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Eur J Cardiothorac Surg 2002;21:644-648
© 2002 Elsevier Science NL
Department of Surgery, Division of Thoracic Surgery, University Hospital, 8091 Zurich, Switzerland
Received 19 September 2001; received in revised form 7 January 2002; accepted 10 January 2002.
* Corresponding author. Tel.: +41-1-255-8802; fax: +41-1-255-8805
e-mail: walter.weder{at}chi.usz.ch
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Abstract |
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 Top Abstract 1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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Key Words: Pneumonectomy in chronic infection • Empyema • Packing of pleural cavity • Pleural space obliteration
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1. Introduction |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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Reviewing the literature concerning the question whether pneumonectomy in chronic infection should be performed and how it should be done, we found the opinion varies depending on the author [1–4].
Based on our experience with the treatment of an established postpneumonectomy empyema [6], we adapted the procedure and applied it when presented with these indications.
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2. Patients and methods |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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The hospital and clinical records and operative reports were retrospectively reviewed and follow-ups were made.
The predominant reason for operating was symptomatic infection. Only in one case of severe hemoptysis did we perform an emergency operation.
Patients usually presented with the clinical signs of chronic infection, including malaise, anorexia and purulent expectoration. None of them displayed a full sepsis syndrome with multiorgan failure. Computed tomography (CT)-scans showed signs of chronic empyema with a shrunken hemithorax, thickened and occasionally calcified pleura parietalis but also evidence of acute infection with intrapulmonary abscess formation in four and acute empyema with contrast enhanced pleura in ten patients.
Pleuropneumonectomy was necessary in four patients with tuberculosis (two right, two left). All of them had had recurrent hospitalizations in other institutions and had been treated with multiple antituberculous agents and antibiotic treatment for superinfection over a period of 6–24 months. One of these patients had a cavitation in the lower lobe with empyema and a severe emphysema of the upper and middle lobe, the others had distinct calcification of the thickened pleura and multiloculated empyema.
Another patient needed a right pleuropneumonectomy because of an esophago-pleural fistula associated with pneumonia. Surprisingly, a diffuse non-Hodgkin-lymphoma was detected at final histology.
One more pleuropneumonectomy on the left was performed because of severe and distinct bronchiectasis with recurrent hospitalizations for pneumonia.
In a patient suffering from aspergillous pneumonia associated with acute empyema 10 years after a unilateral lung transplantation on the right for emphysema had a left pneumonectomy.
Three patients needed a completion pneumonectomy on the right side: one with an ongoing infection caused by tuberculosis in preexisting bronchiectasis 23 days after emergency resection of the upper lobe and apical segment of the lower lobe for severe hemoptysis; one with persistent aspergillosis, thoracic wall abscess and broncho-pleural fistula (BPF) 12 months after resection of the upper lobe and the apical segment of the lower lobe due to mycetoma; and one with insufficiency of the lobar bronchus 2 months after an upper bilobectomy for bronchial carcinoma associated with empyema.
One patient had completion pneumonectomy on the left side after a 6-year history of ongoing infection with putrid expectoration, 36 years after upper lobe resection due to a tuberculosis-related cavern (Table 1).
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Every patient underwent pulmonary function testing and a chest CT-scan, and all but two patients had ventilation-perfusion scans for preoperative planning of the predicted lung function after surgery.
Systemic antibiotic treatment was continued or initiated preoperatively, according to microbiological findings.
The patients were discharged after wound-healing and normalization of the inflammatory parameters in the blood tests (white cell counts, C-reactive protein).
2.1. Operative technique
Patients were intubated with a double lumen endotracheal tube and placed in an antero-lateral decubitus position.
Surgery was generally performed through an antero-lateral incision. An extrapleural approach was used for all except the four cases of completion pneumonectomy. In some cases, a rib resection (6th rib) was made for better exposure. The often thickened and calcified pleura had to be dissected from the chest wall by sharp preparation. Parts infiltrating the diaphragm were often left behind. Bronchus closure generally was made with a stapling device, paying attention not to devascularize the short stump. Primary stump reinforcement was performed by mediastinal fat pad if possible.
Then radical debridement of the pleural cavity and curettage of all necrotic and fibrous infected tissue with a curette were performed, followed by irrigation.
At the end of every surgical intervention, and until definitive closure, the pleural cavity was packed with dressings soaked with povidone–iodine solution (diluted 20:1), avoiding a mediastinal shift through overstuffing. A chest tube with continuous suction of 5 cm H2O was placed and the thoracotomy temporarily closed with a running suture around the ribs and the skin closed with staplers. The patient was extubated and transferred to the intensive care unit.
After 48 h, the antiseptic packing was changed and, in cases without a macroscopically clean surface of the chest wall, the surgical debridement reapplied in the operating room under general anesthesia (conventional tube intubation). If necessary, these steps were repeated until the chest cavity was macroscopically clean.
Finally, the pleural space was obliterated with an antibiotic solution and the thoracotomy was definitively closed.
The instilled antibiotic solution contained 0.3 g netilmicin, 2.2 g amoxicilline/clavulanic acid and 1 g vancomycin per liter of saline. If necessary, additional antibiotic agents or fungicides (0.4 g fluconazol or 0.05 g itraconacol) were added to the solution, according to the microbiologic cultures.
Preoperatively started parenteral antibiotic treatment was continued.
