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Eur J Cardiothorac Surg 1998;14:123-126
© 1998 Elsevier Science NL

Postpneumonectomy empyema¹

Department of General Thoracic Surgery, Medical University of Gdañsk, 80–211 Gdañsk ul. Dêbinki 7, Poland

Received 29 September 1997; received in revised form 24 March 1998; accepted 12 May 1998.

Corresponding author. Tel.: +48 58 461194; fax: +48 58 461194.

	Abstract

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Objective: Postpneumonectomy empyema can be managed in many different ways, with variable results. In the presence of bronchopleural fistula treatment is much more complicated. The results of therapy of postpneumonectomy empyema managed by thoracomyoplasty and closure of the bronchial fistula by pedicled muscle flap are presented. Methods: Seven hundred and seventy-eight pneumonectomies had been performed for bronchogenic carcinoma. Empyema occurred in 35 (4.5%) cases. There were 22 (62.8%) patients with associated bronchopleural fistula. Depending on their management, patients were divided into two groups: I: 15 patients managed with tube and/or open-window thoracostomy only, II: 20 patients who were treated with thoracomyoplasty, which meant the excision of the fibrotic thoracic wall, combined with the transposition of the pedicled muscle flap into the empyema. There was a need to resect three to four ribs. Eight patients had large bronchopleural fistulas. Before thoracomyoplasty was conducted, tube drainage ranged from 16 to 120 days (average 46.6 days), the open-window thoracostomy ranged from 27 days to 13 years (average 574 days). Results: Only one patient from group I was cured, there were five (33.3%) deaths. Nineteen (95.0%) patients from group II were successfully cured. Eight large bronchial fistulas were closed by suturing the muscle flap into the fistula lumen. The length of hospitalisation ranged from 9 to 30 days (median 17.6). The mortality rate in this group was 0%. Conclusions: The excision of the thoracic wall combined with the transposition of the pedicled muscle flap is safe and effective in the management of postpneumonectomy empyema. Bronchopleural fistulae can be definitely closed by suturing the pedicled muscle flap into fistular lumen.

Key Words: Pnemonectomy • Empyema • Bronchopleural fistulas • Muscle flaps

	Introduction

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Amongst the various complications occurring after pneumonectomy, pleural empyema is one of the most serious, and is connected with high mortality, ranging from 16.4% to 71.2%. Mortality is especially high when the empyema is associated with a large bronchopleural fistula [1] [2] [4] [5] [7] [8] [10] [12] [13].

In this study, the results of therapy of postpneumonectomy empyema managed by thoracomyoplasty and closure of the bronchial fistula by pedicled muscle flap are presented.

	Materials and methods

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In the time period from January 1986 to December 1995, 778 pneumonectomy procedures were conducted. Empyema occurred in 35 (4.5%) patients. All patients were male and from 39 to 70 years of age (average 60.1 years).

The indication for performing the pneumonectomy was bronchogenic carcinoma in all cases; 12 (34.3%) patients had stage II disease, 23 (65.7%) patients had stage III-A disease.

In 24 (68.5%) patients the empyema was localised to the right side. The period of time from pneumonectomy to diagnosis of the empyema ranged from 7 to 540 days, average 103.4 days.

Bronchopleural fistula was diagnosed in 22 (62.8%) patients by bronchoscopy. In 19 cases, the fistula was localised on the right side (86.4%) and in three cases on the left side (13.6%). A fistula which was smaller than one-third of the width of the bronchial stump was called a microfistula and was recognised in 13 patients (59.1%). Larger fistulas were discovered in nine patients (40.9%), one of these patients had a large broncho–oesophageal fistula.

Patients were divided into two groups based on the therapy used, group 1: 15 patients, group 2, 20 patients. There were ten patients from group 1 who had microfistula of the bronchus.

Among group 2 were 12 broncho–pleural fistulas, three microfistulas and nine large ones.

Patients from group 1 were treated only with tube drainage and/or window thoracostomy. Four (26.6%) patients from this group died due to haemorrhage from erosion of the greater blood vessels, one (6.6%) patient due to sepsis, and six died due to cancer relapse. Only one patient was treated successfully with tube drainage. After 30 days the microfistula was closed spontaneously, and during the next 2 weeks the empyema was sterilised and then the tube drainage was removed.

