Overview
Definition:
The Eloesser window, also known as an empyema window, is a surgical procedure creating a fenestration in the chest wall, typically involving rib resection and creating a skin flap, to allow continuous drainage of a chronic empyema
It aims to obliterate the pleural space by promoting granulation tissue formation and lung expansion against the chest wall
This technique is reserved for complex, chronic, or loculated empyemas where less invasive methods have failed or are not feasible, often following previous thoracotomies or when lung resection is contraindicated.
Epidemiology:
Chronic empyema is a significant complication of bacterial pneumonia and may occur in 1-5% of pneumonia cases, with chronic forms developing in a subset of these
Risk factors include underlying lung disease, immunocompromise, poor initial management of pleural infection, and prolonged antibiotic therapy
Eloesser windows are indicated in a small percentage of these chronic cases, typically after failure of conventional management such as chest tube drainage or decortication.
Clinical Significance:
Empyema window surgery is a salvage procedure for patients with refractory chronic empyema
It allows for sustained drainage and eventual obliteration of the pleural space, preventing sepsis and improving patient quality of life
Understanding its indications, surgical technique, and potential complications is crucial for surgical residents preparing for DNB and NEET SS examinations, as it represents a management option for a challenging thoracic surgical problem.
Indications
Primary Indications:
Failure of conventional therapy for chronic empyema
Persistent, large pleural space not amenable to obliteration by decortication
Loculated empyema with multiple persistent fluid collections
Bronchopleural fistula with a persistent pleural space infection
Contraindications to extensive lung resection or more complex thoracic procedures.
Patient Selection Criteria:
Patients must have a stable general condition with adequate pulmonary reserve to tolerate the procedure and subsequent healing
Absence of active sepsis or a large, uncontrolled bronchopleural fistula that would preclude effective drainage
Absence of extensive chest wall or mediastinal involvement that would preclude adequate closure
The patient should be medically fit for a prolonged healing period.
Contraindications:
Active widespread sepsis or hemodynamic instability
Large bronchopleural fistula with significant air leak
Extensive chest wall invasion by malignancy or infection
Inability to tolerate prolonged immobility and wound care
Young children where alternative methods may be preferred
Severe pulmonary hypertension or right heart failure.
Preoperative Preparation
Diagnostic Workup:
Thorough history and physical examination
Chest X-ray and CT scan of the thorax to delineate the extent of empyema, loculations, and identify any bronchopleural fistula
Bronchoscopy may be required to assess for underlying pathology or fistula
Laboratory investigations including CBC, electrolytes, renal and liver function tests, and blood cultures.
Medical Optimization:
Empirical broad-spectrum antibiotics covering common pathogens, adjusted based on Gram stain and culture results
Nutritional support to optimize healing
Management of comorbidities such as diabetes, COPD, or cardiac disease
Pre-operative physiotherapy to improve respiratory function.
Surgical Planning:
Detailed pre-operative imaging review
Discussion of surgical approach and potential complications
Consent for the procedure, including possibility of requiring further intervention
Anesthesia consultation to assess fitness for surgery and peri-operative management
Pre-operative chest physiotherapy and mobilization exercises.
Procedure Steps
Anesthesia And Positioning:
General anesthesia with double-lumen endotracheal tube for single lung ventilation
Patient positioned in lateral decubitus position, affected side up
Surgical site is prepped and draped.
Initial Thoracostomy And Drainage:
A formal thoracostomy is performed, usually through a large incision, to allow access to the pleural space
The purulent material is drained, and the pleural cavity is irrigated
The extent of the empyema and any loculations are assessed.
Rib Resection And Window Creation:
A segment of one or more ribs (typically 3-5 cm) is resected, often over the largest loculation or deepest part of the empyema
This creates a bony defect
The intercostal muscles and pleura are incised.
Skin Flap Creation And Placement:
A skin flap is raised, usually from the surrounding intercostal tissues, and is tunneled through the intercostal muscles to lie directly over the pleural cavity defect
This flap is then sutured to the edges of the pleural defect, creating a direct communication between the skin and the pleural space.
