Predictors of successful closure following open-window thoracostomy in patients with empyema: A single-center retrospective cohort study

Background: Open-window thoracostomy (OWT) is an effective life-saving treatment for refractory empyema. Nonetheless, the patients’ mental and physical suffering due to OWT is not minimal, and open-window closure is desirable if infection control is possible. When planning a treatment strategy after OWT, it is important to predict whether open-window closure is possible before OWT. This study aimed to identify factors related to open-window closure based on patient background factors before OWT.

Methods: This observational retrospective cohort study included 42 patients with empyema who underwent OWT at a single institution over a 10-year period from April 2011 to March 2021. Cases in which closure was possible (closure group) were directly compared with cases in which closure was not possible (non-closure group). To identify the factors affecting closure, a logistic regression analysis was conducted to explore the patient background factors immediately before OWT.

Results: Closure was possible in 20 patients (closure group) but was not in 22 patients (non-closure group). The closure methods employed for closure were omentum filling in 11 patients, muscle flap filling in 6 patients, breast tissue filling in 1 patient, spontaneous closure in 3 patients, and vacuum-assisted closure (VAC) in 2 patients. The median duration of the open window in the closed-window group was 242 days (35–1,880 days). The strong factors influencing window closure were “no malignant tumor” [odds ratio (OR): 2.68, 95% confidence interval (CI): 0.77–9.38, P=0.12], “no fistula” (OR: 3.41, 95% CI: 0.74–15.68, P=0.12), “age <70 years” (OR: 2.8, 95% CI: 0.78–9.99, P=0.11)”, and “hemoglobin (Hb) level ≥9.0 g/dL” (OR: 2.77, 95% CI: 0.69–11.08, P=0.15),” with a significant difference observed for “performance status (PS) 0/1” (OR: 7.0, 95% CI: 1.729–28.336, P=0.006).

Conclusions: The PS before OWT is an important factor that affects open-window closure. By preoperatively informing patients with poor PS regarding the possibility of the window not being closed after surgery, we believe that patients and their families will be able to make the necessary adjustments and informed decisions.

Keywords: Open-window thoracostomy (OWT); empyema; closure; performance status (PS)

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Key findings

• The performance status (PS) before open-window thoracostomy (OTW) is an important factor affecting window closure.

What is known and what is new?

• OWT is an effective treatment for refractory empyema, aiming to save lives.

• When planning a treatment strategy after OWT, it is important to predict whether open-window closure is possible; this study revealed that the PS before OWT is an important factor affecting window closure.

What is the implication, and what should change now?

• We believe that informing patients preoperatively about the possibility that the window may not close after surgery will help them and their families be prepared for the challenges that follow such an occurrence.