Introduction: The Clagett procedure was developed in the 1960s for treating postpneumonectomy empyemas and/or bronchopleural fistulas. It is a two part procedure; first forming a window for instilling and draining antibiotics of an infected space and later closure of the window after treatment concludes. In our patient, a modified Clagett was performed as a treatment modality for a patient with a chronic bronchopleural and pleurocutaneous fistula after a severe Covid-19 infection.
Description: The patient is a 57 y/o male who was admitted to the ICU with Covid-19 pneumonia and ARDS. He was intubated shortly after admission and his stay was complicated by severe hypotension and acute renal failure, ultimately requiring tracheostomy, PEG tube placement, and dialysis. On day 28 of his admission, the patient developed a right spontaneous tension pneumothorax requiring multiple chest tubes. There was a persistent air leak preventing the removal of one chest tube and the patient gradually developed severe subcutaneous emphysema. The air leak and the subcutaneous emphysema worsened over the next two weeks, now including the face and extremities. A repeat CT of the chest showed a new right pleurocutaneous and bronchopleural fistula. He underwent a thoracotomy with multiple wedge resection however innumerous bronchopleural fistulas were noted and the surgery was unsuccessful. At this time the patient was briefly transferred to an academic center where two endobronchial valves were placed without success. Hospice was advised however the patient wished to continue pursuing aggressive measures. It was decided to attempt a modified Clagett thoracotomy. Three months after admission the patient underwent removal of the right 4th and 5th ribs and formation of an open window thoracostomy. The patient did extremely well post-operatively. He was discharged to rehab and over the next year he was weaned room air.
Discussion: There was discussion regarding performing an Eloesser flap however our patient remains a transplant candidate and this would likely prohibit his candidacy. There has been considerable granulation of the thoracostomy window over the last year, as is expected, however a persistent small bronchopleural fistula remains. Discussions are currently underway regarding flap closure of the window.
