Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection

ERS/ESTS statement on the management of pleural infection in adults

Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.

[Surgical treatment of bronchopleural complications after lung resection and pleurectomy in patients with tuberculosis]

OBJECTIVE

To increase an efficiency of surgical treatment of bronchopleural complications after lung resections and pleurectomies through the development of modern indications, treatment strategies, techniques and postoperative management.

MATERIAL AND METHODS

We analyzed data in 252 patients with bronchopleural complications after lung resections and pleurectomies. The study included patients who underwent treatment at the Central Research Institute of Tuberculosis for the period 2004-2010, Clinical Hospital of Phthisiopulmonology of the Sechenov First Moscow State Medical University for the period 2011-2017 and Thoracic Center of the Republic of Ingushetia for the period 2015-2019. The study included patients with postoperative pleural empyema divided into two groups: group I - 138 patients with empyema and bronchial fistula; group II - 114 patients with empyema and no bronchial fistula. In the 1^st group, 1 patient had bronchial and esophageal fistulas.

RESULTS

At discharge, empyema and bronchial fistula were eliminated in 245 (97.2%) patients of both groups. Overall in-hospital mortality was 1.6% (4 cases). Two (1.4%) patients died within 30 days in group I and 1 (0.9%) patient died in group II. Within 90 days after surgery, another patient died from acute cerebrovascular accident in group I. In long-term period, overall effectiveness of treatment of bronchopleural complications was 97.2% (208 out of 214 cases).

CONCLUSION

The original surgical approach for bronchopleural complications considers timing of postoperative empyema, its spread and duration. This method together with minimally invasive interventions reduces mortality and ensures stable recovery after bronchopleural complications in 97.2% of patients.

Is open window thoracostomy the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed: Is open window thoracostomy (OWT) the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer? Altogether 442 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Empyema following anatomical lung resection (excluding pneumonectomy) is an uncommon complication but one that remains a challenge to treat effectively. Chest tube thoracostomy and intravenous antibiotics remain the initial steps to management, but evidence is lacking with regard to the best ongoing strategy. Conservative options including chest cavity irrigation, postural drainage and vacuum-assisted closure have been attempted with some success, even in the presence of a broncho-pleural fistula. However, the very limited number of patients on which these various management strategies have been trialled on prevents recommendations and clear guidance being given.

Negative pressure wound therapy for broncho-pleural fistula with collapsed lung

We present a case of the broncho-pleural fistula with a collapsed lung that was developed 2 weeks after right lower lobectomy. The patient urgently underwent open-window thoracostomy. However, the residual lung remained collapsed. To expand the lung and close the broncho-pleural fistula, negative pressure wound therapy was initiated 20 days after the procedure. The lung expanded within a few days, and the residual thoracic cavity gradually contracted. Subsequently, 2.5 months later, the remaining thoracic cavity was successfully closed using omentoplasty. No recurrence of the broncho-pleural fistula was observed for 1 year. If the lung could be inflated to reduce dead space in the thoracic cavity, broncho-pleural fistula with collapsed lung may be treated with bronchial stump coverage and negative pressure wound therapy.

Management of Complications After Lung Resection: Prolonged Air Leak and Bronchopleural Fistula

Prolonged air leak or alveolar-pleural fistula is common after lung resection and can usually be managed with continued pleural drainage until resolution. Further management options include blood patch administration, chemical pleurodesis, and 1-way endobronchial valve placement. Bronchopleural fistula is rare but is associated with high mortality, often caused by development of concomitant empyema. Bronchopleural fistula should be confirmed with bronchoscopy, which may allow bronchoscopic intervention; however, transthoracic stump revision or window thoracostomy may be required.

[Use of pedicled dorsal muscle flap combined with negative pressure therapy in the management of postpneumonectomy septic complications]

SUBJECT

The objective of this study is to report our experience in the management of septic complications arising from pulmonary resection surgery by placing a pedicled upper back muscle flap associated with dressings by therapy. Negative pressure in all patients supported in our center from November 2015 to March 2018.

MATERIAL AND METHODS

Characteristics of fourteen patients with a pedicled dorsal muscle flap in the context of chronic empyema associated with bronchopulmonary fistula were identified. Flap placement time, complications, and success rate were assessed.

RESULTS

The median flap placement after completion of the open window thoracostomy was 19days [3-65]. The median healing time was 3months. Healing was definitively achieved in 12 patients, a success rate of 86%.

CONCLUSION

Through this series we have shown that our coverage by pneumonectomy cavity coverage with an early dorsal muscle flap associated with negative pressure therapy, has a similar mortality rate and success rate to those found in the literature.

Simple chest closure of open window thoracostomy for postpneumonectomy empyema: a case report

BACKGROUND

Management of postpneumonectomy empyema requires comprehensive strategies, especially when the condition is associated with large bronchopleural fistulae. We report a case involving the simple chest closure of open window thoracostomy with remaining residual space.

