinsp;2), hemiplegia (+\u0026thinsp;2), moderate to severe chronic kidney disease (Cr\u0026thinsp;\u0026gt;\u0026thinsp;3 mg/dL or status post kidney transplant\u0026thinsp;+\u0026thinsp;2), solid tumor (localized\u0026thinsp;+\u0026thinsp;2, metastatic\u0026thinsp;+\u0026thinsp;6), leukemia (+\u0026thinsp;2), lymphoma (+\u0026thinsp;2), AIDS (+\u0026thinsp;6).\u003c/p\u003e "},{"header":"Results","content":"\u003cp\u003eWe identified 18 patients who had undergone an OWT. Their demographics are outlined in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients ranged in age from 31 to 79. Nine patients (50%) had a history significant for smoking. All but 3 patients had significant pre-existing comorbidities as graded by the Charleston Comorbidity Index (CCI), an estimate of 10-year survival based on individual comorbidities at the time of the index operation. Two of the 3 patients without pre-existing comorbidities as measured by the CCI had a post-traumatic cause of empyema (one occurring in an otherwise healthy 47-year-old male after a gun-shot wound to the chest and the other in a 31-year-old male with cerebral palsy after a gastrostomy-tube was inadvertently tunneled into the pleural space). Of the patients without comorbidities tabulated by CCI, 2 of 3 did not require readmission after their index operation other than for scheduled delayed closure, and they are both still living. The third patient died secondary to complications of his underlying cerebral palsy. The most common comorbidities among our patient population were metastatic cancer (n\u0026thinsp;=\u0026thinsp;7) and hypertension/coronary artery disease, which is not factored into CCI (n\u0026thinsp;=\u0026thinsp;7). Another common comorbidity was COPD or reactive airway disease (n\u0026thinsp;=\u0026thinsp;4).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographic characteristics of OWT cohort\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCohort Demographics, N\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePatient age at procedure (years), M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003cp\u003ePatient age range\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e59.44\u0026thinsp;\u0026plusmn;\u0026thinsp;14.67\u003c/p\u003e\n\u003cp\u003e31\u0026ndash;79\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eGender, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e11 (61.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e7 (38.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEthnicity/Race, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eNon-Hispanic, Caucasian\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e9 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eBlack, African American\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e4 (22.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAsian\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHispanic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eOther, Unknown\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e3 (16.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSmoking History, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e9 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e9 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eComorbidities, \u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCancer, metastatic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCancer, local\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCOPD or Reactive Airway disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHTN/CAD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eOrgan transplant\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHIV/AIDs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCVA/stroke\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCerebral Palsy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCharleston Comorbidity\u003c/p\u003e\n\u003cp\u003eIndex Score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePredicted 10 year survival\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e0 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e3 (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e77%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e5 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e21%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e6 (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e8 (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e9 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e12 (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eIndication for OWT, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePost-resectional BPF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e8 (44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePost-pneumonectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePost-lobectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eParapneumonic Empyema\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e5 (27.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEsophageal Related\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSubdiaphragmatic Abscess\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePost-traumatic BPF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cp\u003eOperative details of the procedures are listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The most common indication for OWT was a post-resectional BPF (44% with n\u0026thinsp;=\u0026thinsp;3 post-lobectomy and n\u0026thinsp;=\u0026thinsp;5 post-pneumonectomy). Mean number of ribs resected were 2.6 with a range notable for 1\u0026ndash;6 ribs. NPWT was utilized 50% of the time, with Kerlix packing used in patients who did not undergo NPWT. NPWT was primarily used for patients who only had trapped lung, and had no underlying airleak as that would not allow the negative-pressure device to hold suction. The was no trend for NPWT vs Kerlix over time, and 6 of 9 NPWT therapy patients were successfully closed by the end of the study. One patient was lost to follow up and two were deceased prior to closure. Eleven of 18 patients (61.1%) underwent delayed closure, with the most common means of closure being a latissimus dorsi pedicled flap (6 of 11 closed patients). Six patients were not closed as they died in the interim and in one patient, closure status is unknown as they were lost to follow up. In 1 patient who was closed 109 days after the index operation, BPF with empyema recurred within 2 months of closure and was managed with repeat thoracotomy and MEF creation. During the closure there were no signs of ongoing infection; though there was some fibrinous material debrided.