Drainage And Closure:
A large-bore drainage tube (e.g., Foley catheter or chest tube) is secured within the fenestration to ensure continuous dependent drainage
The remaining chest wall incision is closed over this
The skin flap is carefully positioned to facilitate granulation and healing.
Postoperative Care
Drainage Management:
The indwelling drain is crucial for continuous drainage of pus and serosanguinous fluid
Daily irrigation of the window may be performed
The drain is usually clamped and removed when drainage becomes minimal and serosanguinous, typically after several weeks or months.
Antibiotic Therapy:
Intravenous antibiotics are continued, guided by culture and sensitivity results, and then transitioned to oral therapy
The duration of antibiotic therapy is often prolonged, sometimes for many months, until complete healing and obliteration of the pleural space occur.
Wound Care And Monitoring:
Regular dressing changes to the empyema window are essential to prevent secondary infection
Monitoring for signs of systemic infection (fever, elevated white blood cell count) or local complications such as flap necrosis or dehiscence
Pain management is critical.
Physiotherapy And Mobilization:
Early mobilization and ambulation are encouraged to prevent complications like deep vein thrombosis and pneumonia
Chest physiotherapy, including breathing exercises and incentive spirometry, is vital to promote lung expansion and prevent atelectasis
Gradual increase in physical activity as tolerated.
Complications
Early Complications:
Hemorrhage from the chest wall or pleura
Wound infection
Skin flap necrosis or dehiscence
Persistent bronchopleural fistula
Pneumothorax
Recurrence of empyema due to inadequate drainage or closure.
Late Complications:
Chronic draining sinus tract
Granulation tissue overgrowth
Chronic chest wall pain
Respiratory compromise due to persistent pleural thickening or lung entrapment
Recurrence of empyema
Formation of a bronchopleural cutaneous fistula
Thoracic cage deformity.
Prevention Strategies:
Meticulous surgical technique, including adequate rib resection, proper flap design and vascularity, and secure drainage
Aggressive antibiotic therapy
Rigorous wound care and drain management
Close monitoring for early signs of complications
Adequate nutritional support
Patient education on wound care and activity.
Prognosis
Factors Affecting Prognosis:
The success of the Eloesser window is highly dependent on the duration and severity of the empyema, the presence of underlying lung disease, the patient's general health status, the absence of bronchopleural fistula, and the adherence to post-operative care
Prompt and adequate drainage, effective antibiotic therapy, and complete pleural space obliteration are key prognostic factors.
Outcomes:
In selected patients, the Eloesser window can lead to resolution of the chronic empyema, cessation of drainage, and eventual obliteration of the pleural space
However, it is a procedure with a high complication rate and often requires prolonged management
Some patients may still require further surgical intervention, such as decortication or even lung resection, if the window fails to achieve obliteration.
Follow Up:
Long-term follow-up is essential, often for many months or even years, until complete healing and resolution of the empyema are confirmed
Follow-up typically involves regular clinical assessments, wound checks, and sometimes imaging studies to monitor the pleural space and ensure no recurrence
Patients are educated on long-term self-care of the healed window site.
Key Points
Exam Focus:
Eloesser window is a salvage procedure for chronic, refractory empyema
Key steps involve rib resection, skin flap creation, and creation of a direct drainage pathway from skin to pleural space
Indicated after failure of less invasive methods
Complications include flap necrosis, chronic drainage, and recurrence
Requires prolonged antibiotic therapy and meticulous wound care.
Clinical Pearls:
Ensure adequate rib resection to prevent early closure of the fenestration
The skin flap must be well-vascularized and adequately sized
A large-bore catheter (e.g., Foley catheter) is typically used for drainage
Maintain dependent drainage at all times
Consider irrigation of the window under sterile conditions if drainage is sluggish
Prolonged antibiotics are the norm, often for months.
Common Mistakes:
Inadequate rib resection leading to premature closure
Poorly designed or avascular skin flap resulting in necrosis
Not securing adequate drainage with a properly sized catheter
Premature removal of the drainage catheter
Insufficient duration of antibiotic therapy
Failure to monitor for and manage complications like secondary infection or fistula recurrence.