CASE PRESENTATION

We performed open window thoracostomy for empyema with a huge bronchial stump dehiscence after right pneumonectomy for a large lung cancer. We definitively closed the chest window infected with chronic persistent Pseudomonas aeruginosa via a simple chest closure technique with the remaining residual space, after repairing the bronchial dehiscence using an omental flap and the appearance of healthy granulation tissue throughout the cavity. The patient died of recurrent cancer 10 months after the definitive chest closure. Until the patient died, there were no symptoms or signs suggestive of recurrent empyema.

CONCLUSION

This simple chest closure technique allows "silent empyema" to be observed carefully, is less invasive, and can even be applied to cases of recurrent cancer.

Management of Postpneumonectomy Bronchopleural Fistula: From Thoracoplasty to Transsternal Closure

Development of postpneumonectomy empyema with bronchopleural fistula is a life-threatening condition that requires prompt action. Although measures should be taken to prevent bronchopleural fistula at time of pneumonectomy, many patients experience this complication. Management focuses on drainage of the pleural space, control of the pleural infection including repair of the bronchopleural fistula, and obliteration of the residual pleural cavity. Multiple techniques and procedures have been developed over time to achieve these goals. Knowledge of the diverse therapeutic options is important to select the optimal treatment for these complex patients.

Pleural Empyema Menagement: A Brief Review of Litterature

Pleural empyema, defined as the presence of purulent material within the pleural space, is the consequence of a suppurative process involving the serous pleural layers. Thoracic empyema is a dynamic process, inflammatory in origin and taking place within a preformed space bordered by both the visceral and parietal pleura. It is a complex clinical entity, neither a sole clinical, laboratory, nor a radiological diagnosis. The primary therapeutic aim: ‘ubi pus evacua’ — if you find pus remove it—has not changed since the age of Celsus. Therefore, treatment of the acute empyema of the pleura is directed to early and complete evacuation of empirical fluid and content, achieving full re-expansion of the lungs and eradication of the infection using appropriate surgical procedures, antibiotics and other supportive procedures. The optimum method of treating empyema should be adjusted to the condition of the patient and the stage of the disease in which the patient is located. The method of treatment depends on the etiology (pneumonic or traumatic), the general condition of the patient and the stage of disease development. By reviewing the available literature, it can be concluded that treating the pleural empyemas is a demanding procedure, in which it is necessary for the treating physician to apply all of his knowledge, and that there is good cooperation with the patient.

Bronchopleural Fistula After Pneumonectomy: Risk Factors and Management, Focusing on Open-Window Thoracostomy

We evaluated principal risk factors and different therapeutic approaches for post-pneumonectomy bronchopleural fistula (BPF), focusing on open-window thoracostomy (OWT). We retrospectively reviewed all patients treated by pneumonectomy for lung cancer from 1999 to 2014; we evaluated preoperative, operative, and postoperative data; time between operation; and fistula formation, size, treatment, and predicting factors of BPF. Cumulative incidence curves for the development of BPF were drawn according to the Kaplan-Meier method. Differences between groups were assessed with the log rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent risk factors for BPF. P values <0.05 were considered significant. BPF occurred in 60 of 733 patients (8.2%). Bronchial suture with Stapler (EndoGia) (P = 0.02), right side (P = 0.003), and low preoperative albumin levels (< 3.5 g/dL) (P = 0.02) were independent predicting factors of fistula. Early BPF was treated by thoracotomic (12) or thoracoscopic (2) debridement of necrotic tissue and BPF surgical repair. Late BPF was treated by bronchoscopic application of fibrin glue (3) or endobronchial stent (1), chest tube and cavity irrigation by povidone-iodine (15). OWT was performed in 27 patients, followed by muscle flap interposition in 7 of these 27. The survival time of patients after the treatment of BPF was 29.0 months. The overall survival of patients treated by OWT was 50% at 2 years and 27 (8%) at 4 years. Correct management of BPF depends on several factors. In case of failure of different initial therapeutic approaches, we could consider OWT, followed by myoplasty.

WITHDRAWN: Bronchopleural fistula after pneumonectomy: Risk factors and management, focusing on open window thoracostomy

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The role of BioGlue in thoracic surgery: a systematic review

BACKGROUND

BioGlue is a commonly used sealant in thoracic surgery. Prolonged air leak and presence of bronchopleural fistulae (BPF) are often encountered in clinical practice. We therefore, investigated the role and the efficacy of BioGlue in these scenarios.

METHODS

A systematic review was conducted by searching Medline [1966-2016] and Cochrane Central Register of Controlled Trials (CENTRAL) [1999-2016] along with reference lists of the included studies. Included studies reported on thoracic surgery operations and use of BioGlue in thoracic surgical procedures, whereas excluded studies met at least one of the following criteria: non-English language studies, non-human population, studies on surgical specialties other than Thoracic surgery, reviews and meta-analyses and sealants other than BioGlue.

RESULTS

Twelve studies with a total number of 194 patients were included. Amongst them, 178 were treated for alveolar air leaks (AAL), 14 for BPF and 2 for lymphatic leaks. BioGlue was utilized at the time of initial operation in 172 (96.7%) patients for AAL, while at secondary intervention in 13 (92.9%) for BPF and 1 (50%) for lymphatic leak. In terms of AAL, only 2 out of 4 studies showed statistically significant reduction in duration of air leak, duration of intercostal drainage and length of stay (LOS) when BioGlue was applied. No complications were encountered after using BioGlue in sealing BPF, apart from the re-application of BioGlue in 3 cases.

