Role of thoracostomy in the management of postoperative empyema following lung resection: a narrative review of surgical strategies, evolving techniques, and outcomes.

Background and Objective: Postoperative pleural empyema and bronchopleural fistula (BPF) remain devastating complications of anatomical lung resections, especially pneumonectomy. Open management of the residual pleural cavity via thoracostomy is a cornerstone of source control. Unlike prior reviews that discuss open window thoracostomy (OWT) mainly as salvage drainage, this work conceptualizes it as a structured staged strategy: source control, fistula management, physiologic optimization, and definitive reconstruction or planned permanent drainage. This review synthesizes current evidence on OWT as a staged intervention for post-resection empyema, integrating institutional and global literature. Methods: A narrative literature review searched PubMed, Cochrane Library, E-library and Google Scholar from 1983 to 2025 using the search terms "open window thoracostomy", "Clagett procedure", "postpneumonectomy empyema", "bronchopleural fistula", "chest wall reconstruction", "thoracoplasty", "intrathoracic vacuum therapy", "muscle flap thoracostomy". Thirty-four sources were selected for relevance to surgical management, reconstructive strategies, and outcomes. Key Content and Findings: Post-resection empyema is reported in 1-3% of anatomical lung resections, with mortality of 20-78% when complicated by BPF. OWT is an effective initial step, providing drainage and infection control. The procedure has moderate operative time and limited blood loss, making it applicable across a broad spectrum of severity. Pseudomonas aeruginosa predominates in postoperative empyema, underscoring the need for empiric anti-pseudomonal coverage. Open management duration varies considerably, governed not only by infection resolution but also by nutritional status, sarcopenia, and availability of adequate reconstructive tissue. Definitive closure of the thoracostomy window, achieved in a variable proportion of patients, often requires complex reconstruction with pedicled muscle flaps or omentum. Emerging adjuncts such as intrathoracic vacuum-assisted closure (VAC) and modified minimally invasive techniques show promise in expediting cavity sterilization and closure. Conclusions: OWT remains an effective, relatively safe index procedure for staged management of post-resection pleural empyema, particularly with BPF. Available evidence is heterogeneous and largely retrospective; no single technique is universally superior. Successful definitive closure depends on meticulous infection control, patient optimization, and well-vascularized reconstructive tissue. For patients with prohibitive comorbidities, OWT may serve as permanent therapy, offering durable stabilization. Future prospective studies with standardized outcomes are needed to move beyond expert opinion toward evidence-based standardization.