Treatment of postpneumonectomy empyema

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.

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.

Role of Eloesser flap and thoracoplasty in the third millennium

In the modern era of thoracic surgery, few indications remain for thoracoplasty. Indeed, many surgeons believe that the resulting deformity outweighs the usefulness of collapse therapy. Rather than trying to obliterate chronic spaces, these surgeons advocate myoplasty techniques to fill the space. Unfortunately, these techniques are not minor procedures and two to three operations are often necessary to solve the problem. This is the reason why thoracoplasty remains the best option in selected patients. In some cases, it should be a first-line procedure rather than as a last resort when everything else has failed. In their discussion of the article by Horrigan and Snow [31], Pairolero and Trastek [44] summarized well the current attitudes toward these different concepts: "Although management of the chronically infected pleural space has changed over the years, the goals of therapy remain the same to conserve the patient's life with a healed chest wall without evidence of infection. Determination of which techniques are necessary to achieve these goals must be tailored to the individual patients."

Toracostomia triirradiada no tratamento do empiema pleural crônico

Empiema é uma doença comum e representa um problema cirúrgico de grande importância em virtude das dificuldades no diagnóstico e tratamento. Foram descritas três fases do empiema pleural, e o estágio final é a fase três ou crônica, a qual usualmente começa quatro a seis semanas após o desenvolvimento do empiema, quando o pulmão é encarcerado. Esta fase crônica representa a maioria das controvérsias relacionadas ao tratamento. Das diversas formas de drenagem permanente do abscesso pleural, nós concentramos mais recentemente num novo tipo de procedimento, que consiste numa toracostomia triirradiada, a qual permite posicionamento dos retalhos em qualquer porção da cavidade empiemática, assim recobrindo o espaço pleural. Este tipo de toracostomia em janela triirradiada foi descrita por Galvin em 1988. Foram analisados 27 pacientes portadores de infecção do espaço pleural tratados através de um retalho pleurocutâneo confeccionado à semelhança do emblema da marca automotiva Mercedes Benz. A idade média foi de 35,9 anos, sendo 22 homens e cinco mulheres. A infecção pleural foi devida ao staphylococcus aureus em 40,7% (n= 11), sem crescimento bacteriano em 29,6% (n=8), flora mista 1I % (n=3),E. coli7,4% (n=2),Proteus3,7% (n=1). O trauma foi responsável por 40,7% (n=11), pneumonia em 33,3% (n=9), câncer em 11 % (n=3), tuberculose em 7,4% (n=2), empiema pós-operatório e corpo estranho um cada,7 ,4% (n=2). O período de internação variou entre três meses e três dias, com uma média de 25 dias. O tempo médio para a resolução do processo foi de 35 dias (± 10 dias). Não houve mortalidade nesta série. Os objetivos do tratamento do empiema crônico, os quais incluem controle da infecção sistêmica e local, reexpansão do pulmão e melhoria da função pulmonar, restauração da parede torácica e mobilidade diafragmática, foram todos conseguidos com esta operação simples. Conclui-se que este método de drenagem permanente do espaço pleural feito à semelhança da estrela da Mercedes Benz permitiu a esterilização do espaço pleural em 27 pacientes e resolução do processo infeccioso em todos num espaço médio de 35 dias.

Open-window thoracostomy and thoracomyoplasty to manage chronic pleural empyema

BACKGROUND

The purpose of this study is to report our 15-year experience treating chronic empyemas after pulmonary resection and tuberculosis.

METHODS

Open-window thoracostomy and thoracomyoplasty were used to treat 40 patients with chronic pleural empyema characterized by residual empyematic cavity, bronchopleural fistula, and persistent pleural infections that were secondary to tuberculosis (n = 22) or pulmonary resection (n = 18). Between 2 and 7 months after thoracostomy, thoracomyoplasty was performed to eliminate a persistent pleural cavity. In 2 patients with postpulmonary resection empyema and a large bronchopleural fistula, intrathoracic transposition of the latissimus dorsi flap and open-window thoracostomy were performed simultaneously to close the fistula.

RESULTS

The pleural space was eliminated per primam intentionem in 21 of 22 patients with tuberculosis and in 14 of 18 with a postpulmonary resection empyema. Another myoplasty was performed in an additional 3 patients to eliminate the pleural space. During open-window thoracostomy, the latissimus dorsi muscle was preserved with minimal injury to the anterior serratus muscle. One patient died postoperatively.