CONCLUSIONS

Although BioGlue has been shown to be efficient in treating AAL, it should be used with caution against BPF, despite encouraging preliminary results. Potential adverse effects must always be taken into consideration. Future randomized controlled trials are warranted in an attempt to establish its benefit in current clinical practice.

[What place for the thoracostomy-thoracmyoplasty in the management of the chronic pleural empyema?]

INTRODUCTION

The occurrence of empyema after pneumonectomy or in suites with chronic pleural pocket is a dreaded complication. The management is long and difficult. The authors report their experience before this complication including infection control by an emptying of the pleural pocket percutaneous drainage or thoracostomy which will be complemented by a thoracomyoplasty the aim to erase the pleural pocket.

MATERIALS AND METHODS

This is a retrospective study conducted between 2009 and 2015 concerning the records of 9 patients treated for empyema or in the aftermath of a lung resection or as part of a chronic pleural pocket and calcific.

RESULTS

We had identified all 9 male patients aged 30 to 67 years. This was pyothorax complicating pneumonectomy in 4 patients and 1 pyothorax after a left upper lobectomy in 1 case. For the other 4 patients, there was a post-tuberculous pleural pocket, calcified chronic and whose attempts to decortication seemed impossible. We observed 3 cases of bronchopleural fistula. All patients had received evacuation of the contents of the pleural drainage bag is either thoracostomy laying the bed of a possible filling thoracomyoplasty. The evolution of pleural cavities after thoracostomy was favorable on septic map leading to a retraction of the pleural cavity and its spontaneous closure in 1 patient. In 6 patients, filling the cavity with thoracomyoplasty was necessary. The evolution immediate postoperative was favorable in all patients and no deaths were noted in connection with this technique.

CONCLUSION

Pyothorax on pneumonectomy cavity and chronic pleural calcified pockets are serious complications whose management is long and delicate. The thoracomyoplastie is a real alternative to the filling of the cavity in fragile patients with significant operational risk. The results are satisfactory in the hands of a broken team this technique.

Benefits of using omental pedicle flap over muscle flap for closure of open window thoracotomy

BACKGROUND

Open window thoracotomy (OWT) as well as its closure are challenging. Transposition of omental pedicle and muscle flaps is often performed for OWT closure; however, the better technique among the two is unknown. The purpose of this series was to evaluate the outcomes of using both omental pedicle and muscle flaps for the aforementioned closure.

METHODS

This was an observational retrospective cohort study on 27 consecutive patients who underwent OWT closure at a single institution between January 2005 and December 2014. The operation was performed using either omental pedicle or muscle flap with thoracoplasty. We compared both techniques in terms of the patient background [sex, age, body mass index (BMI) and C-reactive protein (CRP) before OWT and serum albumin levels before OWT closure], presence of methicillin-resistant Staphylococcus aureus (MRSA) infection, rate of bronchopleural fistula (BPF), duration of OWT, recurrence of local infection, morbidity, duration of indwelling drainage after operation, success, mortality and postoperative hospital stay.

RESULTS

There were 9 (33.3%) omental pedicle flap procedures and 18 (66.7%) muscle flap procedures. The rate of local recurrence after closure of OWT was significantly higher with muscle flap than with omental pedicle flap (0% vs. 50.0%, P=0.012). The median duration of postoperative hospital stay was significantly shorter with omental pedicle flap than that with muscle flap (16.0 vs. 41.5 days, P=0.037). Mortality was observed in 2 patients (11.2%) in the muscle flap group and no patient in the omental pedicle flap group. Success rate was similar between the two groups (100% for omental pedicle flap vs. 83.3% for muscle flap).

CONCLUSIONS

Omental pedicle flap was superior to muscle flap in terms of reducing local recurrence and shortening postoperative hospital stay. However, mortality, morbidity and success rates were not affected by the choice of flap.

Indications and Results of Reconstructive Techniques with Flaps Transposition in Patients Requiring Complex Thoracic Surgery: A 12-Year Experience

BACKGROUND

Flap transposition is an infrequent but far from exceptional thoracic surgical procedure. The aim of this retrospective study was to report our experience in a referral unit of general thoracic surgery analyzing the early results after flap transposition.

METHODS

We retrospectively analyzed the clinical records, surgical notes, and postoperative results of a cohort of patients who underwent flap transposition in our unit from November 2000 to February 2013.

RESULTS

Overall, a surgical approach adopting flap reconstruction techniques was performed in 81 patients (54 males, 27 females) with a median age of 62 years (range 20-87). Flap transposition was necessary to reconstruct chest wall after resection for malignancy (27 patients), to repair intrathoracic viscera perforation (15 patients), and to fill residual cavities secondary to pulmonary/pleural infection (39 patients). A pedicle muscle flap was transposed in most of cases (64 pts, 79 %), while in the remaining 17 cases (11 %), an omental flap was used. There were no immediate postoperative complications, while three in-hospital deaths occurred due to respiratory or multiorgan failure. Among patients undergone flap transposition to fill a residual cavity, we observed a recurrent bronchopleural fistula in three patients (7.7 %); such patients were treated by repeat flap transposition (2 cases) and by repeat cavernostomy (1 case).

