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

Empyema thoracis: 14-year experience in a teaching center

One hundred two patients with empyema thoracis were managed at the Royal Melbourne Hospital between 1976 and 1989. Fifty-five cases of empyema thoracis were postpneumonic, 8 followed esophageal rupture, and 5 were associated with thoracic trauma. Some form of systemic illness was a major contributing factor in the presentation of 29 patients. A single causal organism was found in 53 patients (the most common being Staphylococcus aureus), multiple organisms in 36, and no growth in 13. During the years 1983 to 1989 there was an increased incidence of empyemas caused by multiple or antibiotic-resistant organisms. Operative drainage was required in 90 patients and 12 were managed by thoracentesis or intercostal tube drainage alone. The in-hospital mortality rate for patients managed nonoperatively was 58% (7 of 12 patients); it was 16% (14 of 90 patients) for those receiving operative drainage. There were seven late deaths, four empyema related and three nonrelated. Early adequate operative drainage is recommended for patients with empyema thoracis.

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.

Management of empyema and bronchopleural fistula. Experience with Eloesser window

Eloesser window was constructed in 8 patients with empyema and sepsis which failed to respond to more conservative measures. The empyema complicated pneumonectomy in 6 cases and was associated with bronchopleural fistula (BPF) in 4. Rapid control of the pleural space infection was obtained in all cases, allowing for further management on an outpatient basis. Closure of the fistula occurred within 4 months in 3 of 4 cases; one patient developed an oesophago-pleural fistula 31½ months later and succumbed from inanition. Spontaneous closure of the thoracostomy window with complete obliteration of pleural cavity has occurred in only 2 patients. In S others the persistent stoma with minimal drainage has been well tolerated. The Eloesser window is an acceptable method for treatment of recalcitrant empyema and BPF in our environment, with minimal morbidity and mortality.

The use of an omental pedicle flap in the closure of bronchopleural fistulae

Two recurrent bronchopleural fistulae in patients in whom previous intercostal myoplasty had failed were successfully closed by an omental pedicle flap and a bucket-handle flap slide over the omentum. The original procedure in both was left lower lobectomy. The advantages of the procedure are its simplicity, the absence of cosmetic defect, and its suitability for left lower or lingular bronchopleural fistulae when other procedures have failed.

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.