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.     

A modified pectoralis muscle flap for closure of postpneumonectomy esophagopleural fistula: technique and results

In surgical treatment of late postpneumonectomy esophagopleural fistula, closure of the empyema space is of prime importance. A wide thoracoplasty and ample decapitation of the empyema cavity allow sufficient room for a modified pectoralis muscle flap, which provides sufficient mass to obliterate the entire empyema cavity. We present the cases of 2 patients in whom an esophagopleural fistula occurring 3 and 16 years after pneumonectomy was successfully closed by this method.     

A new technique for muscle flap closure of the empyema space in complicated chronic bronchopleural fistula

OBJECTIVES: It is difficult to close the empyema space once it is opened, especially in cases complicated with a chronic bronchopleural fistula. A muscle flap closure is generally employed to prevent this situation. However, this operation occasionally fails because the space newly recurs around the fistula due to atrophic change occurring in these translocated muscles. The aim of the present new technique was to prevent inspiratory pressure from the inside of the bronchus by bronchial emboli, and help the adhesion between the fistula stump and the muscle flap, even if they have become atrophic and no longer have sufficient volume to fill the entire empyema space. METHODS: We carried out fiberscopic embolism of causative bronchioles followed by muscle flap closure in 4 patients in whom open drainage had already been performed against parapneumonic empyema within the bronchial fistula. The bronchial fistula was plugged from the inside of the bronchus by silicon material, and stainless steel wire was used to connect this plug tightly to the muscle flaps, so that the fistula was sandwiched between them. In all cases, we succeeded in complete closure of the bronchial fistula and empyema space without using the omentum, and there has been no recurrence. CONCLUSION: The presented new technique was beneficial for achieving muscle flap closure of the empyema space with a chronic bronchopleural fistula.     

Thoracoplasty: its forgotten role in the management of nontuberculous postpneumonectomy empyema

The role of thoracoplasty in the management of empyema complicating pneumonectomy is controversial because alternative techniques, such as pedicled muscle transplants or open-space sterilization, have now replaced the conventional collapse procedures. Among 46 patients treated for postpneumonectomy empyema during the years 1975 to 1984, 17 underwent space-reducing thoracoplasty as the final step in pleural space management. Technical considerations, critical in the success of the operation, were: (a) single-stage extramusculoperiosteal resection of the second to the seventh rib, (b) sparing of the first rib to maintain integrity of the neck and shoulder girdle, (c) intercostal muscle closure of large fistulas and (d) adequate drainage of pleural and extrapleural spaces. Immediate control of the empyema was obtained in 15 (88%) patients. Fourteen patients were alive at the time of follow-up (mean 4.5 years) and none had major thoracic deformity or residual infection. Our data show that thoracoplasty is an excellent therapeutic option for patients with chronic postpneumonectomy empyema. Adherence to strict surgical principles ensures that the space is obliterated and the cosmetic result is satisfactory.     

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.     

Clinical experience of omental pedicle flap for bronchopleural fistula

We present two patients who underwent the omental pedicle flap method for bronchopleural fistula. The first case was a 61-year-old man who developed empyema with bronchial fistula due to recurrent tuberculosis resisted to chemotherapy. He underwent complete muscle and omental flap closure of empyema space. The second case was a 63-year-old man who underwent pneumonectomy for adenocarcinoma of the lung. About two weeks after the operation, a bronchopleural fistula developed at the bronchial stump. He underwent complete omental flap closure of fistula. They are doing well 18 and 9 months following operation, respectively. The omental pedicle flap method is clinically useful as a closure method for bronchopleural fistula because of excellent blood supply of the omentum.     

Treatment of postpneumonectomy empyema with debridement followed by continuous antibiotic irrigation

