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.     

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.     

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。     

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.     

肺切除术后支气管胸膜瘘的外科治疗

目的探索肺切除术后支气管胸膜瘘(BPF)的外科治疗措施和效果。 方法回顾性分析2000年1月至2013年12月上海市胸科医院收治的27例肺切除术后BPF患者的临床资料,分析其发生时间、原因和治疗措施,并总结治疗效果。 结果行肺切除术患者5010例,共发生27例BPF,发生率为0.5%。其中男性21例,女性6例;年龄31～67岁,平均年龄55岁。9例全肺切除后的BPF患者均首先采用了引流加胸腔内冲洗的方法,其中4例治愈,4例改开放引流,1例行心包胸膜修补瘘口,瘘口愈合,但脓胸一直存在。18例肺叶切除后的BPF患者中,手术后早期发生的BPF有12例,直接用大网膜消灭残腔,瘘口修补6例,完全康复;用肋间肌瓣和前锯肌瓣填塞胸腔、堵塞瘘口6例,其中4例完全一期愈合,2例引流时间较长;另6例BPF患者发生时间晚,且伴有营养缺乏,除局部引流外,改善营养后大网膜消灭残腔后4例均自愈,余2例用肋间肌瓣和前锯肌瓣填塞胸腔,术后胸管引流时间较长后痊愈。 结论BPF能够早期诊断,积极引流和冲洗胸腔是治疗BPF的有效措施,一部分可以自行愈合,而自体组织包括心包胸膜、自体肌瓣和带蒂大网膜等填塞胸内残腔、堵塞瘘口是治疗BPF的最有效办法,其中带蒂大网膜效果最佳。     

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.     

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.     

尿液转流在两种一期尿道下裂修复术中作用的比较

目的 通过对40例两种术式一期尿道下裂修复术的回顾性分析,比较尿液转流的作用。方法 将40例分为尿液转流组和非尿液转流组两组进行比较。结果 尿液转流组：阴囊纵隔皮瓣法有2例（2／14例,14％）同时并发尿瘘和感染,阴茎腹侧皮肤岛状瓣法有1／11例（9％）同时发生尿瘘及感染,非尿液转流组中阴茎腹侧皮肤岛状瓣法有4例（50％）发生尿瘘,阴囊纵隔皮瓣法无一例并发感染和尿瘘。结论 应用阴囊纵隔皮瓣一期再造尿道时可以不进行认转流,而在应用阴茎皮肤岛状瓣一期修复尿道下裂时,进行尿液转流有利于较小尿瘘的自行愈合及减少尿瘘的发生。     

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.     

The possibilities of greater omentum usage in thoracic surgery.

OBJECTIVE: To illustrate the wider role of an omental pedicle flap in surgical treatment for diverse thoracic organ disorders we have, retrospectively, reviewed our experience over the last 8 years. METHODS: We used the greater omental pedicle flap in 68 patients. Bronchial stump omentopexy was performed in 35 patients with a high risk of impaired bronchial healing after right pneumonectomy as a preventive method and in two patients with an acute bronchial fistula. In 13 patients after circular tracheal or carinal resections and in four after esophago-respiratory disjoints of fistulas we applied anastomoses or circular omentopexy of the fistula zone. The omental coverage was performed in four patients with chronic empyema, in seven patients after extensive chest wall resection and in two patients with post-sternotomy mediastinites. In one patient with idiopathic fibrosing mediastinitis, one-stage allotransplantation of tracheal thoracic segment was conducted and greater omentum (GO) was used to wrap the allograft. RESULTS: Three patients developed major complications. The first, bronchial fistula after bronchial stump omentoplasty. In two patients circular wide tracheal resection (11-12 rings) was complicated by a tracheal divergence of anastomoses. These complications were cured in a conservative way since a displaced omental flap substituted the tracheal wall and, therefore, the trachea remained hermetically sealed. In other cases, the perfect adhesive properties of the omental tissue promoted perfect adhesive properties promoted prevention of incompetence and inflammatory complications. Immunological and bacteriological examinations showed that pediculated omental flap is a lymphocyte source and promotes a decrease in bacterial quantity and activity. CONCLUSION: We think the series demonstrates the value of the omental method, which offers excellent therapeutic results following an easy surgical procedure. This method extends indications for surgical treatment and decreases the postoperative complications.     

Management of empyema cavity with the vacuum-assisted closure device

Management of empyema after pulmonary resection remains a challenging problem. Along with mandatory drainage of the thoracic cavity and investigations to rule out bronchopleural fistula, a reliable method of thoracic cavity closure is needed. The open thoracic window and Eloesser flap techniques rarely represent definitive therapy. Muscle flap and thoracoplasty procedures may provide well-vascularized tissue to close bronchopleural fistula and obliterate the empyema cavity, but they are quite complex and involve significant patient morbidity. We report a case of empyema without bronchopleural fistula after lobectomy in which the vacuum-assisted closure device was used to achieve complete wound healing after open drainage.     