The second group consisted of 20 patients. A multistage treatment regimen was used in this group, ending with thoracomyoplasty.

The empyema and thoracic wall were resected laterally from the anterior and posterior costomediastinal recesses as well as from the diaphragm to the second rib inclusively. The entire wall thickness of the thoracic cage was removed: the ribs, the intercostal muscles, as well as the pleural and fibrotic layers. Next, the pedunculated greater pectoral muscle was moved into the empyemal cavity, in this way filling the space lying under the first rib.

Small broncho–pleural fistulas, smaller than one-third of the width of the bronchial stump were healed spontaneously, whereas larger ones required closure. They were closed by suturing in the distal pedunculated fragment of the greater pectoral muscle into the fistular lumen, fixing the muscle using singular mattress sutures. In the case of a long bronchial stump, sutures were placed more closely to the bifurcation of the trachea. No attempt was made to separate the bronchial stump from the mediastinum and to suture it directly.

	Results

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Only one of 15 patients from the first group was cured with the use of standard drainage and flushing the empyema with antiseptics. The empyema was not successfully treated in any of the remaining patients of this group. Furthermore, mortality due to empyema was very high: five (33.3%) patients died. The cause of death in four patients was haemorrhage due to erosion of large blood vessels and in one toxaemia. Six patients in this group died due to relapse of the cancer in the sixth, seventh, tenth, 11th,18th and 20th months post-operatively. No patients were observed as having respiratory insufficiency requiring ventilatory support.

The second group included 20 patients who were involved in multistage therapy, ending in thoracomyoplasty. The length of each stage of therapy was as follows: tube drainage: 16–120 days (average 47.5 days),window thoracostomy: 27 days to 6 years, average 574 days (in two patients thoracostomy lasted 6 years). Nineteen patients were treated successfully by thoracomyoplasty (95.0%). The period of time from the operation to hospital release ranged from 9 to 30 days (average 17.6 days).

Three of the patients from group 2 had microfistula which healed spontaneously.

Eight of the patients from this group had a large broncho–pleural fistula. This, however, did not prolong therapy because the fistula was closed using the greater pectoral muscle, sutured into its lumen. The muscle also filled the fragment of the empyemal cavity lying under the first rib.

In one case of a large broncho–esophageal fistula from group 2, the oesophageal fistula as well as the bronchial one was closed using a deltoid muscle pedicle flap, and thoracoplasty was also conducted. The fistula recurred, however, to a much lesser degree. Histopathological examination of tissue taken from the area of the bronchial stump confirmed relapse of the cancer. The patient died 1 year after the operation.

	Discussion

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Very often empyema after pneumonectomy is associated with bronchopleural fistula; in our material it occurred in 62.9%. It should be assumed that in most cases, due to its microscopic size, the fistula is not diagnosed, however it is still the gate of infection of the postresectional cavity.

The surgeon has little influence over general factors affecting slow healing of the bronchus. However, the surgical technique in suturing the bronchial stump is of great importance. The bronchial stump should be short, and should be covered by well-vascularised tissues, especially after right-sided pneumonectomy (19–86.4% of bronchopleural fistulas in our cases occurred on the right side). Of value is the technique of decreased tension in the suture line, depending on the production of a lobe from the membranous part [14].

In acute empyema after pneumonectomy, a recognised method of therapy is tube drainage.

In chronic empyema, when the mediastinum becomes stiff, window thoracostomy is conducted.

Window thoracostomy allows the empyemal cavity to be kept clean, which provides good conditions for the covering of the empyemal walls with well-vascularised granulation tissue.

These two therapeutic methods of acute and chronic empyema after pneumonectomy are not controversial [6] [9] [12]. However, as to the further stages of therapy, differences are cited in the literature. For example, Clagett sterilises the empyemal cavity and resigns from its obliteration, but it still carries the risk of relapse [3].