BACKGROUND: The goal of this study was to determine the efficacy of treating postpneumonectomy empyema (PPE) with debridement followed by continuous antibiotic irrigation for pneumonectomy space sterilization. STUDY DESIGN: All patients presenting with PPE were evaluated. Patients with bronchopleural fistula (BPF) underwent thoracotomy for fistula closure and debridement. Patients without BPF underwent video-assisted thoracic surgery debridement. All patients then underwent intraoperative placement of an 8-F irrigation catheter and a 36-F drainage catheter. Two weeks of continuous antibiotic irrigation, as determined by cultures, were followed by collection of chest cultures on 3 consecutive days. If cultures returned negative, antibiotic was instilled into the chest and all catheters were removed. If cultures were positive, another 2 weeks of irrigation were reinitiated, adjusting the antimicrobial agent based on culture results. This regimen was repeated until three consecutive negative cultures were obtained. RESULTS: Over a 5-year period, 8 consecutive patients with PPE were evaluated. Two had BPF. Mean age was 56 years. Median time to empyema after pneumonectomy was 20 days (range 12 to 497 days). Mean irrigation duration was 40 days (range 18 to 72 days) and mean followup was 580 days (range 75 to 1,666 days). There was no treatment-associated morbidity or mortality. No patients experienced empyema recurrence during followup. CONCLUSIONS: PPE can be successfully treated with thoracic debridement followed by continuous antibiotic irrigation. This method avoids the morbidity of rib resection or thoracic cavity reduction procedures. Closure of BPF, if present, is a prerequisite. Debridement can be performed by video-assisted thoracic surgery in patients without fistula.     

A novel procedure using a tissue expander for management of persistent alveolar fistula after lobectomy

We treated a patient with postlobectomy persistent alveolar fistula using a tissue expander, which is a prosthesis widely used in plastic surgery. The patient had thoracic empyema develop after right bilobectomy for lung cancer, and consequently underwent drainage of empyema followed by muscle flap closure for alveolar fistula. A residual space remained, and air leak persisted. However, implanting and expanding a tissue expander enabled us to tightly fix the flap on the raw pulmonary surface, which eventually solved the air leak. The tissue expander greatly contributed to muscle flap closure for a persistent alveolar-pleural fistula with a large remaining thoracic space.     

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.     

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.     

Intrathoracic Transposition of a Pectoralis Major and Pectoralis Minor Muscle Flap for Empyema in Patients Previously Subjected to Posterolateral Thoracotomy

The latissimus dorsi muscle flap cannot be used to eliminate an empyema cavity in patients who have previously undergone posterolateral thoracotomy, because of the division of this muscle. Moreover, thoracoplasty alone cannot sufficiently eliminate an empyema cavity that includes the thoracic apex, where space remains between the clavicle and the first rib. Therefore, we constructed a flap from the pectoralis major (P.Ma) and pectoralis minor (P.Mi) muscles to eliminate empyema cavities in five patients who had undergone lobectomy (n = 3) or pneumonectomy (n = 2) via posterolateral thoracotomy from 3 months to 40 years previously. All five patients had bronchopleural fistulae, and because of the previous upper lobectomy or pneumonectomy, they had large empyema cavities including the thoracic apex. Open-drainage thoracotomy was performed due to severe infection, and intrathoracic transposition of the P.Ma and P.Mi muscle flap with simultaneous thoracoplasty was carried out 7–124 weeks (mean 38 weeks) later. The P.Ma and P.Mi muscle flap easily reached the apex space with sufficient obliteration of the empyema cavity. All of the patients remained free of empyema 12–85 months after thoracic closure. The P.Ma and P.Mi muscle flap is useful for eliminating empyema cavities including the thoracic apex in patients who have previously undergone a posterolateral thoracotomy. Received: December 28, 1999 / Accepted: November 20, 2000     

The history of surgery of empyema, thoracoplasty, Eloesser flap, and muscle flap transposition

This article discusses the surgical history of empyema, thoracoplasty, the Eloesser flap, and muscle flap transfer. Little has changed in the 2000 years since the treatment of empyema was originally described by Hippocrates. The basic concepts of drainage of the infected empyema and obliteration of the space by allowing the lung to come up to the chest wall, taking the chest wall down to the lung, or by using muscle flaps or antibiotic solution remain the stabilizing forces in the treatment of postresection or postinfectious empyemas.     

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.     

Developing bronchial fistulas as a late complication of extraperiosteal plombage.

A 65-year-old male, who underwent extraperiosteal plombage for pulmonary tuberculosis 46 years ago, was referred to our hospital due to relapsing hemosputa and pneumonia. A chest computed tomography scan revealed a bronchial fistula and a fluid collection in one Lucite ball. On May 20, 1996, a right-anterior thoracotomy was performed in a supine position. Five Lucite balls were removed, and the empyema space was tightly filled with an omental pedicle flap. Although the bronchial fistulas were not sutured directly, the air leakage from the drainage tube ceased 12 days later. Two years postoperatively the patient has remained well. Our simple approach of combining an anterior thoracotomy and replacement of an empyema space with an omental pedicle flap in the same posture, without closing bronchial fistulas, would be an easy procedure, and therefore exploitable in patients who have a similar problem.     