The diaphragmatic flap: A multiuse material in thoracic surgery

BACKGROUND: The use of diaphragmatic pedicle flaps for reconstructive procedures in thoracic surgery is not very popular. Nevertheless, it provides considerable advantages. METHODS: Our experience covers 10 years (1987-1997) with a total of 25 patients in whom the diaphragmatic flap was used for different purposes. In 6 patients we used the diaphragmatic flap to protect the bronchopleural fistula at its early onset, which was not beyond 12 hours from the clinical diagnosis. We performed prophylactic suture protection after neoadjuvant therapy in 9 high-risk patients who underwent pneumonectomy and in 2 who underwent sleeve lobectomy. Postpneumonectomy pericardial defect repair was performed in 4 patients. In another 4 patients the diaphragmatic flap was used after spontaneous (n = 2) and iatrogenic (n = 2) lesions of the esophagus after 24 to 72 hours. RESULTS: No perioperative mortality was recorded. Complications were mainly related to the severe preoperative conditions of the patients: arrhythmia, respiratory insufficiency, and empyema. We report only 2 cases of minimal persistent bleeding from the chest tube, which spontaneously ceased. For those patients who survived for more than 1 year (n = 11), no diaphragmatic hernias were recorded. Bronchopleural fistulas and pericardial defects healed in all instances. The diaphragmatic flap was also effective in bronchopleural fistula. A late fistula caused by cancer relapse at the bronchial stump developed in only one patient. Excellent repair was achieved in all patients with esophageal lesions. CONCLUSIONS: We conclude that the diaphragmatic flap can be considered a practical, safe, and redundant material particularly indicated for defect or fistula closure and for suture line protection in the thoracic cavity.     

One stage repair for an oesophageal fistula after pneumonectomy using an omental pedicle flap.

A 67 year old man developed an oesophageal fistula after a pneumonectomy that was complicated by an empyema. An omental pedicle flap was brought through the diaphragm to repair the fistula and to fill the empyema space. The outcome was successful.     

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.     

尿液转流在两种一期尿道下裂修复术中作用的比较

目的通过对40例两种术式一期尿道下裂修复术的回顾性分析,比较尿液转流的作用。方法将40例分为尿液转流组和非尿液转流组两组进行比较。结果尿液转流组:阴囊纵隔皮瓣法有2倒(2/14例,14%)同时并发尿瘘和感染,阴茎腹侧皮肤岛状瓣法有1/11例(9%)同时发生尿瘘及感染,非尿液转流组中阴茎腹侧皮肤岛状瓣法有4例(50%)发生尿瘘,阴囊纵隔皮瓣法无一例并发感染和尿瘘。结论应用阴囊纵隔皮瓣一期再造尿道时可以不进行尿液转流,而在应用阴茎皮肤岛状瓣一期修复尿道下裂时,进行尿液转流有利于较小尿瘘的自行愈合及减少尿瘘的发生。     

尿液转流在两种一期尿道下裂修复术中作用的比较

目的通过对４０例两种术式一期尿道下裂修复术的回顾性分析，比较尿液转流的作用。方法将４０例分为尿液转流组和非尿液转流组两组进行比较。结果尿液转流组：阴囊纵隔皮瓣法有２例（２／１４例，１４％）同时并发尿瘘和感染，阴茎腹侧皮肤岛状瓣法有１／１１例（９％）同时发生尿瘘及感染，非尿液转流组中阴茎腹侧皮肤岛状瓣法有４例（５０％）发生尿瘘，阴囊纵隔皮瓣法无一例并发感染和尿瘘。结论应用阴囊纵隔皮瓣一期再造尿道时可以不进行尿液转流，而在应用阴茎皮肤岛状瓣一期修复尿道下裂时，进行尿液转流有利于较小尿瘘的自行愈合及减少尿瘘的发生。     

Single-stage repair of urethral fistula by vascular island groin flap

A new technique for the repair of a urethral fistula at the penoscrotal junction is presented. Under local anaesthesia we have successfully repaired six of these fistulae using a groin island pedicle flap. The urethra is repaired by mobilising the mucous lining around the fistula and closing it longitudinally, using absorbable 4/0 chromic catgut sutures. The groin island pedicle flap which is based on superficial circumflex iliac vessels is used to cover the repaired lining. The donor defect is closed primarily. In all six cases there was primary healing. This procedure is recommended for cases where the skin around the fistula is badly scarred or where previous attempts at closure have failed. Moderate defects of penile and scrotal skin can also be repaired by this type of flap.     

Closure of a large bronchial fistula with a latissimus dorsi myocutaneous flap

We describe a case of a large bronchial fistula and empyema after right upper lobectomy that was treated successfully with open window thoracostomy followed by a latissimus dorsi myocutaneous flap and limited thoracoplasty. A latissimus dorsi myocutaneous flap can provide immediate airtight closure of a large bronchial fistula, allowing lavage and curettage of the empyema cavity to reduce the chance of postoperative infection. An important aspect of this technique is that the deepithelialized skin side rather than muscle is sutured to an opening of the bronchus. As compared with other techniques, a latissimus dorsi myocutaneous flap is superior in that it requires a single incision and does not require an intraop-erative change of position. In addition, the technique causes little dysfunction of the chest and shoulder and preserves the vascular supply to ensure the viability of the flap even if it was divided in a previous operation.     

带蒂膀胱瓣修补膀胱阴道瘘38例疗效分析

目的：探讨带蒂膀胱肌瓣修补膀胱阴道瘘的临床疗效。方法：对我院38例行带蒂膀胱肌瓣覆盖修补膀胱阴道瘘患者进行回顾性分析。初次修补患者22例,二次以上修补患者16例;单纯瘘口修补术25例,修补并输尿管膀胱再植术13例。结果：38例患者中有37例获得随访,1例失访。一次手术成功率94.59％（35／37）;1例手术失败,行二次修补治愈;1例术后出现膀胱缝合口漏尿,留置导尿2周后消失。术后随访患者均未出现阴道漏尿,6例患者出现轻度。肾积水,13例患者出现轻度尿失禁。结论：利用带蒂膀胱瓣覆盖修补瘘口是治疗膀胱阴道瘘的有效方法。