CONCLUSION

Flap transposition may be indicated as part of a multimodal treatment for severely ill patients requiring complex thoracic surgery.

Omentoplasty in Treatment of Early Bronchopleural Fistulas after Pneumonectomy

This study was undertaken to assess the efficacy of omentoplasty in 12 cases of bronchopleural fistula after pneumonectomy. All fistulas formed within 16 days after the primary operation (median, 7 days). In 10 cases, omentoplasty was performed within 10 hours of diagnosis; the other 2 cases were treated at 28 and 31 hours. The greater omentum was mobilized through a laparotomy and secured tightly around the bronchial stump using original principles of fixation. After omentoplasty, dehiscence of the bronchial stump was observed in 5 (42%) patients, but owing to reinforcement with greater omentum, recurrence of the fistula was observed in only one case. In 3 patients, recurrence of pleural empyema did not lead to the return of the bronchopleural fistula. Hospital mortality was 8.3% (one patient). In patients without bronchopleural fistula recurrence, the median postoperative hospital stay was 31 days. Early omentoplasty for bronchopleural fistula after pneumonectomy is an effective procedure that eliminates purulent bronchopleural complications completely within the shortest possible period of time.

The treatment of chronic pleural empyema with laparoscopic omentoplasty. Initial report

Introduction

Pleural empyema is the most serious, life-threatening postoperative complication of pneumonectomy, observed after 1–12% of all pneumonectomies, with bronchopleural fistula being its main cause.

Aim

The aim of this publication is to present early outcomes of minimally invasive surgical management of pleural empyema. Patients were subjected to a single, complex procedure, consisting of the laparoscopic mobilization of the greater omentum and its transposition via the diaphragm into the pleural cavity to fill in the empyema cavity with the consecutive pleuro-cutaneous fistuloplasty (thoracoplasty).

Material and methods

Between May 2011 and April 2013, 8 patients were qualified to undergo the procedure. The mean age was 61 years (range: 46–77 years). Presence of bronchopleural fistula was confirmed in 3 cases. The median time of treatment with thoracostomy was 14.5 months.

Results

The mean operative time was 125 min. The mean duration of post-operative hospital stay was 13.5 days (range: 7–31 days). In 6 patients (75%) the objective of permanent resolution of pleural empyema was achieved. In total, 4 patients had complications: pleural empyema recurrence (2 patients), splenic injury, hiatal hernia, gastrointestinal bleed. Two patients with empyema recurrence had Staphylococcus aureus infections prior to surgery. They were successfully managed both with prolonged thoracic drainage and antibiotics.

Conclusions

Use of the greater omentum that was laparoscopically mobilized and transpositioned into the pleural cavity allows simultaneous management of the pleural empyema cavity and thoracostomy. The procedure is safe, with few direct complications. It is well tolerated and has at least a satisfactory cosmetic effect. The minimally invasive approach allows faster recovery and return to daily activities in comparison to the fully open technique.

Post-pneumonectomy broncho-pleural fistula successfully closed by open-window thoracostomy associated with V.A.C. therapy

Broncho-pleural fistula (BPF), is a dramatic complication that may occur after lung resection. The treatment is challenging due to its high rate of morbidity and mortality. Herein, a case of BPF associated with empyema, occurred in an elderly patient who had undergone to left pneumonectomy for non-small cell lung cancer (NSCLC), is reported. After various treatments including chest drainage and endoscopic procedures, BPF was successfully closed by open-window thoracotomy associated with vacuum assisted closure (V.A.C.) device therapy. The authors conclude that V.A.C. is a convenient and safe measure in the management of empyema with BPF. Moreover, in similar clinical contexts, V.A.C. may be the only option available that may assure the survival of the patient and the avoiding any later-phases of residual cavity.

Pericardial flap: an effective method of surgical repair of late post-pneumonectomy fistula

BACKGROUND

We report our experience with the surgical closure of late post-pneumonectomy bronchopleural fistula (PBF) using our own method of coverage of the bronchial stump: Pedicled pericardial flap in combination with fibrin glue.

METHODS

We reviewed the surgical results of 33 patients who underwent surgical closure of PBF by thoracotomy access using three methods: Myoplasty (MYO)-12, omentoplasty (OMT)-10, and pedicled pericardial flap (PPF) with fibrin glue-11. Post-operative follow up was six months.

