Surgical Management of Recurrent MRSA Empyema with Eloesser Flap in a Complex Thoracic Patient: Lessons from Endobronchial Valve Failure

Background: Chronic empyema with bronchopleural fistula represents a challenging complication in thoracic surgery. We present a case of recurrent methicillin-resistant Staphylococcus aureus (MRSA) empyema due to persistent bronchopleural fistula successfully managed with an Eloesser flap following documented failure of endobronchial valve therapy. Case presentation: A 74-year-old male with a history of left-sided radiation for non-small cell lung cancer, right lower lobectomy, post-operative bronchopleural fistula, and recurrent MRSA empyema presented with worsening respiratory symptoms despite previous interventions including endobronchial valve placement. Direct intraoperative visualization during Eloesser flap creation revealed displacement of both previously placed endobronchial valves, providing unique insights into a specific mechanism of valve failure in chronic empyema. Conclusions: This case demonstrates critical limitations of endobronchial valve therapy in the setting of chronic infection and highlights the continued relevance of the Eloesser flap in modern thoracic surgical practice when newer technologies fail and specifically as a potential salvage procedure.