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.     

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.     

Accelerated treatment for early and late postpneumonectomy empyema.

BACKGROUND: Postpneumonectomy empyema is a rare but serious complication of pneumonectomy. Despite use of various therapeutic approaches and techniques during the last five decades, successful therapy remains difficult and is often associated with high morbidity and prolonged hospitalization. METHODS: We evaluated a concept for accelerated treatment, which consists of radical debridement of the pleural cavity and packing with wet dressings of povidoneiodine. This was repeated in the operating theater every second day, until the chest cavity was macroscopically clean. If present, bronchial stump insufficiency was closed and secured by omentopexy. Finally, the pleural space was obliterated with antibiotic solution. RESULTS: Twenty patients, 13 with early postpneumonectomy empyema (10 to 89 days; mean, 37 days) and 7 with late postpneumonectomy empyema (124 to 7,200 days; mean, 1,126 days) were treated. Fifteen patients presented with bronchopleural fistula (11 right, 4 left), which developed after chemotherapy (n = 6) or after radiotherapy (n = 3) (unknown cause in 4 patients). Six patients were referred after previously unsuccessful surgical attempts. Pleural cultures were positive in 17 cases for one or several bacteria including fungoides (n = 2). The average number of interventions was 3.5 (3 to 5). The chest was definitively closed in all patients within 8 days. Mean hospitalization time was 17 days (7 to 35 days). During the same hospitalization, 2 patients needed reoperation because of an undetected bronchopleural fistula. Postpneumonectomy empyema was successfully treated in all patients. There was no in-hospital or 3-month postoperative mortality. CONCLUSIONS: Repeated surgical debridement combined with closure of bronchopleural fistula and antimicrobial therapy enables successful treatment of early and late postpneumonectomy empyema within a short period and is a well-tolerated concept.     

Postpneumonectomy Empyema in Pulmonary Carcinoma Patients

The postpneumonectomy empyema of 12 pulmonary carcinoma patients was treated with open window thoracostomy and, whenever possible, with later closure of the thoracostomy. Six of the patients had no bronchial fistula and the pleural cavity of four of them remained healed after the closure of the thoracostomy. Six patients had bronchopleural fistulae. The pleural cavity of one of them remained healed after the closure of the thoracostomy following spontaneous healing of a small bronchial fistula. The cases, in which closure of thoracostomy was not undertaken on account of open bronchial fistula and those in which recurrence of empyema necessitated reopening of the thoracostomy, were managed satisfactorily with permanent open window thoracostomy.     

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

OBJECTIVE: Successful treatment of postoperative empyema remains a challenge for thoracic surgeons. We report herein our 12-year experience in the management of this condition by means of open window thoracostomy. METHODS: Open window thoracostomy was used in the treatment of 46 patients with empyema complicating pulmonary resection. A bronchopleural fistula was associated in 39 of 46 cases. Previous operations included pneumonectomy (n = 30), bilobectomy (n = 5), lobectomy (n = 9), and wedge resection (n = 2) performed for benign (n = 10) or malignant (n = 36) disease. In 10 patients open window thoracostomy was definitive because of patient death (n = 2), concomitant major illness (n = 2), tumor recurrence (n = 4), spontaneous closure (n = 1), or patient choice (n = 1). In 36 cases intrathoracic flap transposition was eventually performed. Muscular (n = 29), omental (n = 5), or combined muscular and omental (n = 2) flaps were used to obliterate the thoracostomy cavity and to close a possibly associated bronchopleural fistula. In 9 patients with postpneumonectomy cavities too wide to be filled by the available flaps, a limited thoracoplasty represented an intermediate step. RESULTS: Among patients treated with definitive open window thoracostomy, local control of the infection was achieved in all the survivors (8/8). After open window thoracostomy and subsequent flap transposition, success (definitive closure of the thoracostomy and, if present, of the bronchopleural fistula) was achieved in 27 (75. 0%) of 36 patients. Four initial failures could be salvaged by means of reoperation (initial reopening of thoracostomy and subsequent muscular or omental transposition). CONCLUSION: Open window thoracostomy followed by intrathoracic muscle or omental transposition represents a valid therapeutic option in patients with empyema complicating pulmonary resections.     

Closure of chronic postpneumonectomy bronchopleural fistula using the transsternal transpericardial approach

Thirteen patients with postpneumonectomy bronchopleural fistula occurring 4 months to 10 years after the initial operation have been treated with a transsternal transpericardial approach after the associated empyema had been treated by either tube thoracostomy or open-window thoracostomy. In 10 patients, there were contraindications to using an ipsilateral transthoracic approach. In 10 of the 13 patients, the procedure was successful. Three fistulas recurred; two were quite small, one of them closing spontaneously within 6 months. There were no deaths or clinically significant morbidity related to the transsternal approach. We have found this technique to be most applicable in those patients in whom other procedures have failed to resolve the problem. The technique is relatively simple and safe.     