Developing bronchial fistulas as a late complication of extraperiosteal plombage

A 65-year-old male, who underwent extraperiosteal plombage for pulmonary tuberculosis 46 years ago, was referred to our hospital due to relapsing hemosputa and pneumonia. A chest computed tomography scan revealed a bronchial fistula and a fluid collection in one Lucite ball. On May 20, 1996, a right-anterior thoracotomy was performed in a supine position. Five Lucite balls were removed, and the empyema space was tightly filled with an omental pedicle flap. Although the bronchial fistulas were not sutured directly, the air leakage from the drainage tube ceased 12 days later. Two years postoperatively the patient has remained well. Our simple approach of combining an anterior thoracotomy and replacement of an empyema space with an omental pedicle flap in the same posture, without closing bronchial fistulas, would be an easy procedure, and therefore exploitable in patients who have a similar problem.     

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.     

Thoracoplasty: current application to the infected pleural space

Thoracoplasty, once commonly used in the management of cavitary pulmonary disease, continues to find application in the obliteration of infected pleural spaces. This study reports a series of 13 patients receiving thoracoplasty between 1976 and 1989. Five patients had chronic apical empyema spaces without prior resection of lung tissue. Two of the empyemas were due to tuberculosis, two were due to atypical mycobacteria, and one was due to postpneumonic empyema. All patients had extensive destruction of upper lobe tissue. Eight patients had undergone prior pulmonary resection; 3 had persistent infected spaces in the early postoperative period, 3 had development of empyemas and bronchopleural fistulas late (5 to 19 years) after pulmonary resection, and 2 had postpneumonectomy empyema. All patients had rigid cavity walls preventing space obliteration by rib removal alone and required concomitant resection of the thickened pleura and intercostal muscle tissues. Bronchopleural fistulas were present in 11 patients and were closed with adjacent nonintercostal muscle. All patients survived and had successful obliteration of the infected spaces with acceptable physiological and cosmetic results. We conclude that thoracoplasty remains a useful procedure in the management of the infected pleural space in select patients.     

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.     

Chest wall resection and reconstruction: a case series of 20 patients in Hospital Kuala Lumpur,Malaysia

Chest wall resection is defined as partial or full-thickness removal of the chest wall. Significant morbidity has been recorded, with documented respiratory failure as high as 27%. Medical records of all patients who had undergone chest wall resection and reconstruction were reviewed. Patients’ demographics, length of surgery, reconstruction method, size of tumor and chest wall defect, histopathological result, complications, duration of post-operative antibiotics, and hospital stay were assessed. From 1 April 2017 to 30 April 2019, a total of 20 patients underwent chest wall reconstructive surgery. The median age was 57 years, with 12 females and 8 males. Fourteen patients (70%) had malignant disease and 6 patients (30%) had benign disease. Nine patients underwent rigid reconstruction (titanium mesh for sternum and titanium plates for ribs), 6 patients had non-rigid reconstruction (with polypropylene or composite mesh), and 5 patients had primary closure. Nine patients (45%) required closure with myocutaneous flap. Complications were noted in 70% of patients. Patients who underwent primary closure had minor complications. In total, 66.7% of patients who had closure with either fasciocutaneous or myocutaneous flaps had threatened flap necrosis. Two patients developed pneumonia and 3 patients (15%) had respiratory failure requiring tracheostomy and prolonged ventilation. There was 1 mortality (5%) in this series. In conclusion, chest wall resections involving large defects require prudent clinical judgment and multidisciplinary assessments in determining the choice of chest wall reconstruction to improve outcomes.     

Postpneumonectomy esophagopleural fistula--successful one-stage repair with omental flap and thoracoplasty

A 69 year-old man, who had undergone left pneumonectomy for squamous cell carcinoma of the lung 21 months ago, was admitted with a high temperature and chest pain. A diagnosis of empyema was made, and a chest tube was inserted for drainage. Bronchopleural fistula was not noted. Noticing that food was leaking through the drainage tube, a diagnosis of esophagopleural fistula was made radiologically. Surgery was done in October, 1987, after irrigating an empyema space for two months. The fistula was approximately 4 cm below the carina, and it was closed directly. The omentum was sutured around the closed site to reinforce and obliterate the empyema space. Furthermore, additional thoracoplasty was done because the cavity was too large to close only with the omentum. The postoperative course was uneventful. He was able to eat specially prepared foods within 4 weeks, and was discharged on the 60th day after the operation. This patient could possibly be the first case who had undergone an omental flap for the closure of a postpneumonectomy esophagopleural fistula.