RESULTS

The patients' demography was comparable among the groups. The diameter of the fistulas ranged from 5 mm to total dehiscence. The mean time of the fistula manifestation (in weeks) was 21.5 in the MYO group, 19.50 in the OMT, and 20.1 in the PPF group. The shortest period of hospital drainage of the pleural space was noted in the PPF group. Healing of the fistula was obtained in 66.67% in the MYO group, 80% in the OMT, and 100% in the PPF group. The number of complications was similar in all groups. The hospitalization time was significantly shorter in the PPF group (13.00 d) versus the MYO group (19.58 d) and the OMT (20.01 d). Overall mortality rate was 18.18%; 33.33% of the patients in the MYO group and 20% in the OMT group died. There were no hospital deaths in the PPF group.

CONCLUSION

Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of postpneumonectomy PBF in selected patients. Compared with other methods of bronchial stump coverage (omentopasty and myoplasty), this one showed a higher percentage of healing of the fistulas and shorter duration of hospital drainage and hospitalization.

Sleeve pneumonectomy

Sleeve pneumonectomy remains a surgical challenge with specific problems of intraoperative surgical and anesthesiologic management. In the present chapter we expose the techniques currently employed in our institution. Sleeve pneumonectomy is associated with a non-negligible mortality, with figures ranging from 8% to 15%. This operation is able to provide microscopic free margins (R0) for the majority of the patients, which is an important prognostic factor. Results in terms of long-term survival are encouraging as overall 5-year survival rates range from 25% to 45%, which is to be considered as a satisfactory result for these patients with a locally advanced cancer. Nodal status is a relevant prognostic factor as patients with N2 disease have survival rates lower than 15%.

Alternatives to resectional surgery for infectious disease of the lung: from embolization to thoracoplasty

Surgical treatment of lung diseases is based on removal of the affected lung tissue, achieved by atypical or anatomic lung resection. Infectious lung diseases are generally treated by medical therapy, including medications, chest physiotherapy, bronchoscopic toilet, and respiratory rehabilitation. Surgical management of infectious disease of the lung is integrated in the multispecialty care. This article focuses exclusively on nonresectional surgery and other alternatives to lung resection and addresses bacterial infection and fungal disease of the lung.

Comprehensive treatment approach is necessary for the closure of open window thoracostomy: an institutional review of 35 cases

PURPOSE

Although life-threatening situations can be avoided using an open window thoracostomy (OWT), the closure is often difficult. We investigated the predictors of a successful closure of an OWT at the time of OWT creation.

METHODS

Thirty-five consecutive patients who underwent an OWT at our institute between January 1991 and December 2010 were reviewed. We directly compared the patients with and without a successful OWT closure. A logistic regression analysis was employed to determine the predictive factors of a successful closure.

RESULTS

OWT closure was only achieved in 12 patients. The closure of the OWT and absence of diabetes mellitus significantly influenced the survival of the OWT patients. The OWT in patients with preceding lung resection was difficult to close, especially if the underlying disease was lung cancer. The existence of a bronchopleural fistula (BPF) was not related to successful closure. Among the post-lung resection patients, the nutritional status tended to affect the success of the closure.

CONCLUSION

Successful closure is difficult to predict at the time of the creation of an OWT. A comprehensive approach, including nutritional support and the precise timing of intervention is critical to promote a successful closure.

[Multidisciplinary approach of ventilated necrotizing pneumonia]

Les pneumopathies infectieuses peuvent se compliquer, du fait de facteurs liés aux germes, à l’hôte ou à l’interaction entre les deux, par la survenue d’une nécrose et/ou d’une destruction du parenchyme pulmonaire. La nécrose et la destruction du parenchyme pulmonaire sont à l’origine de deux entités cliniques principales, les abcès pulmonaires et les pneumonies nécrosantes (PN). Les PN sont des entités rares mais dont le pronostic est redoutable. Elles sont caractérisées par une hépatisation diffuse, possiblement bilatérale du parenchyme pulmonaire avec cavitations et nécrose. Les PN sont généralement associées à un sepsis sévère et à une insuffisance respiratoire aiguë. Nous envisagerons la physiopathologie et le traitement médical qui comprend des mesures symptomatiques, le support des différentes défaillances d’organe, en particulier respiratoires, et le traitement antibiotique. Les indications chirurgicales et leurs modalités seront aussi détaillées. Une prise en charge multidisciplinaire associant réanimateurs, pneumologues, infectiologues, radiologues, chirurgiens et kinésithérapeutes doit permettre d’améliorer les taux de survie et surtout la qualité de vie des patients à distance d’une PN.

Salvage therapy with topical antifungal for Aspergillus fumigatus empyema complicating extrapleural pneumonectomy

We describe an unusual case of Aspergillus fumigatus empyema and bronchopleural fistulae after extrapleural pneumonectomy (EPP) and chemoradiotherapy (CRT), which was treated successfully under salvage conditions with debridement, an innovative topical antifungal application and supplemented systemic antifungal therapy and which went on for a definitive surgical procedure. Combinations of CRT and EPP have been recommended in a select group of patients with malignant mesothelioma. Irrespective of the combination, EPP is associated with mortality in the range of 4-15% and a complication rate as high as 62%.

