Is Definitive Closure Always Needed After Open-Window Thoracotomy for Post-Lung Resection Empyema?

INTRODUCTION: Open-window thoracostomy is a recognized treatment for postresection empyema, especially when complicated by bronchopleural fistula (BPF). However, the necessity of definitive closure surgery remains unclear. METHODS: We retrospectively analyzed 24 patients who developed empyema after anatomical lung resection and underwent open-window thoracostomy at our institution between April 2010 and March 2024. We evaluated factors associated with spontaneous closure of BPF and the empyema cavity, as well as the clinical indications for definitive surgical closure. RESULTS: BPF was present in 17 of the 24 patients (71%). Among them, 10 experienced spontaneous fistula closure, while two required surgical closure. Smaller fistula size (<5 mm) was significantly associated with spontaneous closure, whereas the absence of contralateral aspiration pneumonia showed a trend toward spontaneous closure but did not reach statistical significance. Definitive closure of the empyema cavity was performed in 11 patients and was more common in those with higher body mass index and a better general condition. Of the 13 patients who did not undergo definitive closure, the cavity closed spontaneously in five. Notably, negative-pressure wound therapy was significantly associated with spontaneous cavity closure (80% versus 12.5%, P = 0.032). Patients who had undergone pneumonectomy failed to achieve cavity closure within 2 y, whereas 87.5% of those who had undergone lesser resections did. CONCLUSIONS: Spontaneous closure of BPF and the empyema cavity is possible, particularly in patients with small fistulas and no history of pneumonectomy. Negative-pressure wound therapy appears beneficial in promoting spontaneous healing, supporting a tailored, patient-specific approach to managing postresection empyema.