Application of Vacuum-Assisted Closure Device in Management of Postpneumonectomy Empyema
A 57-year-old man visited Seoul National University Hospital due to an incidentally detected hilar mass. It was a 4.2 cm mass encasing the left main pulmonary artery and involved the left main bronchus within 2 cm from the carina but not the carina itself (). Bronchoscopic examination showed an exophyting mass in the left upper lobar bronchus and tumor infiltration in the left main bronchus. A hypermetabolic mass in the left hilum was identified without metastasis by a positron emission tomography-computed tomography scan. He underwent left intrapericardial pneumonectomy and mediastinal lymph node dissection by hemi-clamshell incision after mediastinoscopic lymph node biopsy in April 2007. The pericardium was resected in en bloc fashion and the pulmonary artery was divided in the pericardial cavity. The pericardial defect was reconstructed with a Gore-Tex patch. The patient was discharged on postoperative day 15 without any complications. The final pathologic result reported a clear resection margin at the bronchial and pulmonary arterial stump; however, there was microscopic single nodal metastasis at the subcarinal lymph node.\nOn regular outpatient follow-up, the patient was readmitted on diagnosis of postoperative empyema with bronchopleural fistula (BPF) and received a window operation in March 2008 (). However, for fear of exposure of the pericardial cavity externally, we did not remove the Gore-Tex patch at that time. The BPF closed spontaneously several months after the window operation; however, the remaining Gore-Tex patch caused repeated infection and continuous dirty discharge. Therefore, we removed the Gore-Tex patch in October 2009 and noted that the heart was covered with a thick peel of empyema.\nSix months after removal of the Gore-Tex patch, we screened for any cancer recurrence and decided to perform a Clagett procedure. As a first step, a widening of the window was performed to create enough space for the irrigation and debridement to follow. A vacuum-assisted closure (VAC) device was applied at postoperative day 1, and VAC sponge change was repeated at postoperative day 6, 9, and 12 (). Finally, the Clagett procedure completed by filling the pleural space with antibiotic solution at postoperative day 14 and the patient was discharged without complications ().\nFor a 1-year period of outpatient follow-up, the cavity was fully filled with pleural effusion, and there was no recurrence of empyema or lung cancer.