Thoracomyoplasty in the treatment of empyema: current indications, basic principles, and results

Empyema remains a challenge for modern medicine. Cases not amenable to lung decortication are particularly difficult to treat, requiring prolonged hospitalizations and mutilating procedures. This paper presents the current role of thoracomyoplasty procedures, which allow complete and definitive obliteration of the infected pleural space by a combination of thoracoplasty and the use of neighbourhood muscle flaps (latissimus dorsi, serratus anterior, pectoralis, rectus abdominis, omentum, etc). Recent publications show an overall rate of success of 90%, with a quick and definitive healing. Although rarely indicated in our days, this kind of procedures remain in the armamentarium of modern thoracic surgery. The importance of thoracomyoplasty derives from the fact that it may be a simple and definitive solution for complicated cases of chronic empyema not amenable to standard decortication.

Open window thoracostomy and thoracoplasty to manage 90 postpneumonectomy empyemas

BACKGROUND

Postpneumonectomy empyema (PPE) is a serious complication. The treatment options are similar to the management of any abscess, with drainage, ideally open, often of critical importance. After infection control, many techniques for space obliteration have been described. This study summarizes a 10-year experience in the management of PPE in our center.

METHODS

From 2000 to 2010, 90 patients (83 men) with PPE were treated. Median follow-up was 5.3 years. Once the diagnosis of empyema was confirmed, chest drainage was performed through open window thoracostomy (OWT), with ensuing extramusculoperiosteal thoracoplasties if healthy tissue was present.

RESULTS

Pneumonectomy was performed in 72 patients with lung cancer. Mortality after PPE was 2.2%. OWT achieved infection control in 89 patients. Seven OWT spontaneously healed, and 24 were never closed. The remaining 59 patients with OWT underwent thoracoplasty. Mortality after thoracoplasty was 5%. Empyema recurred in 3 patients. Overall success rate of PPE control after pleural obliteration was 91.5%.

CONCLUSIONS

Thoracoplasty is a reliable filling procedure. It has a significantly higher success rate and a lower mortality rate than the other techniques. We believe that this procedure has a part to play in the future management of PPE.

Large thoracomyoplasty and negative pressure therapy for late postpneumonectomy empyema with a retrosternal abscess: a modern version of the Clagett procedure

A 63-year-old male with a history of cancer, and who had undergone a left pneumonectomy seven years before, presented with deterioration in his general status and recent dyspnea [stage III (New York Heart Association) NYHA]. Imaging revealed a contralateral mediastinal shift and cardiac compression caused by pneumonectomy cavity enlargement and a retrosternal liquid mass. Late empyema associated with a retrosternal abscess caused by Propionibacterium acnes was diagnosed after thoracoscopy and an anterior mediastinotomy. Surgical treatment included an axillary open-window thoracostomy associated with negative pressure therapy (NPT), followed by a large thoracomyoplasty where part of the latissimus dorsi was harvested, and then guided healing. The chest was closed after eight months. This case is an unusual observation of a late post-pneumonectomy empyema with Propionibacterium acnes presenting like recurring cancer, but that was treated effectively using traditional (Clagett procedure) and newer (NPT) strategies.

Intrathoracic vacuum-assisted management of persistent and infected pleural spaces

PURPOSE

This study was designed to assess the use of the intrathoracic vacuum-assisted management of persistent and infected pleural spaces.

DESCRIPTION

Five patients with a persistent and infected pleural space after pulmonary resection underwent intrathoracic vacuum-assisted management to reduce the duration and frequency of dressing changes and to accelerate the formation of granulation tissue and the obliteration of the pleural space. Three patients also underwent a pleural space filling procedure.

EVALUATION

Resolution of the infection or complete obliteration of the pleural space, or both, was in all patients achieved using fewer dressing changes than with traditional methods. No major complications related to the vacuum-assisted management were reported.

CONCLUSIONS

The use of intrathoracic vacuum-assisted management of a persistent and infected pleural space after lung resection may reduce the duration and frequency of dressing changes necessary to allow spontaneous chest closure or a space filling procedure. Its use may decrease patient discomfort and contribute to a faster resolution of the infectious process.

Empyema thoracis

Epmyema thoracis is associated with high mortality ranging between 6% to 24%. The incidence of empyema is increasing in both children and adults; the cause of this surge is unknown. Most cases of empyema complicate community- or hospital-acquired pneumonia but a proportion results from iatrogenic causes or develops without pneumonia. Parapneumonic effusions (PPE) develop in about one half of the patients hospitalized with pneumonia and their presence cause a four-fold increase in mortality. Three stages in the natural course of empyema have long been described: the exudative, fibrinopurulent, and organizing phases. Clinically, PPE are classified as simple PPE, complicated PPE, and frank empyema. Simple PPE are transudates with a pH > 7.20 whereas complicated PPE are exudates with glucose level <2.2 mmol/l and pH < 7.20. Two guidelines statements on the management of PPE in adults have been published by the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS). Although they differ in their approach on how to manage PPE, they agree on drainage of the pleural space in complicated PPE and frank empyema. They also recommend the use of intrapleural fibrinolysis and surgical intervention in those who do not show improvement, but the level of evidence for the use of intrapleural fibrinolysis is not high highlighting the need for more research in this area. A recently published large randomized trial has shown no survival advantage with the use of intrapleural streptokinase in patients with pleural infection. However, streptokinase enhances drainage of infected pleural fluid and may still be used in patients with large collection of infected pleural fluid causing breathlessness or ventilatory failure. There is emerging evidence that the combination of intrapleural tPA/DNase is significantly superior to tPA or DNase alone, or placebo in improving pleural fluid drainage in patients with pleural space infection. A guideline statement on the management of PPE in children has been published by the BTS. It recommends the use of antibiotics in all patients with PPE in addition to either video-assisted thoracoscopic surgery (VATS) or tube thoracostomy and intrapleural fibrinolysis. Prospective randomized trials have shown that intrapleural fibrinolysis is as effective as VATS for the treatment of childhood empyema and is a more economic treatment and therefore, should be the primary treatment of choice.