Decortication in chronic thoracic empyemas —A report of three cases—

Three cases of chronic thoracic empyema treated by decortication are reported with special reference to the indications for surgery. The first patient was a 68-year-old man who had right chronic thoracic empyema with a bronchopleural fistula. He underwent open thoracostomy, and decortication was performed after 8 months. The second patient was a 74-year-old man who had right chronic empyema without bronchopleural fistula. Open thoracostomy was also performed and decortication was done after 2 months. Postoperative pulmonary function was significantly improved in both patients. The third patient was a 66-year-old man who had left chronic empyema with a bronchopleural fistula. He underwent open thoracostomy and left lower lobectomy, and then decortication and the omental pedicle flap method were performed after 4 months. All three patients are still doing well currently. It is concluded that decortication significantly improves pulmonary function in properly selected patients, and that computed tomography is helpful for assessing the re-expansion ability of the collapsed lung.     

Thoracoscopic management of postpneumonectomy empyema

Background

Even when there is no associated bronchopleural fistula, empyema is a serious complication of pneumonectomy. Aggressive surgical treatments are usually applied. However, a minimally invasive approach might achieve satisfactory results in selected patients.

Methods

Out of 17 patients presenting with a postpneumonectomy empyema (PPE), 11 had a thoracoscopic approach. There were 9 males and 2 females, (age, 38-74; mean, 59 years). Ten patients had no proven bronchopleural fistula (BPF). One of them had a minor (< 3 mm) BPF. Empyema was confirmed by thoracentesis and bacteriological examination. All patients had immediate chest tube drainage and underwent emergency thoracoscopic debridement of the empyema. No irrigation was used postoperatively.

Results

There was no mortality and no morbidity related to the procedure. The average duration of thoracoscopic debridement was 62 minutes (range: 45-80 minutes). In 8 patients the chest tube was removed between the fifth and thirteenth postoperative day (average, 8.6 days). They were discharged between the 9th and 24th postoperative day. In 3 patients, clinical and/or biological signs of infection persisted and reoperation was decided at day 5, day 10, and day 11. All 3 patients underwent open-window thoracostomy. The average follow-up of the 8 patients who underwent only thoracoscopy was 10 months (range, 2-27 months). None had recurrent empyema. The patient who presented with a minor BPF remained asymptomatic and is doing well after a 27 month follow-up.

Conclusions

Thoracoscopy might be a valuable approach for patients presenting with PPE with or without minor bronchopleural fistula.     

Videothoracoscopic debridement of the postpneumonectomy space in empyema.

OBJECTIVE: Simple irrigation has proven to be an efficient method to treat postpneumonectomy empyema provided that bronchopleural fistula is not present or successfully closed. However, with this treatment modality, infected material inside the thoracic cavity is not removed and this can be a potential source of empyema recurrence if the patient's immune system is compromised. The removal of the infected material should result in a lower recurrence rate. METHODS: As soon as diagnosis of postpneumonectomy empyema was established, a chest tube drainage was inserted. A concomitant bronchopleural fistula was evaluated bronchoscopically. If the fistula was smaller than 3 mm, bronchoscopic sealing with fibrin glue (Tissucol, Immuno, Vienna) was initiated. Fistulas closed surgically were excluded from this analysis. The thoracic cavity was cleared of infected material by videothoracoscopy and bacteriological samples were taken. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection; WBC and CRP were controlled. RESULTS: Nine patients (five men, four women) between 55 and 72 years (mean 61, SD 6), all initially operated on for malignancy, were successfully treated with this regimen. In three cases a concomitant bronchopleural fistula was successfully closed before videothoracoscopy. The interval between primary operation and empyema was between 7 and 436 days (mean 93, SD 141). There was no postoperative mortality and no procedure related morbidity. Operating time ranged from 45 to 165 min (mean 92.7, SD 36.6), the suction volume (consisting of blood, debris and pus) was 300 to 1000 ml (mean 880, SD 600). Duration of thoracic drainage was 12-38 days (mean 22, SD 9), duration of hospital stay after videothoracoscopy 21-46 days (mean 29, SD 9). During the follow-up period of 204-1163 days (mean 645, SD 407) no recurrence of tumour or empyema was observed. CONCLUSIONS: Videothoracoscopic debridement of the postpneumonectomy space with postoperative antibiotic irrigation of the pleural space is an efficient method to treat postpneumonectomy empyema, provided that a concomitant bronchopleural fistula can be closed successfully. No early empyema or fistula recurrence were observed. However, late recurrence may occur many years after operation, therefore close follow-up is indicated.     

