Multidisciplinary treatment of thoracic fistulous empyema caused by pulmonary infection: a retrospective study

Background: In cases of thoracic empyema, the presence of a fistula is known to be difficult to treat and associated with a poor prognosis. Few reports have described the management of fistulous empyema caused by lung parenchymal infection. The aim of this study was to describe the outcomes of multidisciplinary management of fistulous empyema caused by pneumonia or lung abscess due to common bacteria and mycobacteria. Methods: Among 108 cases of empyema surgically treated at Kanagawa Hospital over a 10-year period, 14 patients with fistulous empyema due to common bacteria (CBFE) or fistulous empyema due to mycobacteria (MFE) were analyzed. Fistulous empyema due to lung resection was excluded. Results: Eight out of the 9 patients with CBFE and 4 out of the 5 patients with MFE were male. Patients with CBFE were more likely to be >65 years of age (p=0.052) and to have a poor performance status (p=0.078). The time from onset to first surgical treatment was significantly longer in MFE (median, 5 months; p=0.004). Five patients with CBFE and two patients with MFE underwent open window thoracostomy, while three patients with CBFE and four patients with MFE underwent endobronchial occlusion (EBO). Six patients (66%) with CBFE and 3 patients (60%) with MFE achieved fistula closure. Of the patients who underwent EBO, fistula closure was achieved in 3 (100%) of the patients with CBFE and in 2 (50%) of the patients with MFE. Fistula closure was not achieved in any case with non-tuberculous mycobacteria. Conclusions: Fistulous empyema caused by common bacteria or Mycobacterium tuberculosis could be cured by surgical treatment and endobronchial intervention with adequate antimicrobial therapy, but fistulous empyema caused by non-tuberculous mycobacteria proved to be intractable. The challenge in the treatment of fistulous empyema due to non-tuberculous mycobacteria is the achievement of bacterial negativity.