Eur J Cardiothorac Surg 1999;16:636-638
© 1999 Elsevier Science NL
One-stage pedicled omentum majus transplantation into thoracic cavity for treatment of chronic persistent empyema with or without bronchopleural fistula
Mingke Duan,
Guosheng Chen,
Tianri Wang,
Yu Zhang,
Ju Dong,
Zhanqing Li,
Tiequan Sui
Department of Thoracic and Cardiovascular Surgery, Affiliated Hospital of North China Coal Medical College, 063000 Tangshan, People's Republic of China
Corresponding author. Tel.: +86-315-372-5279; fax: +86-315-285-2195
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Abstract
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Objective: Assessment of the present results of surgical treatment for chronic persistent empyema with or without bronchopleural fistula (BPF) using one-stage pedicled omentum majus transplantation into the thoracic cavity. Methods: From November 1979 to December 1996, 50 patients with chronic persistent empyema were treated by pedicled omentum majus transplanted into the thoracic cavity. There were 35 men and 15 women, and the age range was 15–58 years. Empyema had been present for 0.5–18 years. Twenty-six of 35 cases with chronic tuberculous empyema and six of 15 cases with chronic bacterial empyema suffered from concomitant BPF (n=32). In the latter, the most common organisms were Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli. Results: There were no perioperative deaths. Two cases had a significant air leak on the first postoperative day. One of them underwent rethoractomy 30 h after the initial operation to stop the fistula using intrathoracic omentum. Thoracic dead space disappeared in most of the operated cases and a sterilized dry cavity remained in some cases. Conclusions: One-stage pedicled omentum majus transposition is a safe and easy procedure for chronic persistent empyema and BPF, it breaks down residual or recurrent inflammatory foci mechanically and closes the BPF effectively with minimal deformity of the chest wall.
Key Words: Chronic persistent empyema • Pedicled omentum majus transplantation • Bronchopleural fistula
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1. Introduction
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The key of treatment for chronic persistent empyema is thorough cavitary debridement with removal of all pus and necrotic tissue and re-expansion of healthy lung to fill the pleural space. Controlling any residual pulmonary disease and removing constricting tissue that prevents full lung expansion are, therefore, important considerations. In contrast, tuberculous empyema needs thoracoplasty [1]. A chronic organizing empyema is extremely morbid, can be very difficult to eradicate, and has a significant mortality rate. We have used a modified decortication and one-stage pedicled omental flap transplantation into thoracic cavity for treatment of 50 patients with chronic persistent empyema with or without bronchopleural fistula (BPF).
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2. Materials and methods
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From November 1979 to December 1996, 50 patients with chronic persistent empyema were treated by pedicled omentum majus transplanted into the thoracic cavity. There were 35 men and 15 women, and the age range was 15–58 years (mean of 38.2 years). The empyema had been present from 0.5 to 18 years. As shown in Table 1, 26 of 35 cases with chronic tuberculous empyema and six of 15 cases with chronic bacterial empyema suffered from concomitant BPF. Ninety percent of all patients had been underwent tube thoracostomy previously and the others had been required repeated puncture of the chest. For latter tube thoracostomy was performed firstly. Three patients with tuberculous empyema underwent decortication and conventional thoracoplasty 3, 3.5 and 5 years before admission, respectively. One case had a piece of 10-cm rubber tube in his thoracic cavity, stemming from previous open drainage. Another patient had undergone a plombage procedure 30 years previously in order to cure severe pulmonary tuberculosis with cavity formation. Two patients with postpeumonectomy empyema suffered from benign lung disease previously. One of them associated stage II silicosis concomitantly. Low to moderate fever was noted in 35 cases. Thirty of all patients had varying degrees of anemia and five had severe chronic obstructive pulmonary disease (COPD). In 37 cases significant functional limitation of their lung was present, despite maximum medical therapy and long-term tube drainage. Despite the administration of antibiotics in all patients before hospital admission, cultures from wounds, drainage or puncture were positive for pathogens in 41 cases (82%) and negative in nine (18%). In many patients there was mixed infection. The underlying organisms are illustrated in Table 2, the most common organisms being Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli. Aside from correction of anemia and hypoproteinemia, an effective antibiotic regime was started in all patients considered for operation. A combination of antituberculotic agents comprising isoniazid, rifampin and streptomycin was begun at the least 2 weeks preoperatively and was continued with isoniazid for the first postoperative year in all patients with tuberculosis of the lung or pleural.