Closure method of bronchopleural fistula with omental pedicle flap in three cases following pneumonectomy

This report presents that successful closure of bronchopleural fistula was performed by using omental pedicle flap for three postpneumonectomy patients. In our department, these cases were experienced among 142 pneumonectomies from January 1984 to July 1989. The initial operations were a pleuropneumonectomy for empyema, a pneumonectomy and a sleeve pneumonectomy for lung cancer. Our technique was direct closure of bronchopleural fistula with omental pedicle flap without thoracoplasty. Although none of them had recurrence of bronchopleural fistula nor other complications in postoperative course, two patients died of cancer.     

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.     

Management of postpneumonectomy empyema and bronchopleural fistula

Empyema after pneumonectomy is often associated with a bronchopleural fistula (BDF) and has a significant mortality. Management options include systemic antibiotics and observation, adequate pleural drainage, appropriate parenteral antibiotics, removal of necrotic tissue, and obliteration of residual pleural space. We prefer to treat the empyema with the procedure originally described by Clagett and Geraci in 1963. They demonstrated that postpneumonectomy empyema could be successfully treated by open pleural drainage, frequent wet-to-dry dressing changes, and when the thorax was clean, secondary chest wall closure with obliteration of the pleural cavity with an antibiotic solution. Failure was most often caused by a persistent or recurrent fistula. Because of this, when a BPF is present, the original Clagett technique was modified to include transposition of a well-vascularized muscle to cover the stump at the time of open drainage to prevent further ischemia and necrosis. Our preference is intrathoracic transposition of extrathoracic skeletal muscle. The goals of therapy for postpneumonectomy empyema remain a healthy patient with a a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients by using the Clagett procedure and intrathoracic muscle transposition when a BPF is present.     

Omentopexy as the operation of choice in treating recurrent postpneumonectomy pleural empyema with a bronchopleural fistula]

In 6 patients with recurrent postpneumonectomy pleural empyema and bronchopleural fistula the transdiaphragmatic omentopexy for the pleural cavity remnant was performed. In 5 patients the complete remission was noted, one patient died, the death's cause was not related directly with the operation performed. The control group of 20 patients had similar pathological findings and to them conventional methods of treatment were applied. In 10 patients the remission was achieved, in 5--the bronchial fistula recurrence was noted, 5 patients died. Thus, the total clinical efficacy was 83.3 and 50% accordingly.     

胸廓造口开窗引流术在结核性脓胸伴支气管胸膜瘘中应用的疗效分析

【摘要】 目的 总结分析胸廓造口开窗引流术(OWT)在结核性脓胸伴支气管胸膜瘘中应用的治疗经验。方法 对我科在2003年至2012年56例结核性脓胸伴支气管胸膜瘘病例采用胸廓造口开窗引流术的外科治疗进行回顾性分析。本组病例胸廓造口开窗换药引流3~12个月后,分别采用Heller胸廓成形术加瘘修补术、胸膜外全肺切除术或余肺切除术、永久的开放性胸廓造口术等方法治疗。结果 全组患者有效地控制胸腔感染后,36例行Heller胸廓成形术加瘘修补术;14例胸膜外全肺切除术或余肺切除术后关闭胸廓造口,其中有5例术后出现围手术期胸腔再次感染并发症发生再次行胸廓造口术;6例患者选择永久的开放性胸廓造口开窗换药引流,无围术期死亡病例发生。结论 对结核性脓胸伴支气管胸膜瘘的患者应用胸廓造口术能有效地控制胸腔感染,降低死亡率,改善身体状况,为二期瘘修补术及消灭残腔手术创造有利条件并提高手术成功率。     

Non-surgical treatment for post pneumonectomy empyema

We describe an alternative treatment for postpneumonectomy empyema in patients for which Claggett procedure is inappropriate. During the years 1990-2002 eight patients with postpneumonectomy empyema were treated by continuous soft tube thoracostomy, intrapleural fibrinolysis and antibiotics. The medical records of these patients were reviewed retrospectively. The procedure was well tolerated by all patients and there were no significant complications during the treatment period. One patient died 9 months postpneumonectomy due to metastatic disease. The remaining patients have successfully completed the treatment with no recurrence of empyema. Continuous soft tube drainage with intrapleural fibrinolysis and antibiotics is a safe treatment for postpneumonectomy empyema in patients who are not appropriate candidates for operative management.     

