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.     

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.     

Intrathoracic muscle flaps. An account of their use in the management of 100 consecutive patients.

One hundred consecutive patients underwent intrathoracic muscle transposition between May 1977 and February 1988. Seventy-three procedures were performed to manage the complications of infection, which included treatment of bronchopleural fistula, postpneumonectomy empyema, perforations of the heart or great vessels, and fistulae of the esophagus and trachea. Prophylactic reinforcement of the repaired viscus was done in the remaining 27 patients because of either increased airway tension or previous intrathoracic radiation. There were 71 male and 29 female patients. Ages ranged from 16 to 82 years (median, 58 years). One hundred thirty muscle transpositions were performed and included 60 serratus anterior flaps, 33 latissimus dorsi, 28 pectoralis major, 3 intercostal, 2 rectus abdominus, and 4 others. The number of operations per patient ranged from 1 to 13 (median, 2). Seventy-six complications occurred in 35 patients. There were 16 operative deaths. Follow-up ranged from 3.4 to 150.7 months (median, 41 months). Infection was controlled or avoided in 73 patients. Forty-three of the operative survivors died. Cause of death was cancer in 27 patients, cardiac in 4, pulmonary in 3, infection in 3, suicide in 1, and unknown in 5. We conclude that although associated with a significant morbidity and mortality, intrathoracic muscle transposition when there is an actual or potential leak of an intrathoracic viscus can be life saving. Long-term survival, however, is determined by the pre-existing thoracic disorder.     

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.     

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.     

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.     

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.     

Bronchopleural fistula repair during Clagett closure utilizing a collagen matrix plug

We describe a 65-year-old man who was treated for an empyema after a right middle and lower lobectomy for adenocarcinoma with a Clagett procedure who subsequently had a bronchopleural fistula develop. After adequate debridement of the cavity through dressing changes, the right bronchus intermedius bronchopleural fistula was closed using a collagen porcine plug (Surgisis anal fistula plug [Cook Medical Inc, Bloomington, IN]) placed through the cavity into the fistula along with the placement of omentum into the cavity. This case report illustrates the utility of collagen plugs to close bronchopleural fistulas.     

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.     

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.     

支气管胸膜瘘合并难治性脓胸个体化综合治疗分析

目的总结和分析支气管胸膜瘘合并难治性脓胸个体化综合治疗的方法和疗效。 方法2015年7月—2019年11月共收治支气管胸膜瘘合并难治性脓胸患者12例,其中男性10例,女性2例;年龄23～78岁,平均(60.75±15.05)岁。初始手术为非小细胞肺癌4例,肺部良性疾病4例,包裹性胸腔积液3例,恶性胸腺瘤肺转移1例。胸膜瘘发生后,采取经脓胸引流控制感染和介入封堵瘘口治疗;病情基本稳定后,行肌瓣移植术填塞脓腔等综合措施,并根据病情进行个体化治疗。 结果全组无围手术期死亡病例;在平均17.45个月的随访中,1例患者因肿瘤转移死亡;1例复发小脓腔;其余10例无支气管胸膜瘘和脓胸复发,肌瓣存活,复查胸部CT/MRI显示脓腔被彻底填塞。 结论对支气管胸膜瘘合并难治性脓胸患者采取个体化综合治疗措施,能达到彻底根治的目的,成功率高,疗效显著,值得推广。     

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。     

Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication

The management of postpneumonectomy empyema remains a disturbing and controversial area in the field of thoracic surgery. Many methods have been described and have had varying degrees of success. We present a series of 5 consecutive patients who underwent single-stage complete muscle flap closure of the pneumonectomy space with extrathoracic muscle flaps and omental grafts between October, 1981, and April, 1983. Two men and three women ranging from 37 years to 64 years old underwent such a closure from 3 to 13 months after original resection. Two patients had associated bronchopleural fistula. Prior to closure, 3 patients were managed with chest tubes and 2 with a modified Eloesser procedure. All operations were single-stage procedures, and all wounds closed primarily, with no permanent tubes or chest wall openings. There was no morbidity or mortality, and no subsequent operation has been required. Single-stage complete muscle flap closure of the postpneumonectomy empyema space has not been described previously, and we think it offers a possible solution to this potentially fatal complication.     

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.     

Clagett open-window thoracostomy in patients with empyema who had and had not undergone pneumonectomy

Patients with empyema not responding to simple chest-tube drainage and antibiotic therapy have been managed by a "Clagett"-type procedure that consists of open-window thoracostomy, antibiotic irrigation and closure of the window. The results of such treatment were reviewed. Of the 103 patients with empyema treated between 1967 and 1983, 41 underwent open-window thoracostomy. Twenty-eight (group 1) had empyema after pneumonectomy, 13 (group 2) did not; however, 9 of the 13 in group 2 had undergone lobectomy. The mean follow-up was 46 months for group 1 and 42 months for group 2. When surgical closure of the open-window thoracostomy was attempted, the success rate in group 1 was 85% for those without concomitant bronchopleural fistula, but only 36% in patients with a fistula. In group 2 the respective success rates were 50% and 57%. Unsuccessful closure resulted in chronic fistulas in four patients in each of the two groups. Six deaths in group 1 and two in group 2 were related to the original disease, but one was an operative death. These results demonstrate both the effectiveness and limitations of open-window thoracostomy in the management of these difficult cases.     

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.     

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.     

Transposition of modified latissimus dorsi musculocutaneous flap in the treatment of persistent bronchopleural fistula after posterolateral incision

The condition of a 51-year-old man was complicated with empyema and bronchopleural fistula (BPF) after left upper lobectomy and thoracoplasty for pulmonary aspergillosis. On the postoperative day (POD) 12, the opened bronchial stump was directly closed and covered with a pedicled pectoralis major muscle flap. On POD 66, an open-window thoracostomy was done, because of empyema with Pseudomonas aeruginosa. Two years later, we could fill the empyema cavity, and close the multiple BPFs with the transposition of a modified pedicled musculocutaneous (MC) flap and the additional thoracoplasty to gain good quality of life. Although the MC flap was a proximal part of the latissimus dorsi muscle, which was dissected along the posterolateral incision of the first operation, it could be successfully transplanted to cover the BPFs in the open-window. In some patients with a small open-window on the upper anterior chest wall, the pedicled proximal latissimus dorsi MC flap may be very useful for treating persistent BPFs even after a standard posterolateral incision.     

Endoscopic closure of bronchopleural fistula after pneumonectomy by submucosal injection of polidocanol

We report two cases of a bronchopleural fistula with, and without, empyema treated by endoscopic submucosal injection of polidocanol (sclerotherapy) and application of cyanoacrylate. Case 1: A 60-year-old man underwent left pleuropneumonectomy for lung cancer. He developed bronchopleural fistula with empyema at 32 days after the operation. We performed sclerotherapy around the fistula. The air leakage stopped at 2 weeks after the sclerotherapy, and the fistula was closed. He was eventually cured of the empyema by pleural drainage. Case 2: A 61-year-old man underwent left pneumonectomy for lung cancer. He developed bronchopleural fistula without empyema at 50 days after the operation. We performed sclerotherapy and application of cyanoacrylate. After this therapy, the air leakage stopped immediately, and the bronchopleural fistula was closed. The sclerotherapy and application of cyanoacrylate are not only technically easy, but also very effective for treatment of bronchopleural fistula. Sclerotherapy and cyanoacrylate may be advocated as a first therapeutic step.