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."     

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.     

The Eloesser flap: past and present

Leo Eloesser designed a flap to drain acute tuberculous empyema in the 1930s. The original concept and design are no longer efficacious because of the introduction of antibiotics and antituberculous drugs. The flap has been modified in both concept and design over the years and is used today for drainage of chronic empyemas, with or without bronchopleural fistulas. The history of the flap will be discussed.     

Study of surgical treatment with omental flap transposition for chronic empyema

It is difficult to determine what kind of appropriate operations should be applied for which phase of chronic empyema would be administered, especially for a surgical management. We report that the postoperative outcomes of the treatment should be recommended for chronic empyema with the aid of omental flap transposition. Seven cases of chronic empyema (the averaged age was 66.1 +/- 7.5, 6 males and 1 female) in our hospital were operated during from June 1993 to January 2001. The disease-carrying time was 3 to 16 months and the inflammation findings at the admission were positive in all cases. The cause of chronic empyema was pneumonia (n = 3), plombage for tuberculosis (n = 2), and postlobectomy empyema (n = 2). As the first-stage of treatment for empyema cavity, intrathoracic tube drainage and lavage were performed for all cases. The operative procedures were described as below; one-stage operation with both thoracostomy and omental flap transposition was performed after the first-stage treatment (n = 2), simple thoracostomy (n = 1), and two-stage operation with thoracotomy and omental flap transposition (n = 4). Three of the 4 cases with two-stage operation could be completely treated for 1 month interval. However, the rest one case had not been able to be radically cured, which empyema had been extensively turned for the worse for one month after the two-stage operation. Thoracostomy had been redone, and it took 8 months to be cured. All cases could be finally recovered and discharged. On the priority of treatment for chronic empyema, at first, both thoracic tube drainage and thoracostomy should be performed as a first-stage operation, and if they could not be effective, after the combined inflammation was settled down, then the omental flap transposition should be considered as a two-stage operation.     

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.     

Paraspinous muscle flap for the treatment of an empyema cavity

For the reconstruction of defects localised near the midline region of the back, there have been occasional reports of reconstruction using a paraspinous muscle flap; however, to the best of our knowledge, there have been no reports of empyema space reconstruction using a paraspinous muscle flap. A patient who developed empyema after a pulmonary lobectomy and in whom a paraspinous muscle flap was used to reconstruct a dead space in the medial region of the upper back created by fenestration is presented. The dead space was filled sufficiently, and the patient had a favourable course without complications. Although the rotation arc of the paraspinous muscle flap is limited, the flap's blood flow is stable, and flap elevation is easy and less invasive. The paraspinous muscle flap is useful for filling and closing a defect near the midline region of the back.     

Orbicularis transposition flap for muscle suspension in lower blepharoplasty

Different problems can be encountered when planning a lower blepharoplasty, such as festoons, prominent fat bags, and a conspicuous transition from eyelid to cheek. Frequently, they occur simultaneously. In such cases, a larger amount of skin excision is needed to achieve an adequate correction. This carries an increased risk of eyelid retraction when dealing with hypotonic eyelids. Orbicularis muscle suspension can provide vertical support to the eyelid and so achieve a safer, more effective correction. Several techniques have been reported to obtain this effect. We have found a laterally based transposition orbicularis flap to be a safe end effective method to transmit a controlled amount of traction to the lower lid.     

Intrathoracic muscle flap transposition in the treatment of fibrocavernous tuberculosis