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eShort and long-term outcomes of OWT cohort\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCohort Outcomes, N\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRibs resected (number), M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD; range\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2; 1\u0026ndash;6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNPWT utilized, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKerlix packing, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDelayed Closure, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (61.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLatissimus dorsi pedicled flap\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePectoralis major pedicled flap\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFree flap\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReapproximation of surrounding tissue\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo, due to death\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnknown, lost to follow up\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTime from index surgery to closure, M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (months); range\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.8 \u0026plusmn; 6.7; 3 days \u0026ndash; 22.2 months\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient Deceased, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes, total\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (66.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes, within 30 days post-operatively\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- N\u0026thinsp;=\u0026thinsp;2 Respiratory failure, sepsis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- N\u0026thinsp;=\u0026thinsp;1 Acute MI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes, within 90 days post-operatively\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- Tracheoinnominate fistula, hemorrhage, sepsis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes, \u0026gt; 90 days post-op\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e6 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMajor post-operative complication (within 90 days), \u003cem\u003en(%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRecurrent infection after closure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDVT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePulmonary Embolism\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStroke\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOR take-back\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- POD1: Hemorrhage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- POD 7: Subcutaneous emphysema\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReadmission\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes, total\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e7 (38.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes, within 30 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- N\u0026thinsp;=\u0026thinsp;1 scheduled closure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- N\u0026thinsp;=\u0026thinsp;1 fall, altered mental status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- N\u0026thinsp;=\u0026thinsp;1 dyspnea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes, within 90 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- N\u0026thinsp;=\u0026thinsp;2 scheduled closure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- N\u0026thinsp;=\u0026thinsp;1 aspiration pneumonia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e- N\u0026thinsp;=\u0026thinsp;1 bleeding from OWT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e6 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot applicable, death on primary admission\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e5 (27.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOverall Survival (months), M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e24.0\u0026thinsp;\u0026plusmn;\u0026thinsp;32.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e1 patient re-opened for recurrent infection and repeat OWT/Eloesser flaps\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\nAt the end of the review period, 12 patients (66.6%) were deceased, with 3 (16.7%) patients dying within 30 days postoperatively with the following etiologies: respiratory failure/sepsis, respiratory failure/BPF, and acute myocardial infarction (MI). One patient died within 90 days due to tracheoinnominate fistula. A significant long-term complication was recurrent infection after closure (1 or 5.6% of patients). Additionally, 2 patients required OR takeback within 30 days, one for hemorrhage and the other for subcutaneous emphysema resulting in respiratory failure requiring intubation and chest tube placement in the contralateral pleural space to the OWT site. Total readmissions within 90 days included 7 patients (38.9%); though 5 patients (27.8%) had died on admission for index surgery. The mean overall survival was 24 months. Our Kaplan Meier curve shows the probability of survival after OWT to 1 month is 88% and 30% at 30 months (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eNo literature has been published in the last 10 years looking at outcomes of