Reply to Krueger et al.

We thank Krueger et al. for their interest in our paper [1, 2]. The Lausanne group uses the Pairolero’s modification of the Clagett’s procedure [3, 4]—only with vacuum assisted closure VAC in lieu of repeated dressing changes [3]. In the past, we have used and still use this time-honoured approach for critically ill patients. However, we wanted to verify the possibility of managing stable (i.e. >1 month after primary surgery) post-pneumonectomy patients in an outpatient setting, and we opted for the openwindow thoracostomy (OWT) as per our previous experience published in 2006 [5]. Contrary to Dr Krueger’s interpretation, we did not suggest OWT and vacuum assisted closure (VAC) in an outpatient setting for the ‘critically ill’ [3]. In addition, in the Lausanne group’s series, there were only eight post-resectional empyemas [3]. Of these, only two occurred after primary pneumonectomy performed for mesothelioma and extended thymoma [3]. We suspect that applying VAC after primary pneumonectomy may be different from using VAC for somewhat smaller, contained, chronic areas of infection [5]. As to the OWT issue, contrary to Dr Krueger’s interpretation, OWT is obtained by refashioning the original thoracotomy without the need for additional incisions and repeated general anaesthesia [5]. If a broncho-pleural fistula (BPF) is identified, it is sutured and reinforced with a muscle flap [5]. In fact, we were successful in 1 patient despite several techniques used for bronchial closure (Table 1) [2]. The closure of the thoracostomy is done by an approximation of the myocutaneous edges after obliteration by granulation tissue and Clagett solution or additional intrathoracic viable tissue transposition [5]. Accordingly, to include, among the advantages of VAC therapy via thoracotomy, the ‘preserved integrity of the chest wall’ is at least questionable. We do not think that VAC should not be considered an alternative to OWT [5]. We believe that OWT is, rather, an alternative approach to redo thoracotomy under general anaesthesia [5]. Possibly, both could be considered in different stages of the management of postpneumonectomy empyema (PPE). Nevertheless, VAC can be used through the OWT despite the adverse effects observed in our patients [2]. We feel that soaking the foams with local anaesthetic, avoidance of the vagus nerve and the interposition of gauzes on the mediastinum may easily improve our learning curve [3]. Similarly to our experience, the lack of exposure upon removal or the application of the VAC foam directly on the mammary vein may have caused a similar incident in the series from Lausanne [2, 3]. In conclusion, we think that two different categories of patients and two—not necessarily alternative— approaches are compared to manage PPE [2, 3]. In fact, OWT and VAC can speed up recovery in stable pneumonectomy patients, thus avoiding psychologically burdensome and costly prolonged hospitalizations. However, the jury is still out as to the role of VAC in the closure of BPF. Conversely, for critically ill PPE patients whose condition obviously mandates a high level of care, the use of VAC instead of repeated dressing changes via the Pairolero-Clagett’s procedure may be a reasonable alternative to accelerated treatment of PPE [6].