Transsternal transpericardial closure of a postpneumonectomy bronchial fistula in a patient who underwent pneumonectomy because of a war injury

Most common causes of intrathoracic empyema include pulmonary infections and postoperative bronchopleural fistulas complicating a lung surgical resection, mainly pneumonectomy, as a result of the failure of the bronchial stump to heal. A 22-year-old Serbian patient presented with chronic posttraumatic empyema. Two years before during a war, he experienced chest injury due to a firearm wound, with massive intrathoracic bleeding and need for emergency left pneumonectomy. Empyema with a bronchopleural fistula occurred during the postoperative course. The patient underwent left open window thoracostomy with a daily bandage change. Here we report the treatment of the bronchopleural fistula using sequential surgical approach including transsternal transpericardial closure of the fistula followed by reconstruction of the chest wall with a regional muscle flap. Our case report highlights the feasibility and efficacy of the transsternal surgical approach to treat postpneumonectomy bronchopleural fistula, thereby avoiding the direct approach to the bronchial stump through the infected pneumonectomy cavity.

Non-surgical closure of post-pneumonectomy empyema with bronchopleural fistula after open window thoracotomy using basic fibroblast growth factor

Empyema with bronchopleural fistula (BPF) is one of the severest complications following pneumonectomy. Many papers have reported that it is difficult to cure, with a high rate of associated mortality. Closure of the fistula and an appropriate choice of obliteration materials are crucial for successful treatment. However, obliteration is sometimes impractical because of a lack of suitable materials, excessive surgical risk, or lack of patient willingness to undergo the procedure. We report a case of post-pneumonectomy empyema with BPF that was treated by non-surgical closure after open-window thoracotomy (OWT) with the use of basic fibroblast growth factor (bFGF), which was sprayed into the unepithelialized empyema cavity transiting from epidermis and surrounding the fistula. After spraying, the orifice of the OWT was covered by a film dressing. This procedure yielded successful results after two months.

L'ambiance musculaire salvatrice en chirurgie réparatrice des cavités de pyothorax

SUBJECT

The chronic empyema is a dreadfull outcome of pulmonary resection. Its management is difficult: a thoracostomy or a thoracoplasty by resection of rib segments are rarely efficient. A large debridement associated with a muscular flap is helpfull in the treatment of these cavities. These flaps allow the filling of these pleural spaces and the treatment of the bronchopleural fistulae which are constant and responsible of the perenniality of such infection.

PATIENTS AND METHODS

From June 1997 to December 2006, 12 patients, aged from 25 to 45 years old, were treated for chronic empyema following total pulmonary resection by using muscular flaps. The causes were: post-tuberculosis pulmonary deterioration in 8 cases, bronchic cancer in 3 cases, post-traumatic tracheobronchic breaking in 1 case. An open window thoracostomy was performed for all the patients and with a follow-up of 2 years, there was no healing of this infection. In our procedure, the patients underwent in the same time a large thoracoplasty that involved 3 to 5 rib segments (10 cm in length) to reduce the pleural space and a myoplasty. The muscular flaps used were pedicled in 8 cases: a latissimus dorsi in 6 cases, a latissimus dorsi with an anterior serratus in 2 case, and were free in 4 cases: a latissimus dorsi in 3 cases, a latissimus dorsi with an anterior serratus in 1 case. These flaps were sufficient to fill the cavities and were applied and stitched around the fistulae.

RESULTS

There was no complication during or after the operations with a mean follow-up of 3 years. These chronic empyema were completely healed in all cases without recurrence of the suppuration or the bronchopleural fistulae.

CONCLUSION

The one-stage thoracomyoplasty including the resection of rib segments and local or regional muscular flaps is a very efficient treatment of the chronic pleural empyemas. It is very important, for an easy treatment of such cavities, to teach the thoracic surgeons the great interest of preserving the local muscular flap during the initial thoracotomy.