OWT. Our study illustrates the often-significant comorbidities of patients undergoing OWT in the modern era as well as the associated poor outcomes for patients and pitfalls that continue to be associated with this morbid procedure. There were two previous major studies published on this subject prior to the era of widespread use of fibrinolytic therapy. The first is a study by Thourani et al. in 2003 which examined 78 patients from 1975\u0026ndash;2001 who received strictly MEFs for empyema thoracis\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The second is a study by Reyes et al. in 2010 which looked at 78 patients who underwent OWT from 1998\u0026ndash;200815. However, our cohort is distinct from both of theirs for multiple reasons. Compared to Reyes\u0026rsquo; study which found a 6% 30-day mortality and Thourani\u0026rsquo;s study which found a 5% 30-day mortality, our study demonstrates a 12% 30-day mortality predicted by a Kaplan-Meyer curve or 16.7% based on raw data (n\u0026thinsp;=\u0026thinsp;3 of 18 deceased at 30 days, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Our increased mortality and smaller cohort are in part explained by the advent of fibrinolytics and endobronchial valves, and improved conservative interventions for empyema management. Given these advances, fewer patients go to the operating room for OWT as their index case, and often those who do undergo OWT have either failed or were not candidates for less-invasive surgical interventions.\u003c/p\u003e \u003cp\u003e The First and Second Multicenter Intrapleural Sepsis Trial (MIST I, MIST II) in 2005 and 2011 respectively (after the publication of the aforementioned studies) revolutionized care for the patient with empyema through the intrapleural use of fibrinolytics. First streptokinase was trialed, which compared to placebo did not improve mortality (MIST I), followed by combined tPA and DNAase (MIST II), which was shown to reduce the frequency of surgical referral and the duration of the hospital stay\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Additionally, in current practice decortication with same day closure (either VATS or via open thoracotomy) are considered the procedures of choice before OWT as they are known to have superior outcomes\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Furthermore in both Reyes\u0026rsquo; and Thourani\u0026rsquo;s study the primary indication for OWT was for parapneumonic empyema, whereas in our study it was postoperative BPF\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. This is likely explained by current practice of management of patients with parapneumonic empyema with the aforementioned conservative modalities. The wide-use of endobronchial valves has also changed the management of persistent airleaks, albeit only in sterile fields\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFurthermore, our study supports the recent work of Nayak et al. 2020, which analyzed the epidemiology and trends in management of thoracic empyema from 1996-2015\u003csup\u003e20\u003c/sup\u003e. Like our study, Nayak et al. used the Charleston Comorbidity Index to analyze morbidity and mortality risk in their population. They observed an increased incidence over time of thoracic empyema in patients aged 50\u0026ndash;70 and postulated that this trend both reflects a change in the etiology of empyema from risk factors affecting a younger or more at risk population (IV drug use, Tuberculosis) as well as the greater presence of risk factors such as COPD and diabetes \u0026ndash; both independent risk factors for empyema development \u0026ndash; in the aging population\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Our study likewise had older patients (an average age of 59.44) with significant comorbidities as measured according to the CCI, supporting the changing epidemiological trends reported in Nayak et al\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere are several limitations to our study. First, the cohort of OWT patients (n\u0026thinsp;=\u0026thinsp;18) in this study is limited by its small size. However, it still provides a valuable illustration of the various etiologies for which OWT is still indicated, most notably for trapped lung that cannot be expanded via VATS or open decortication or post-resectional dead space which is a nidus for infection in the setting of BPF. Additionally, our study further illustrates \u0026ndash; similarly to past studies\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e -- that NPWT can be utilized as potential way to obliterate the pleural space and manage an open chest in absence of an airleak, as this method ultimately led to successful closure in six of nine patients with NPWT.\u003c/p\u003e \u003cp\u003eIn our study, most patients who underwent OWT were debilitated at baseline and poor surgical candidates irrespective of their underlying severe pleural space infection as evidenced by their high Charleston Comorbidity Score\u0026rsquo;s (n\u0026thinsp;=\u0026thinsp;13 with a score\u0026thinsp;\u0026ge;\u0026thinsp;5 indicating 21% 10 year survival or less) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A particularly undesirable, yet possible outcome of empyema management with OWT is premature window closure leading to recurrent infection, as seen in one patient in our cohort (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This patient was significantly immunocompromised at the time of closure given his underlying stage IV non-small cell lung cancer, which likely increased his risk of recurrent infection. Cases such as this illustrates the need to be wary of the possibility of recurrent or ongoing sub-clinical infection in patients who seem otherwise well and ready for closure. This is particularly poignant for immunocompromised patients who may not mount a clinical, symptomatic response (fever, leukocytosis) to ongoing infection. While there is no consensus as to when to close OWT patients, particular care should be taken in the immunocompromised patient to give enough time to truly decontaminate the space and ensure that colonization of the pleural space has decreased to \u0026lt;\u0026thinsp;10\u003csup\u003e5\u003c/sup\u003e colonies/hpf.