What is a Clagett window (open‑window thoracostomy) and when is it indicated?

Clagett Window (Open-Window Thoracostomy)

Definition and Procedure

A Clagett window is a surgical procedure that creates an open thoracostomy (window in the chest wall) to provide continuous drainage and access to an infected pleural space, most commonly used for refractory empyema, particularly after pneumonectomy. 1

The procedure involves:

• Resection of 2-3 ribs (typically 8-10 cm in length) at the most expanded position of the empyema
• Creating a window approximately 5 cm in diameter
• Suturing the skin edge to the empyema wall to create a permanent opening
• Allowing for serial debridement, frequent packing changes (1-2 times daily), and irrigation of the infected space 1, 2

Primary Indications

The creation of an open thoracostomy window is indicated for:

Postpneumonectomy Empyema

• Most common indication, occurring in 5% of standard pneumonectomies and 10% of completion pneumonectomies
• Over 80% of postpneumonectomy empyemas have an associated bronchopleural fistula (BPF)
• Mortality rates of 28-50% make this a serious complication requiring aggressive management 1

Failed Medical Management

• Empyema not responding to chest tube drainage and antibiotics
• Persistent or recurrent infection despite optimal medical therapy including intrapleural TPA/DNase 3, 4

Specific Patient Populations

Open window thoracostomy is particularly appropriate for: 1

• Patients with recurrent or persistent BPF who are medically unfit for another operation (Class IIa recommendation)
• Patients with recurrent cancer
• Complex empyema from pulmonary resection, cancer, or infection unmanageable by conservative strategies 5

Clinical Algorithm for Management

Initial Assessment

When postpneumonectomy empyema is suspected, immediately perform flexible bronchoscopy with the patient semi-upright under local anesthesia to identify or rule out BPF 1. If BPF is present with respiratory distress:

• Position patient lateral decubitus with pneumonectomy side down
• Emergency chest tube drainage to control infection and prevent contralateral spillage

Staged Approach (Modified Clagett Procedure)

Stage 1: Open Window Creation and Debridement

• Create thoracostomy window as described above
• Serial operative debridements
• Frequent wet-to-dry dressing changes (1-2 times daily)
• Continue until the thorax is clean and granulation tissue forms 1

Stage 2: Closure (When Appropriate) After infection control is achieved, closure options include:

• Primary closure with antibiotic solution filling the cavity (Class IIb recommendation - if patient is medically fit) 1
• Vascularized tissue transposition (muscle flap or omental pedicle) - success rate 75% 1
• Permanent open window - acceptable for patients unfit for closure or with recurrent cancer 1

Critical Management Points

BPF Management

If BPF is present, attempt closure at the time of empyema debridement with:

• Careful identification of bronchial stump (use saline fill with ventilation to identify air bubbles)
• Minimal trauma to bronchus
• Preservation of blood supply
• Vascularized muscle flap reinforcement (used in 60 patients in one series with 81% success) 1

Timing Considerations

• Median time from initial diagnosis to OWT: 70 days (range 1-720 days) 5
• Median duration of open window before closure: 242 days (range 35-1,880 days) 6
• Immediate creation of thoracostomy window after empyema identification correlates with successful eventual closure 1

Outcomes and Prognosis

Infection Control

• Infection controlled in nearly all patients (92%) 5
• Success rate for closure without BPF: 85% (postpneumonectomy) 4
• Success rate for closure with BPF: 36-57% depending on underlying pathology 4

Survival

Patient survival rates after OWT: 5

• 1 month: 94%
• 6 months: 82%
• 1 year: 74%
• 5 years: 60%
• In-hospital mortality: 6.4%

Predictors of Successful Closure

Factors favoring successful window closure include: 6

• Performance status 0/1 (OR: 7.0, P=0.006) - most significant predictor
• Age <70 years (OR: 2.8)
• Hemoglobin ≥9.0 g/dL (OR: 2.77)
• Absence of malignant tumor (OR: 2.68)
• Absence of fistula (OR: 3.41)

Closure Rates

• Only 19% of patients undergo surgical closure 5
• 2.6% experience spontaneous closure 5
• Modified techniques may achieve higher spontaneous closure rates 7

Common Pitfalls

Avoid these critical errors:

• Delaying bronchoscopy to assess for BPF in suspected postpneumonectomy empyema
• Inadequate window size preventing proper drainage and access for packing
• Attempting closure before adequate granulation tissue formation
• Failing to reinforce bronchial stump closure with vascularized tissue when BPF is present
• Not counseling patients with poor performance status about the high likelihood of permanent open window 6