Background and objective: Conventionally, pulmonary resection with thoracoplasty is used to treat fibrocavernous complication of pulmonary tuberculosis. This operation is usually bloody, time-consuming with complicated postoperative course. To prevent massive blood loss and preserved pulmonary function, a more simplified operative procedure, cavernostomy combined intrathoracic muscle flap transposition was used and the outcome was evaluated in this study. Design: Retrospective review. Methodology: Between December 1989 and June 1996, a total of ten patients with fibrocavernous pulmonary tuberculosis were managed using cavernostomy combined with intrathoracic muscle flap transposition. Five of them had concomitant aspergilloma within the cavity while three had multiple drug resistant pulmonary tuberculosis. The muscle flap was used to plombage the cavity and reinforce the closure of bronchopleural fistula after cavernostomy. Results: Six postoperative complications occurred in five patients, including reformation of cavity (2), bronchopleurocutaneous fistulae (3), and postoperative bleeding (1). The success or failure of intrathoracic muscle flap transposition on patients with fibrocavernous tuberculosis was significantly correlated with the size of the cavity (194.0±11.2 vs. 283.0±44.6 cm³, P=0.016) and the number of bronchopleural fistulae (1.6±0.4 vs. 4.0±0.4, P=0.008). There was no operative death and in long term follow-up, there was no recurrence of hemoptysis or deterioration of pulmonary function in the successful group of patients. Conclusions: Cavernostomy combined with intrathoracic muscle flap transposition can be used to treat well-selected fibrocavernous pulmonary tuberculosis patients, except on patients with large size cavity, multiple bronchopleural fistulae or multiple drug resistance tuberculosis.     

Treatment of complicated pulmonary aspergillomas with cavernostomy and muscle flap: interest of concomitant limited thoracoplasty

Objective: Lung resection for complex aspergilloma (CA) carries high morbidity and mortality and remains controversial in high-risk patients. Cavernostomy followed by muscle-flap plombage has been recommended for patients considered unfit for resection, but subsequent muscle-flap atrophy may be a main cause of failure. We reviewed the place of a limited thoracoplasty in association with that procedure. Methods: Five patients complaining of haemoptysis related to CA were denied lung resection because of bilateral lung destruction (n = 1), and required completion pneumonectomy (previous lobectomy for cancer followed by adjuvant radiation therapy, n = 4). We analysed the data concerning the alternative surgical procedures performed and their immediate and late results. Results: The surgery consisted in cavernostomy, removal of the fungus ball, cavity obliteration with the most directly available muscle flaps (rhomboid muscle n = 2, trapezius and rhomboid n = 2, serratus major and subscapular n = 1). A limited thoracoplasty ranging from 2 to 5 portions of rib (mean resected rib portions n = 3.4) was performed in addition to this procedure. The postoperative course was uneventful. All patients are still alive (mean follow-up 3 years; range: 1–6 years) and faring well without thoracoplasty-related aftereffect, complication related to muscle-flap disuse atrophy nor recurrence of the disease. Conclusion: Cavernostomy followed by muscle transposition has been reported to provide encouraging results. Combining a limited thoracoplasty during the same operation is a simple, safe and well-tolerated procedure regularly achieving good results, and thus deserving consideration.     

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.     

Conjoint muscle free flap for obliteration of an upper thoracic empyema cavity

Successful obliteration of an empyema cavity with vascularized flaps can, on occasion, best be accomplished using a free tissue transfer. A conjoint free muscle flap captures the immunological attributes of muscle necessary in the infectious milieu of these defects, augments the potential flap volume required to fill these often large defects, yet relies on only a single recipient site for the requisite microanastomoses. These advantages are demonstrated by a case using a combined latissimus dorsi/serratus anterior conjoint muscle free flap to obliterate a chronic upper thoracic empyema cavity. The internal mammary vessels were the most readily accessible recipient site, and should be considered an important alternative when managing these challenging wounds of the upper chest.     

易位扩张皮瓣的逆行设计和应用

目的:总结易位扩张皮瓣在修复头面颈部皮肤缺损中的设计方法及应用体会,探讨提高软组织扩张术效果的方法。方法:对25例头面颈部瘢痕、皮肤肿瘤患者,根据易位转移扩张皮瓣的设想,根据其皮肤缺损的形态、位置,进行合理逆行设计,采用国产硅橡胶扩张器行皮肤扩张术,应用易位转移扩张皮瓣为主的方式修复。结果:本组共形成40个易位扩张皮瓣,其中单纯易位扩张皮瓣11个,易位结合推进及旋转皮瓣29个。有1个易位扩张皮瓣出现远端血运障碍(0.5～2cm),其余皮瓣良好,修复效果满意。结论:根据易位转移扩张皮瓣的设想逆行设计,合理埋置扩张器,不失为提高软组织扩张手术效果的一种好方法。