I believe, that permanent recovery is possible through the obliteration of the empyemal cavity [4] [5] [12]. Classic thoracoplasty based on hypoperiosteal rib resection, leaving the fibrous and non-viable thoracic wall in place cannot be successful, however, resection of the entire thoracic wall including the ribs, intercostal fibrotic muscles and fibrotic pleurae, allows for direct contact with the flexible and well-nourished thoracic wall to the mediastinum and diaphragm. The operative trauma associated with this procedure is not great, because the cavity size of the chronic empyema is not large and it is not necessary to resect a large area of the thoracic wall. Moreover, the thoracic cage wall lying over the empyemal chamber is functionally inactive, its role having been taken over by a stiffened mediastinum.

The combination based on transposition of the pedicled muscle flap and thoracoplasty also decreases deformity of the thoracic cage. Although this deformation is of lesser importance for the acutely-ill patient in the context of freeing them of empyemal symptoms.

The approach to therapy of often-coexisting broncho–pleural fistulas is also varied. Transpericardial closure of the fistula is too big an operation and indicated only when the bronchial stump is too long, furthermore, this method does not solve the problem of the existing empyemal cavity, which in turn requires still another operation [2] [7] [11]. Separation of the bronchial stump from the mediastinum and direct closure of the bronchial fistula is dangerous and not very successful.

The suturing in of pedunculated muscle into the fistular lumen is a simple and very successful procedure ( Fig. 1 ). This has also been confirmed by the present author. Furthermore, the problem of a `long stump' does not exist, because the lobe can be attached in the bronchial lumen using sutures applied deeper, near the area of the bifurcation of the trachea.

View larger version (24K): [in this window] [in a new window]   Fig. 1. Closure of the large bronchiopleural fistula.

	Conclusions

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1. Thoracomyoplasty allowed for obliteration of the empyemal cavity and successful recovery in 95% of patients, and is a very effective method of treatment of empyema after pneumonectomy.
   
2. The closure of a large bronchopleural fistula with the use of a pedicle flap of the pectoral muscle sutured into its lumen is a safe and effective method.
   
3. Thoracomyoplasty is a universal procedure, possible to carry out with any empyema regardless of position, adaptation is only needed for thoracic cage wall resection.
   
4. Wide resection of the empyemal wall prevents constricture around the vascular pedicle of the muscular lobe.
   
5. Deformity of the thoracic cage being a result of thoracoplasty is accepted by patients who were formerly forced to deal with the burden associated with chronic empyema.
   

	Footnotes

 
Presented at the 11th Annual Meeting of The European Association for Cardio-thoracic Surgery, Copenhagen, Denmark, September 28 – October 1, 1997.

	Appendix A. Conference discussion

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Dr J. Thorpe (Sheffield, UK): This is a complicated area. I think, first of all, we must not get confused between postpneumonectomy empyema without a fistula and with a fistula. I think the managements are different to a certain extent. First of all, for the patients who have a postpneumonectomy empyema and you cannot identify a fistula, do you treat those with antibiotic irrigation and tube drainage?

Dr Jadczuk: Yes, first we use the normal tube drainage, and after a short time when the mediastinum is going to be stabilised we will do window thoracostomy, and, of course, we have a solution with the water and changing of the dressing in the pleural cavity. It is very important not to keep the window thoracostomy for a long time-period, as it is very important to choose a perfect time for the next step.

Dr Thorpe: And what do you think is the best time? When you have done a window thoracoscopy do you wait 1 month, 2 months?

Dr Jadczuk: Ranging from 3 to 6 weeks, not longer, because afterwards the granulation tissue is going to be fibrotic again and infection can come back.

Dr J.-M. Whilm (Strasbourg, France): It's interesting work with the kind of rehabilitation of thoracoplasty as a means to treat these patients, but I don't exactly agree. I would like you to explain to me better why just a good thoracoplasty is not good enough to obliterate the whole space, because you can take all the fibrous thickening of the cavity and you can twist the intercostal spaces which are just in front of your fistula and put the muscle on the other side without taking the pectoralis major as a muscle.