CONCLUSIONS

Successful treatment of chronic pleural empyema requires adequate timing of surgical procedures. Our two-procedure technique is relatively simple and safe.

Treatment of postpneumonectomy empyema and associated bronchopleural fistula. Experience of 100 consecutive postpneumonectomy patients

Experience in the management of 100 consecutive patients with postpneumonectomy empyema is presented. Open-window thoracostomy was used for treatment of the empyema in all cases. The patients were grouped according to surgical procedure after this treatment. In group 1 the thoracostomy window was left permanently open. In group 2 it was closed, and in group 3 the open pleural cavity was covered with skin, using a pedicle of muscle and skin and free skin transplants. The pectoralis skin pedicle was used to close large bronchopleural fistulas. The results in each group are presented and a staged method, which can be used in all cases of postpneumonectomy empyema, with or without bronchopleural fistula, is described.

Empyema and bronchopleural fistula. Experience with open window thoracostomy

Open window thoracostomy (OWT) was created in 12 patients with empyema and sepsis after conventional therapy with antibiotics and drainage had failed. After creation of OWT all infections subsided within ten days to four months and all fistulae closed within one to four months. Complete obliteration of the empyema cavity by granulation tissue occurred in 11 of 12 patients within one to eight months, depending upon the size of the space. All patients tolerated the procedure well. Creation of OWT has not caused lung collapse in any of the patients due to fibrosis caused by the preceding infection. There was no complication or death. OWT is a safe procedure recommended in all patients with empyema resistant to conventional therapy. It does not need to be restricted to post-pneumonectomy cases. Operative closure of bronchopleural fistulae, a major surgical undertaking with an uncertain outcome, is usually unnecessary.

Treatment of postpneumonectomy empyema: the case for fenestration

In Mearnskirk Hospital, Glasgow, 29 patients with postpneumonectomy empyema were treated by fenestration in a 12-year-period. Seven of these were not considered fit enough for definitive closure and died of continuing disease or respiratory infection. Twenty-two patients went on to closure of their fenestra, and in 17 (77%) the pneumonectomy space was rendered permanently sterile. If the empyema recurred treatment was repeated but proved less successful. Fenestration is an effective method of dealing with postpneumonectomy empyema, but also has several other advantages, particularly if the empyema is associated with a bronchopleural fistula.

Late-onset post-pneumonectomy empyema

Nine cases of empyema developing more than three months after pneumonectomy are presented. Diagnosis is difficult; with one exception, all the patients had been ill for at least three weeks and some for several months before the cause was discovered. In four, the radiological demonstration of gas in a previously opaque hemithorax led to the diagnosis. One of these had a bronchial fistula, two had oesophageal fistulae, and one had both. The remaining patients had no fistulae and the diagnoses were not made until empyema necessitatis had developed. Two from this group yielded pure cultures of pneumococci and one a pure culture of Streptococcus viridans. Except for one patient admitted moribund, all were treated in the first instance by rib resection and open drainage without tubes and all survived. Four of the five without fistulae subsequently had their drainage sinuses successfully closed after the infection of the chest wall had cleared. The belief that a pneumonectomy space normally becomes obliterated is challenged. The history and mode of onset of some of these cases suggested that infection of the residual fluid was bloodborne.

Pedicle thoracoplasty and free skin transplantations in the treatment of open postpneumonectomy cavity after empyema

The method of covering the open postpneumonectomy pleural cavity with skin is used when closure of the thoracostoma is not possible. The operation is performed with pedicles and free skin transplantations. The results in 16 patients treated this way are presented. This method makes it possible to cover the whole open pleural cavity with skin and to reach a satisfactory postpneumonectomy state.

Use of pectoralis skin pedicle flap for closure of large bronchial fistula connected with postpneumonectomy empyema

In 4 patients, the postpneumonectomy empyema was connected with a large bronchopleural fistula. The empyema was in all cases treated by a permanent open window thoracostoma. The fistulae were closed later with pedicle flaps made of the pectoralis muscle and the adjoining skin. In 2 patients the closing of the bronchial fistula was successful, and the treatment of one patient is not completed. In one patient the open pneural cavity was covered completely by skin using an additional pedicle flap and free skin transplantation. The surgical technique of the pedicle flap operation is described and the cases are reported.