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003ePatients that undergo OWT are a sick population at baseline, and the poor outcomes associated with OWT in current practice are unsurprising as patients receiving this operation are either too sick for other interventions or are out of other treatment options. A pitfall to avoid in management of OWT patients is early closure of the window to avoid the dire effects of reinfection. Further studies are needed to compare fibrinolytics versus all surgical interventions for empyema, albeit the results can be expected to be better for the former cohort of patients.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eVideo assisted thoracoscopic surgery (VATS), Open window thoracostomy (OWT), Eloesser flap (EF), Modified Eloesser flap (MEF), negative pressure wound therapy (NPWT), Charleston Comorbidity Index (CCI), Bronchopleural fistula (BPF)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable; IRB approved study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e CJC and PGK acquired, analyzed, and interpreted the patient data on patients undergoing the regional block. CJC, MM, JFL, HRH, MEH, SM, and PGK interpreted the data, substantially revised the manuscript, and were major contributors in writing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The illustrations were done by author CC.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRahman NM, Phil D, Maskell NA, et al. Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection. \u003cem\u003eThe New England Journal of Medicine\u003c/em\u003e. Published online 2011:9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOyetunji TA, Dorman RM, Svetanoff WJ, et al. Declining frequency of thoracoscopic decortication for empyema \u0026mdash; redefining failure after fibrinolysis. 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The Annals of Thoracic Surgery. 1969;8(4):355\u0026ndash;7. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0003-4975(10)66250-9\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThourani VH, Lancaster RT, Mansour KA, Miller JI. Twenty-six years of experience with the modified eloesser flap. The Annals of Thoracic Surgery. 2003;76(2):401\u0026ndash;6. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0003-4975(03)00470-3\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReyes K, Mason D, Murthy S, Su J, Rice T. Open Window Thoracostomy: Modern Update of an Ancient Operation. Thorac cardiovasc Surg. 2010;58(04):220\u0026ndash;4. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0029-1240972\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaskell NA, Gleeson FV, Woodhead MA, Davies RJO. U.K. Controlled Trial of Intrapleural Streptokinase for Pleural Infection. \u003cem\u003eThe New England Journal of Medicine\u003c/em\u003e. Published online 2005:10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong BC, Hanna J, Toloza EM, et al. Outcomes of Video-Assisted Thoracoscopic Decortication. The Annals of Thoracic Surgery. 2010;89(1):220\u0026ndash;5. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.athoracsur.2009.09.021\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChambers A, Routledge T, Dunning J, Scarci M. Is video-assisted thoracoscopic surgical decortication superior to open surgery in the management of adults with primary empyema? Interact CardioVasc Thorac Surg. 2010;11(2):171\u0026ndash;7. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1510/icvts.2010.240408\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFiorelli A, D\u0026rsquo;Andrilli A, Cascone R, et al. Unidirectional endobronchial valves for management of persistent air-leaks: results of a multicenter study. J Thorac Dis. 2018;10(11):6158\u0026ndash;67. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/jtd.2018.10.61\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNayak R, Brogly SB, Lajkosz K, Lougheed MD, Petsikas D. Two Decades of Thoracic Empyema in Ontario, Canada. Chest. 2020;157(5):1114\u0026ndash;6. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.chest.2019.11.040\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo C-H, Chen Y-C, Chu C-C, Wang J-J, Liao K-M. Age-adjusted Charlson comorbidity score is associated with the risk of empyema in patients with COPD. Medicine. 2017;96(36):e8040. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MD.0000000000008040\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishii K. Management of thoracic empyema with broncho-pulmonary fistula in combination with negative-pressure wound therapy. \u003cem\u003eGeneral Thoracic and Cardiovascular Surgery\u003c/em\u003e. Published online January. 2021;3:7. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11748-020-01554-5\u003c/span\u003e\u003c/span\u003e.\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":true,"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":"Empyema, Open Window Thoracostomy, Bronchopleural fistula","lastPublishedDoi":"10.21203/rs.3.rs-547627/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-547627/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eBackground:\u003c/u\u003e \u003c/strong\u003eOpen window thoracostomy is indicated for patients with bronchopleural fistulae or trapped lung in the setting of empyema refractory to non-surgical interventions.\u0026nbsp;We investigated the role of open window thoracostomy in the era of minimally invasive surgeries, endobronchial valves and fibrinolytic therapy.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eMethods:\u003c/u\u003e\u003c/strong\u003e A retrospective chart review of all patients who underwent open window thoracostomy at a single institution from 2010-2020 was performed. Indications for the procedure as well as operative details and morbidity and mortality were evaluated to determine patient outcomes for open window thoracostomy.