Omentoplasty and Thoracoplasty for treating postpneumonectomy bronchopleural fistula in a patient previously submitted to aortic prosthesis implantation

Bronchopleural fistula following pneumonectomy is a serious and frightening complication in chest surgery with a high mortality rate. The possibility of curing this complication using a conservative treatment is extremely poor. Below we describe a case of a patient affected by left pleural empyema due to a postpneumonectomy bronchopleural fistula. The patient had previously undergone an aortic prosthesis implantation. He was successfully treated using omental pedicle in order to cover the bronchial stump, to fill the pleural space and to protect the aortic prosthesis. He also underwent thoracoplasty to collapse the residual pleural space. The postoperative course was uneventful. During the follow-up, after thirty months, the patient was asymptomatic, and no recurrence of the fistula was present.     

A method of early irrigation of the contaminated postpneumonectomy space

A modified balanced drainage system was used with other measures in a patient with an obstructing pulmonary carcinoma, infection, and necrosis. Management included right pneumonectomy, perioperative systemic antibiotics, protection of the remaining lung, and a modified balanced drainage system that allowed early irrigation of the postpneumonectomy space. On the tenth postoperative day, irrigations were discontinued, the right chest was filled with an antibiotic solution, and the thoracostomy tubes were removed. The mediastinum remained in a satisfactory position, and the patient recovered without evidence of empyema. He died of a cerebral metastasis five and a half months postoperatively. This method combines principles that have been used for many years. A balanced drainage-irrigation system permits early irrigation of the contaminated postpneumonectomy space while the mediastinum is still mobile. Prolonged hospitalization and formal closure of the thoracostomy sites can be avoided.     

Chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae treated by open window thoracostomy followed by thoracoplasty and latissimus dorsi muscle transposition

We describe a case of chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae successfully treated by open window thoracostomy followed by thoracoplasty and transposition of the latissimus dorsi muscle. A 69-year old man with a history of artificial pneumothorax for pulmonary tuberculosis was referred to our hospital with fever and purulent bloody sputum. He was diagnosed as having right chronic tuberculous empyema with bronchopleural fistulae. Immediate tube thoracostomy markedly relieved symptoms except for low-grade fever. Sputum and empyema cavity cultures were repeatedly positive for MRSA. Open window thoracostomy (5th to 7th ribs resection) was performed to control the infection. The empyema cavity was cleaned with no residual calcified pleura. His condition gradually improved and he underwent thoracoplasty and transposition of the latissimus dorsi muscle 22 months after the initial surgery. He was discharged 25 days postoperatively in good condition. Seventeen months after the curative surgery, he remains well with no evidence of recurrence. A two-stage operation, open window thoracostomy to control infection followed by thoracoplasty and transposition of the latissimus dorsi muscle, is useful in cases of chronic tuberculous MRSA empyema with bronchopleural fistulae.     

Bronchoscopic sclerotherapy combined with thoracoscopic drainage for postpneumonectomy bronchial fistula and empyema

A postpneumonectomy bronchial fistula is a very morbid complication that often requires major surgical procedures for treatment. Since patients with postpneumonectomy bronchial fistula and empyema are physiologically compromised, corrective surgical interventions pose considerable risk. We report a case of a postpneumonectomy fistula with an associated empyema. Our patient's empyema was treated with thoracoscopic debridement and antibiotic instillation (modification of the Clagett procedure). Bronchoscopic and thoracoscopic treatment strategies that are appropriate for selected patients with postpneumonectomy bronchial fistula and empyema are discussed.     

Postpneumonectomy empyema. The role of intrathoracic muscle transposition

Forty-five patients (36 male and nine female) were treated for postpneumonectomy empyema. All were initially managed with the first stage of the Clagett procedure (open pleural drainage). In 28 patients with associated bronchopleural fistula the fistula was closed and reinforced with muscle transposition at the time of open drainage. Seven patients had multiple flaps. The serratus anterior muscle was transposed in 28 patients, latissimus dorsi in 11, pectoralis major in four, pectoralis minor in one, and rectus abdominis in one patient. After the fistula was closed and the pleural cavity was clean, the second stage of the Clagett procedure (obliteration of the pleural cavity with antibiotic solution and closure of the open pleural window) was done. The number of operative procedures ranged from 1 to 19 (median 5.0). Length of hospitalization ranged from 4 to 137 days (median 34.0 days). There were six operative deaths (mortality rate 13.3%), none in the patients who had both stages of the Clagett procedure. Follow-up of the 39 operative survivors ranged from 2.1 to 90.2 months (median 21.8 months). Eighty-four percent of patients in whom the Clagett procedure was completed (26/31) had a healed chest wall with no evidence of recurrent infection. The bronchopleural fistula remained closed in 85.7% of patients (24/28). There were 19 late deaths, none related to postpneumonectomy empyema. We conclude that the Clagett procedure remains safe and effective in the management of postpneumonectomy empyema in the absence of bronchopleural fistula and that intrathoracic muscle transposition to reinforce the bronchial stump is an effective procedure in the control of postpneumonectomy-associated bronchopleural fistula.