Cut Chest Tube Offers Less Invasive Alternative to Fenestration in Two Empyema Cases

In a case report published in General Thoracic and Cardiovascular Surgery Cases, the team converted ordinary chest drainage tubes into long-term open drainage channels by simply cutting them short, avoiding the rib-resecting operation known as fenestration in both patients.

Postoperative empyema, an infection that fills the pleural space after lung resection, becomes especially difficult when it is accompanied by a persistent air leak, often caused by a bronchopleural fistula. Standard management demands adequate drainage, control of infection and closure of the leak. When these measures fail, fenestration, frequently combined with thoracoplasty or muscle-flap transposition, remains the established definitive treatment. But that operation requires resecting ribs and marsupializing the cavity into an open window, commits patients to prolonged wound care, and carries substantial morbidity for people with poor respiratory reserve or severe comorbidities.

The report, authored by Hidetoshi Inoue, Nobuhiro Izumi, Kazuya Kishimoto and colleagues, presents two men treated at the authors’ institution. The first was a 72-year-old man with idiopathic pulmonary fibrosis who developed a left pneumothorax during steroid treatment. After four pleurodesis attempts over 24 days failed, he underwent thoracoscopic bullectomy, but on postoperative day 5 he developed a new pneumothorax with fluid accumulation and aspiration pneumonia in the right lung. Aspergillus fumigatus was isolated from the pleural fluid, and treatment with tazobactam, piperacillin and voriconazole began. A right-sided pneumothorax followed on day 6.

Given his high operative risk from the fibrosis, the pneumonia and the contralateral pneumothorax, the team avoided radical surgery for the left empyema. Bronchoscopy showed no visible bronchial fistula, and a balloon occlusion test localized the leak to the left B6 segment. Because CT showed no bronchus communicating directly with the empyema cavity, the leak was judged to arise from peripheral lung rather than a bronchial fistula. To prevent aspiration of infected fluid into the lungs, the segment was occluded with an endobronchial Watanabe spigot. The fever resolved, inflammatory markers fell, and drainage dropped to roughly 20 milliliters per day, though air leak persisted.

With the cavity localized and stable, the catheter was cut and shortened on postoperative day 23 to create open drainage, which the authors define as atmospheric drainage achieved by cutting the tube without surgical fenestration. When CT on day 48 showed no cavity reduction, the team exchanged the catheter for a larger Portex nasopharyngeal airway tube with a 7.0-millimeter internal diameter, inserted under local anesthesia through a reopened incision with the length predetermined from CT. The patient went home on day 59 on oral voriconazole. By day 120 no leak was audible on coughing and CT showed the cavity replaced by granulation tissue. Drainage and antifungal therapy stopped on day 150 after fungal cultures turned negative and serum beta-D-glucan normalized. The wound closed spontaneously within about three weeks, and there was no recurrence two years after surgery.

The second patient, a 71-year-old man with stage IIIB squamous cell lung carcinoma, underwent left lower lobectomy with lingulectomy and bronchoplasty. A small air leak from the intersegmental plane persisted despite intraoperative repair, and early bronchoscopy confirmed an intact bronchial anastomosis. Pleurodesis with 50 percent glucose was performed on day 7 and the chest tube was removed on day 12, but on day 14 inflammation worsened with aspiration pneumonia in the residual lung. A 20-Fr double-lumen trocar catheter was reinserted into the post-lobectomy dead space; Pseudomonas aeruginosa grew from the pleural fluid on days 14 and 32. After the pneumonia resolved, the tube was upsized to 32 Fr through the reopened wound.

Once the patient was afebrile with a white blood cell count of 9,500 per microliter, a C-reactive protein level of 6.71 milligrams per deciliter, and drainage of roughly 40 milliliters per day, the tube was cut and converted to open drainage on day 32. He was discharged on day 44. By day 90 the discharge had become less viscous, the air leak was judged resolved, and CT showed the cavity markedly reduced and filled with granulation tissue. The tube was withdrawn stepwise and removed on day 120, when CT confirmed complete obliteration. The wound again closed spontaneously within about three weeks, and no recurrence occurred during four years of follow-up.

The authors argue that the central clinical question is not whether open drainage can be performed but which patients can safely forgo fenestration. They propose a set of selection criteria: infection judged clinically controlled, defined by absence of fever, normal or near-normal white cell counts, substantially decreased C-reactive protein, falling drainage volume and no radiological progression; low drainage output; a localized, stable cavity; stable expansion of the residual lung; and, critically, confirmation on contrast-enhanced CT that the cavity is anatomically separated from the pulmonary artery and other major hilar vessels. That last condition is mandatory because contact between the cavity and major vessels could cause fatal hemorrhage during tube exchange or shortening. Notably, microbiological clearance was not required before conversion: no culture was repeated in the first case, and the pleural fluid remained culture-positive in the second, because the authors consider open drainage itself a form of source control.

The practical protocol was deliberately simple. Tube exchange was performed under direct vision through the reopened incision rather than blindly, and was needed only once in each patient. Outpatient visits occurred every one to two weeks, with air leakage assessed by listening for an audible leak at the tube orifice during coughing, alongside chest radiography; CT was obtained every few months or once the leak became inaudible. The tube was then withdrawn by about two centimeters every two weeks and removed when no leak was audible and CT showed the cavity filled with granulation tissue. A nasal airway tube can be fixed by its flared proximal end, and a cut chest tube left protruding about five centimeters can be laid flat under gauze or an absorbent pad. If drainage volume increased or inflammation recurred, additional drainage procedures or tube exchange were considered.

The authors are explicit about the limits of the evidence. The report includes only two patients and no comparative data against fenestration, and the proposed criteria derive from limited experience that requires validation in larger series. They therefore state that the technique should not replace standard surgical management including fenestration, but may serve as a less invasive option for carefully selected high-risk patients, and that when criteria are not met, in particular with uncontrolled infection or a cavity abutting major hilar vessels, fenestration remains the treatment of choice and should not be delayed. Within those boundaries, the report offers a concrete, reproducible bedside alternative: a cut tube, a CT-mapped length, scheduled outpatient checks and gradual withdrawal, enough in these two cases to obliterate infected cavities and close persistent leaks without ever opening the chest wall.

Subject of Research: Prolonged open drainage using a cut chest tube as an alternative to fenestration for localized postoperative empyema with persistent air leak

Article Title: 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

Article References: Inoue, H., Izumi, N., Kishimoto, K., Kinoshita, H., Tanimura, T., Suzuki, S., Hara, K., Tsukioka, T., & Soh, J. (2026). 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. General Thoracic and Cardiovascular Surgery Cases, 5(1), Article 50. https://doi.org/10.1186/s44215-026-00286-x

Image Credits: AI Generated

DOI: 10.1186/s44215-026-00286-x

Keywords: postoperative empyema, persistent air leak, bronchopleural fistula, fenestration, open drainage, chest tube, lung surgery, case report, thoracic surgery, granulation tissue, selection criteria, less