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eResults:\u003c/u\u003e\u003c/strong\u003e Eighteen patients were identified for the study. The most common indication for open window thoracostomy was post-resectional bronchopleural fistula (n=8). Patient comorbidities were quantified with the Charleston Comorbidity index (n=11 score≥5, 10-year survival ≤21%). Three (16.7%) patients died \u0026lt;30 days post-operatively and 12 (66%) patients were deceased by the study’s end (overall survival 24.0 ± 32.2 months). Mean number of ribs resected were 2.6 ± 1.2 (range 1-6). Patients were managed with negative pressure wound therapy (n=9) or Kerlix packing (n=9). Eleven patients (61.6%) underwent delayed closure (mean time from index surgery to closure 4.8 ±\u0026nbsp;6.7 months). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConclusions: \u003c/u\u003e\u003c/strong\u003eOur study illustrates the significant comorbidities of patients undergoing open window thoracostomy, the poor outcomes therein, and pitfalls associated with this procedure. We show that negative pressure wound therapy can be utilized as potential way to obliterate the pleural space and manage an open chest in the absence of an airleak; however open window thoracostomy procedures continue to be extremely morbid.\u003c/p\u003e","manuscriptTitle":"Short and Long-Term Outcomes of Surgical Intervention for Empyema in The Post-Fibrinolytic Era","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-05-26 19:54:09","doi":"10.21203/rs.3.rs-547627/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-06-05T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-06-04T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nAlthough the study covers a long period, it includes a small number of patients. Moreover, a significant portion of these patients have complications related to surgery. The study is not strong enough to affect daily practice and does not contribute to the current knowledge and literature.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Level of interest: **An article of limited interest**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2021-06-03T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major Revision\nForm responses:\n---\n\nComments to Author:\n---\nAuthors reviewed a subset of patients that are difficult to treat manifested by the very high mortality and worth reporting. Few comments might be worthwhile addressing:\n1-Page 3, line 44: \"range of ribs resected 1-6: Can authors explain situations where more than 3 ribs were needed to be resected? Typically 1-2 ribs are resected. More than 3 is very unusual. Was increased number of ribs resected associated with higher mortality?\n2-Page 5, line 36: change EF to Eloesser flap (EF): Words should be mentioned first time before abbreviation is used.\n3-Page 8, line 31: further details regarding post resection patients would be informative. Did surgeons consider other options such as, stump revisions or omentum /muscle flaps to fill cavity?\n4-Page 10- 26: agree with author's assessment in explaining the higher mortality seen compared to earlier studies. Can authors comment if these less invasive methods were actually attempted in these patients prior to undergoing OWT? And if so any explanation why these methods failed?\n5-Page 9 line 58: How was fibrinolytic treatment utilized in this pt population, where many of them are post resection and lytic treatment is usually contraindicated or at least avoided? How many days post op was lytic treatment started and what was the agent? Dose? Any bleeding complications?\n6-These are different patient cohort from average primary empyema that almost always resolves with lytic therapy or surgical decortication and I don't think MIST trials apply here. I would recommended the discussion part not concentrated on typical empyema patient, but more on the subset of patients that are post resection or with concomitant advanced cancer. This is really completely different patient population than primary empyema that is very rarely ever treated with OWT!\n7- In the patients treated with flap closure, what was time interval after index operation? When was OWT performed after flap closure? Any insights why the closure failed?\n8-Page 12 line 12: \"most patients were debilitated at base line\": is that at time of initial ling resection? In retrospect should these patients not undergone major lung resection such as pneumonectomy?\nPage 12 line 24: Metastatic cancer and infection is a deadly combination with not many good long-term treatment options and expected high mortality. Any comments regarding hospice care for these patients and not putting them through OWT?\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Level of interest: **An article of importance in its field**\n* Quality of written English: **Not suitable for publication unless extensively edited**\n* Declaration of competing interests: **'I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2021-05-23T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-05-22T09:00:00+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-05-22T08:49:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-05-22T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2021-05-21T08:19:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-05-20T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-05-20T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2021-05-20T12:53:03+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":"c359eb19-3710-4765-8df0-5251a321aaa6","owner":[],"postedDate":"May 26th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":4598607,"name":"Cardiothoracic Surgery"}],"tags":[],"updatedAt":"2021-06-18T08:21:58+00:00","versionOfRecord":[],"versionCreatedAt":"2021-05-26 19:54:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-547627","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-547627","identity":"rs-547627","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}