Current surgical treatment of thoracic empyema in adults

A review of the recent literature on treatment modalities of adult thoracic empyema was conducted in order to expose the controversies and verify where consensus exists. Critical reading filtered through clinical experience was the method followed. The roles of surgical drainage, lavage techniques, debridement via VATS, decortication, thoracoplasty and open window thoracostomy were considered using the Oxford Center of Evidence Based Medicine criteria. The roles of the different therapeutical modalities were interpreted in the light of the triphasic nature of empyema thoracis. The randomised controlled trials came up with conflicting results. With two exceptions all of the papers reviewed provide level (2b) or below evidences. The lack of a single ideal treatment modality or policy reflects the complexity of the diagnosis and staging of this heterogeneous disease. Basic elements of intervention--drainage, different evacuation techniques, decortication, thoracoplasty and open window thoracostomy--are well-established technical modalities; however, neither a universally acceptable primary modality nor the gold standard of their sequence is available. Drainage remains to be the initial treatment modality in Phase I disease. Debridement via VATS is a safe, reliable and efficient method in the fibrinopurulent phase. Organised pleural callus requires formal decortication. Open window thoracostomy is a simple and safe procedure for high-risk patients and results in quick detoxication. Thoracoplasty kept its final role in pleural space management. Acute postoperative bronchial stump insufficiency requires immediate surgery. Evacuation of toxic material is mandatory. No single-stage procedure offers a solution. An optimised agressivity treatment modality should be tailored to the condition of the patient and to the potential of the persisting cavity. Decision-making involves a triad consisting of the aetiology of empyema (i.e. primary vs secondary), general condition of the patient and stage of disease, while considering the triphasic nature of development of thoracic empyema. The current attitudes show that the present concepts are based mainly on expert opinion. Flexibility and patience on behalf of the surgeon and nursing staff, the patient and the hospital management, as well as a good understanding of the complexity of this condition are the cornerstones of the treatment. No exclusive sequence of procedures leading to a uniformly predictable successful outcome is available. Individualised approaches can be recommended based on institutional practice and local protocols. Thoracic empyema in general seems to remain resilient to fit completely into the categories of evidence-based medical approach.

Pleural space sterilization using gentian violet irrigation for postbullectomy empyema associated with artificial material infection

Postoperative empyema associated with artificial material infection involves several treatment problems. We report the successful treatment of a case of post-bullectomy empyema with a small alveolar fistula that was associated with artificial material infection by Streptococcus viridans. In this case, complete empyema space sterilization was obtained by tube drainage and daily pleural irrigation using 0.1% gentian violet solution. This treatment circumvented the need for invasive surgery, including removal of the infected artificial materials and space-filling and/or collapse procedures. Consequently, gentian violet irrigation may be a useful treatment option in selected cases with complicated thoracic empyema.

Management of a Large Bronchopleural Fistula Using a Tracheobronchial Stent

Bronchopleural fistula, one of the most serious complications following pneumonectomy, has a complicated treatment protocol and carries a high mortality rate. We present a case report of a 75-year-old female with squamous cell carcinoma of the lower lobe with positive peribronchial hilar nodes who underwent a right pneumonectomy. She represented with a large bronchopleural fistula one month postoperatively, eventually treated by a novel tracheobronchial stenting procedure.

Management of empyema cavity with the vacuum-assisted closure device

Management of empyema after pulmonary resection remains a challenging problem. Along with mandatory drainage of the thoracic cavity and investigations to rule out bronchopleural fistula, a reliable method of thoracic cavity closure is needed. The open thoracic window and Eloesser flap techniques rarely represent definitive therapy. Muscle flap and thoracoplasty procedures may provide well-vascularized tissue to close bronchopleural fistula and obliterate the empyema cavity, but they are quite complex and involve significant patient morbidity. We report a case of empyema without bronchopleural fistula after lobectomy in which the vacuum-assisted closure device was used to achieve complete wound healing after open drainage.

Predictors of successful closure of open window thoracostomy for postpneumonectomy empyema

BACKGROUND

Although the open window thoracostomy (OWT) represents the ideal method for drainage of postpneumonectomy empyema (PPE), several controversies exist concerning its closure.

METHODS

Between January 1993 and December 2003, an OWT was created in 31 patients (29 male and 2 female) with PPE. The median age was 61 years (range, 32 to 76). In 26 patients (84%) a bronchial stump fistula developed. The OWT closure was correlated with characteristics of PPE and the timing of OWT.

RESULTS

In 15 patients (48%), the OWT could be closed by obliteration of pleural cavity with antibiotic solution (3 patients) or intrathoracic muscle transposition (12 patients). A successful closure was observed in 13 of the 15 patients (87%). All patients closed by Clagett's procedure remained empyema free. Recurrent cancer (n = 4), poor functional status (n = 3), refusal of further operation (n = 2), and persistent tuberculous empyema (n = 2) were common causes of failure of OWT closure. Univariate analysis revealed that the timing of empyema development after surgery (p = 0.02) and the timing of OWT (p = 0.03) were significant predictors of thoracostomy closure.

CONCLUSIONS

Late onset of PPE and immediate OWT creation are significant predictors of OWT closure. Smaller dimensions of the pleural cavity appeared to increase the likelihood of closure. When the pleural cavity shows healthy granulation tissue and no bronchopleural fistula, the Clagett's procedure is safe and effective to obliterate the pleural cavity. Obliteration by muscle flap transposition can be reserved for patients with persistent or recurrent bronchopleural fistula.