Double-lumen endotracheal intubation was used for operation in all cases of BPF. Posterolateral chest incision was performed over the mid point of the empyema cavity or using previous chest incisions. After resection of one or two ribs and wide exposition of the empyema cavity a modified decortication was performed. Pus and all necrotic debris were thoroughly aspirated and scraped using a steel spoon. The parietal peel of the empyema cavity usually remained in place while the visceral peel was removed as far as possible in order to allow for obliteration of the dead space by expansion of the lung. In case of technical difficulties with decortication, netlike incisions of the visceral peel down to the surface of the lung was carried out. After August 1990 observation of tuberculous reactivation of the lung postoperatively in one case, in whom the visceral peel was removed successfully and complete expansion of the lung was observed 2 months postoperatively, the procedure of removal of the visceral peel was abandoned in the patients with pulmonary tuberculosis. In patients with BPF and lung abscess local debridement was necessary to close it. Then the cavity was sterilized by using tincture of 2% iodine. After the thoracic procedure patients were positioned supine with the affected hemithorax elevated with rolls. A supraumbilical upper midline incision was made and the omentum majus was separated from the stomach and the transverse colon, saving the right gastroepiploic vessels. The pedicled omentum was transferred into the thoracic cavity through an anterior incision of the diaphragm according to the side of the empyema. It was sutured to the uppermost portion of the cavity and the lung tissue or the incised peel. In the cases with BPF, the cleared fistula should be filled and covered by the omentum. Then the omentum was fixed onto the surrounding tissue with a few sutures. A drainage tube was inserted and was kept in place from 3 to 5 days.
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3. Results
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There were no perioperative deaths. Two cases had a significant air leak on the first postoperative day because the fistula either had not been found or was incompletely covered with the greater omentum. One of them underwent rethoractomy to obliterate the fistula using intrathoracic omentum 30 h after the initial operation with an uneventful recovery. In the other patient the tube drainage kept for long-term due to limitations of her general condition and financial problems. One case with severe COPD developed coma for 7 days and abdominal wound dehiscence because of accidentally taking an overdose of diazepam on the 8th postoperatively day. Ventilatory support was followed for 10 days and finally he was rehabilitated without any further problems. Follow-up (1–16 years, mean 8.5 years) was complete for all patients except two living in remote areas. Good control of the septic focus was obtained in all patients except for one who had undergone a plombage procedure previously. He developed a recurrent empyema due to complete expansion of the lung leading to tuberculous reactivation in the residual lung 4 months postoperatively. One of two cases with postpneumonectomy empyema recurred 5 months after the initial procedure but the fistula was closed successfully. In the other operated patients infection and fistula did not recur. Operative interventions was successful in 93.1% of the patients and the closure rate of BPF was 89.5%. In one patient with empyema and main stem bronchous fistula after left total pneumonectomy, was found to have right lung cancer as detected by bronchoscopy 5 years after the operation. She ultimately died of respiratory failure. One patient underwent successfully pericardiectomy because of calcified tuberculous pericarditis 10 years after the operation. Thoracic dead space disappeared in most of the operated cases and a sterilized dry cavity demonstrated by roentgenogram remained in some. There was minimal deformity of the thorax as compared with thoracoplasty and muscle transposition.
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4. Discussion
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Chronic persistent empyema is a difficult therapeutic problem. Despite advances in antibiotic and supportive therapy as well as operative technique including tube thoracostomy and decortication, some cases with chronic persistent empyema with or without BPF require special treatment which may include either skeletal muscle transposition or omentum majus transplantation. The key for restoring health in patients with a chronic thoracic empyema is thorough cavitary debridement with removal of all pus and necrotic tissue and reexpansion of healthy lung to fill the pleural space. Controlling any residual pulmonary disease and removing any constricting tissue that prevents full lung expansion are, therefore, important considerations [2,3]. In some cases, the empyema persists and the visceral fibrous peel undergoes marked thickening. In them a single tube drainage is usually unsuccessful and decortication is requires [4]. Sometimes, however, the empyema with or without BPF persists long-term and decortication and extensive thoracoplasty are not tolerated due to the high operative risk in undernourished and immunocompromised patients or in those with severe underlying diseases [4,5]. In this condition two-stage surgical procedures may become necessary. An open window thoracostomy first is performed. This is followed by thoracoplasty and/or muscle flap transfer in order to obliterate the cavity or fistula [6,7]. The overall success rate of thoracoplasty in eliminating thoracic dead space problems is 73% [8]. The major disadvantages of an extensive thoracoplasty are the severe operative trauma, disability, frozen shoulder and significant deformity.
Muscle transposition into the thoracic cavity is effective for chronic empyema, as it can obliterate the dead space and eliminate infection. This procedure can be applied singly or in combination to obliterate any sizable residual pleural space [9,10]. However, this takes a long time since the majority of patients require two-stage operation. In any case, deformities of the thoracic cage are produced.
We utilized one-stage pedicled omentum majus transposition into the thoracic cavity for treatment of chronic persistent empyema with or without BPF in 50 consecutive patients and obtained good clinical results without any abdominal complications. The omentum causes highly vascularized adhesions with surface of the lung and visceral peel and offers a variable amount of tissue supplied by the gastroepiploic arcade and can reach any location in the chest cavity. It not only can eradicate the dead space and limit infection but help to ultimately control infection because of its rich blood supply. The advantages of this one-stage approach rest in its safety and efficacy producing only minimal deformity of thorax. The time required to obliterate the cavity and the cost of treating the disease thus are markedly reduced.
In conclusion, we believe that one-stage pedicled omentum majus transposition is an adequate procedure for chronic persistent empyema and BPF, it eliminates residual or recurrent inflammatory foci mechanically and closes the BPF effectively with minimal deformity of the chest wall.
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References
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Received January 30, 1999;
received in revised form October 13, 1999;
accepted October 27, 1999.
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Abstract
1. Introduction
