Outpatient management of post-pneumonectomy and post-lobectomy empyema using the vacuum-assisted closure system

A Comparison of Negative Pressure and Conventional Therapy in Infected Open Chest Wounds

Background: The role of negative pressure wound therapy (NPWT) in the management of open chest wounds is unclear. Our aim was to determine the safety and efficacy of NPWT compared with conventional therapy for open chest wounds. Methods: Ten patients with infected open chest wounds were included in a prospective trial of NPWT after surgical debridement. Their outcomes were compared with those of 11 control patients treated during the same period with surgical debridement and open chest packing only. The control group data were obtained by retrospective review of medical records. Results: The median duration of NPWT was eight days (range 2-29 days), with closure in eight patients (80%). Two patients having NPWT had unveiling of occult pleural fistulas leading to early discontinuation. The patients having NPWT had a shorter median time to closure (7 versus 18 days; p = 0.071) and shorter initial (median 6 versus 20 days; p = 0.026) and total (median 6 versus 25 days; p = 0.024) hospital length of stay. Control patients had higher rates of new-onset atrial fibrillation (46% versus 0; p = 0.035) and septic shock (64% versus 10%; p = 0.024). The chest was either closed or healing at the time of the last visit in 100% of the NPWT patients versus 73% of control patients (p = 0.28). The 1-year survival estimates were 90% for the NPWT patients and 80% for the control patients (p = 0.69). Conclusion: Negative pressure wound therapy is feasible and safe for open infected chest wounds in selected patients compared with open packing alone and may reduce hospital stay duration and major complication rates.

Is open window thoracostomy the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed: Is open window thoracostomy (OWT) the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer? Altogether 442 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Empyema following anatomical lung resection (excluding pneumonectomy) is an uncommon complication but one that remains a challenge to treat effectively. Chest tube thoracostomy and intravenous antibiotics remain the initial steps to management, but evidence is lacking with regard to the best ongoing strategy. Conservative options including chest cavity irrigation, postural drainage and vacuum-assisted closure have been attempted with some success, even in the presence of a broncho-pleural fistula. However, the very limited number of patients on which these various management strategies have been trialled on prevents recommendations and clear guidance being given.

Use of abdominal negative pressure wound therapy in different indications: a case series

Negative pressure wound therapy (NPWT) is a widely used wound management system. Several articles have been published on the advantages and complications of this system. Abdominal dressing negative pressure system (abdominal NPWT) is a newer technology, developed and used in open abdomen cases. The adherence of the sponge to the intra-abdominal organs is prevented by a polyurethane foam. This study presents a number of case series where an abdominal NPWT (ABThera, KCI, US) has been used to treat other vital organs, helping to prevent complications such as organ rupture and fatal bleeding.

Application of vacuum-assisted closure device in management of postpneumonectomy empyema

A 57-year-old man was diagnosed with lung cancer and underwent pneumonectomy and mediastinal lymph node dissection. He was discharged without acute complications, but on a regular outpatient follow-up, he was readmitted with postpneumonectomy empyema. He was successfully treated with a vacuum-assisted closure device and for 1 year period of outpatient follow-up, there was no recurrence of empyema or lung cancer.

Management of pleural empyema with a vacuum-assisted closure device and reconstruction of open thoracic window in a patient with liver cirrhosis

The patient is a 21-year-old female, diagnosed with cryptogenic cirrhosis at the age of 9. She presented with left post-pneumonic empyema that did not remit with conventional medical management and evolved with fistulization to the skin in the 7th intercostal space in the left subscapular region. We performed an open thoracic window procedure, and on the 6th day the patient was sent home with a portable vacuum-assisted closure device, with changes of the material every 4 days until the cavity was completed obliterated (92 days). Imaging tests showed full expansion of the lung, and chest wall reconstruction was performed with titanium rods. The high mortality of empyema in patients with liver disease requires both implementing and searching for new adjuvant therapies, like the use of vacuum-assisted closure systems and reconstruction with titanium rods. Controlled studies with a wide range of cases are needed for proper evaluation.

The use of vacuum-assisted wound closure therapy in thoracic operations

BACKGROUND

Conventional treatment of complex, nonresolving empyemas after an episode of pneumonia or a chest operation often requires an open-window thoracostomy. This necessitates frequent, often painful dressing changes and is associated with prolonged hospitalization. The wound is often malodorous, causing significant social distress to patients and unquestionably affects their quality of life. We assessed the value of using vacuum-assisted closure (VAC) therapy in managing patients with a persistent infected pleural space.

METHODS

The study included 10 patients. All patients signed an informed consent and were debriefed before the procedure. An empyema developed in 1 patient after an episode of pneumonia. The other 9 had recently undergone a thoracic surgical procedure. All patients underwent initial open drainage of the pleural cavity and debridement. A VAC therapy system was then inserted intraoperatively or on the first postoperative day. The patients were discharged home with a portable VAC therapy system in situ. Subsequent dressing changes were managed by tissue-viability nurses in the community, without the need for further anesthesia or analgesia. Over a period of time, the cavity was sterilized and eventually obliterated spontaneously.

RESULTS

All patients were mobilized early and fast-tracked through the hospital. This prevented the need for daily dressing changes; hence, minimizing the disruption of normal activities and reducing the need for nursing care. Overall, the length of hospitalization was shorter, and the VAC therapy facilitated closure of the infected wound cavity. The use of the VAC therapy system negated the need for a second surgical procedure to close the wound cavity. None of the patients reported pain, odor, or inconvenience associated with the VAC therapy system.

CONCLUSIONS

Our observations suggest that the use of VAC therapy to treat such patients is safe, facilitates early discharge and recovery, and offers a "civilized," cost-effective treatment in a community setting.