Dr Jadczuk: This question is very important. A good thoracoplasty must remove every corner of the empyema, but besides such a large thoracoplasty there is some space in the capula of the pleura, so this space is going to be filled by pectoral muscle, additionally it is being used to close the bronchial fistula, so there are two reasons to prepare that pectoral muscle; one, to fill the space below the first rib, the first fib is not resected and there is no chance for this region to collapse, and second, to close the bronchial stump.

Dr Whilm: Actually the good, the real thoracoplasty includes as the first treatment...

Dr Jadczuk: Yes, transposition of the pectoral muscle we combined with thoracoplasty.

Dr W. Klepetko (Vienna, Austria): We have a very limited experience with those cases. However, I want to make a plea for an alternative method which has the main strategy to avoid the need for any thoracoplasty. In the past few years we came upon four cases in whom we were able to make the thoracic cavity completely sterile. First the thoracic cavity was rinsed with antibiotics for two weeks. After gross cleaning patients were operated, and the empyema was handled like a normal empyema would be handled; that means a complete decortication, taking out all of the cortex, parietally and even on the mediastinal side, so that you get a grossly and microscopically completely clean thoracic cavity. Then the bronchial stump was closed by reshortening, if possible, and covered with omentum or any other biological material available. In these four cases there was one extraordinary case included. It was a patient who was referred from outside, with a history of two attempts to close the bronchial stump. First it was just resutured and 4 weeks later, in another attempt the omentum, was brought up. Even in that difficult patient, it was possible to clean the thoracic cavity completely. Drainages were left until the fluid that comes out proved to be sterile. This is a limited experience, with four cases, but it should point out the fact that there is a chance to get the thoracic cavity sterile if you really aggressively debride all of the necrotic tissue within the thoracic cavity.

Dr Jadczuk: I would be little bit afraid abut removing all this fibrotic tissue from the mediastinal side of the empyema. It can be quite risky. Also, I'm not trying to desect the bronchial stump because it can produce ischaemia of the bronchus. So I think it's better to just do a simple procedure, just suture the muscles inside the bronchial stump. Besides a bigger fistula is much easier to close than a small one.

	References

Top Abstract Introduction Materials and methods Results Discussion Conclusions Appendix A. Conference... References

 

1. Asamura H., Naruka T., Tsuchiya R. Bronchopleural fistulas associated with cancer operations. J Thorac Cardiovasc Surg 1992;104:1456.[Abstract]
2. Baldwin J.C., Mark J.B.D. Treatment of bronchopleural fistula after pneumonectomy. J Thorac Cardiovasc Surg 1985;90:813.[Abstract]
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4. Deschamps C., Trastek V., Arnold G., Pairolero C. Surgical approach to chronic empyema: decortication and muscle transposition. Int Trend Gen Thorac Surg 1990;6:233.
5. Virkkula L., Eerola S., Varstela E. Surgical approach to the chronic empyema: space sterilization. Int Trend Gen Thorac Surg 1990;6:263.
6. Eloeser L. Of an operation for tuberculous empyema. Ann Thorac Surg 1969;8:355.[Medline]
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8. Hankins J.R., Miller J.E. Attar S Bronchopleural fistula. J Thorac Cardiovasc Surg 1979;76:755.[Abstract]
9. Meyer J.A. Gottard bulau and closed water-seal drainage for empyema, 1875–1891. Ann Thorac Surg 1989;48:597.[Abstract]
10. Muller L.C., Abendstein B., Salzer G.M. Use of the greater omentum for treatment and prophylaxis of anastomotic and stump dehiscense in major airway surgery. Thorac Cardiovasc Surgeon 1992;40:323.[Medline]
11. Saito H., Tatsuzawa T., Kikkawa H. Transpericardial bronchial closure with omentopexy for postpneumonectomy bronchopleural fistula. Ann Thorac Surg, 1989;47:312.[Abstract]
12. Pairolero P.C., Arnold P.G., Piehler J.M. Intrathoracic transposition of extrathoracic skeletal muscle. J Thorac Cardiovasc Surg 1983;86:809.[Abstract]
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14. Sarsam M.A.I., Moussali H. Technique of bronchial closure after pneumonectomy. J Thorac Cardiovasc Surg 1989;98:220.[Abstract]

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