A less invasive alternative to fenestration for selected localized postoperative empyema with persistent air leak: prolonged open drainage using a large-sized cut tube in two patients

Postoperative empyema with persistent air leak remains a challenging complication after pulmonary resection. Fenestration may be required in refractory cases but is highly invasive, particularly in high-risk patients. We report two patients successfully treated with prolonged open drainage using a large-sized cut tube without fenestration and propose clinical criteria for selecting suitable candidates. A 72-year-old man with idiopathic pulmonary fibrosis developed Aspergillus empyema with persistent air leak after bullectomy for pneumothorax, and a 71-year-old man developed empyema with persistent air leak after left lower lobectomy and lingulectomy with bronchoplasty for lung cancer. Both were initially treated with closed chest drainage and antimicrobial therapy. On days 23 and 32, respectively, after infection was controlled, drainage volume decreased to < 50 mL/day, the empyema cavity became localized, and residual lung expansion remained stable despite persistent air leakage, the drainage tubes were cut and shortened to convert them to open drainage. CT confirmed that both cavities were anatomically separated from the pulmonary artery and other major hilar vessels. Both patients were subsequently managed as outpatients, and the empyema cavities gradually became obliterated by granulation tissue, allowing tube removal without fenestration. No recurrence occurred during 2 and 4 years of follow-up, respectively. Prolonged open drainage with a large-sized cut tube may provide a less invasive alternative to fenestration in selected patients with postoperative empyema and persistent air leak. Suitable candidates may be characterized by controlled infection, low drainage volume, a localized empyema cavity, stable residual lung expansion, and anatomical separation from major hilar vessels.