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3. Results |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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The mean number of interventions per patient, including initial pneumonectomy and debridement, changing of dressings and definitive closure of the chest wall, was 2.9 (range, 2–4). In all patients, definitive chest closure was achieved within 7 days.
One patient with a severely destroyed lung caused by aspergilloma developed a wound infection, which required reoperation without reopening of the chest.
In four patients—all after a right pneumonectomy—the bronchial stump was additionally reinforced with a mediastinal fat patch because of BPF (two), esophago-pleural fistula (one) or immunosuppression (one). One of them needed reoperation due to a ‘pinhole’ BPF 3 months after completion pneumonectomy. The stump was initially covered with mediastinal fat and at reoperation with omentopexy. He was discharged within 20 days the first time and 17 days after reoperation. Today, 18 months after the final intervention, he has neither signs of recurrence of the bronchial carcinoma nor of infection.
Results of microbial cultures of the pleural cavity are shown in Table 1.
The follow-up time ranged from 10 to 54 months (mean 26 months). One patient was lost to the follow-up after he returned to his home country. There was one in-hospital postoperative death (day 31) due to multiorgan failure in sepsis (oldest patient of cohort: 84 years).
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4. Discussion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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In recent literature, high rates of recurrent or persisting infection (i.e. postpneumonectomy empyema up to 40%) and of BPF (up to 12%), together with an elevated mortality rate, were quoted.
In our study, we introduce a new treatment regimen based on the repetitive scheduled revisions under general anesthesia, local application of antiseptic packings and systemic antimicrobial therapy. This leads to a rapid and thorough consolidation with a success rate of more than 90% and low mortality within the first 3 postoperative months. The only patient who died was a multimorbid 84-year-old gentleman with severely reduced general health at the time of operation.
Despite all the surgical measures and advances in perioperative management, pneumonectomy for chronic infection is still associated with a high complication rate.
Risk factors for BPFs are right-sided (pleuro-)pneumonectomy, completion pneumonectomy and immunosuppression. Filled with potentially contaminated bradytroph tissue, the cavity is a perfect medium for ongoing or recurrent infection. Therefore, postpneumonectomy empyema is very frequent, especially in preexisting empyema.
The concept for treating the contaminated cavity follows the established rules for managing any persisting infection and consists of the removal of necrotic tissue (i.e. debridement) accompanied by a parenteral antibiotic, anti-fungal or antituberculous regimen. To minimize the rate of recurrent infection, Conlan et al. [7] propose postoperative irrigation. If gross intraoperative spillage into the pleural cavity was observed, they treated the patients with an extensive saline solution irrigation and placed two tubes with 1% povidone–iodine for continuous postoperative irrigation and drainage. Before tube removal, an antibiotic solution was administered. Nevertheless, they had a recurrent infection in 15.3%. The recurrent empyema was than treated by open pleural drainage (thoracostoma). Other authors [5,8] cope with this challenge through primary reinforcement of the bronchus and obliteration of the infected cavity with a muscle flap that leads to a successful treatment in up to 85%.
In our series, we establish a standardized concept of repeated debridement in the operating theater in order to optimize the cleansing of the pleural space. Initially tailored for early and late postpneumonectomy empyema, we extended this concept to a prophylactic reapplication in inflammatory lung disease because of our promising results.
Using our concept, the chest could be finally closed definitive in all 11 patients within 7 days with only one recurrence of infection due to a BPF after completion pneumonectomy. All patients but one (died on day 31) were discharged after a mean hospital stay of 19 days. It is noteworthy that accelerated treatment did not increase morbidity, particularly of the thoracotomy wound. We attribute this to the consequence of performing the treatment in a sequential and standardized fashion, treating each revision as an independent operative step where maximum gain in surgical debridement is paramount.
In addition, due to the packing of the pleural cavity after debridement, we did not see bleeding complications.
Although the patients had to go back to the operating theater, the chest was closed between each debridement session. Therefore, respiratory mechanics were not impaired and patients profited from physiotherapy.
In this present series of 11 patients, we were able to demonstrate a new treatment concept for pneumonectomy or completion pneumonectomy in chronic pulmonary infection with an acceptable low mortality and morbidity rate. Modern-day preoperative assessments, conditioning of the patients and anesthesia are important co-factors. This may help see the treatment of a destroyed lung associated with empyema as a chance for cure in a selected group of patients.
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Acknowledgments |
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Footnotes |
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Appendix A. Conference discussion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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Dr Schneiter: There have been two patients with fistulas of the lobar bronchus. None of our patients had a fistula of the main bronchus.
Dr Kshivets: A second question. How do you close the fistula?
Dr Schneiter: There were two patients with formal lobectomy, so when we did completion pneumonectomy, we closed it with a stapler device.
Dr Kshivets: Through the pericardium?
Dr Schneiter: No, in a standard approach from an antero-lateral thoracotomy.
Dr E. Medovarov (Nizhny Novgorod, Russia): What do you think about such method in treating of chronic empyema like thoracostomy? You used staged thoracotomy with examination of pleural cavity. For example, in our clinic we use the method of thoracostomy, so making a foramen in the lowest part of the empyemic cavity.
Dr Schneiter: This procedure originally described by Clagett is widely used, and the thoracostomy is one option. We experienced that patients are doing much better if the chest is closed after pneumonectomy and repeated debridement is performed in a scheduled operation. They were mobile as well, and they have not this open cavity. The overall therapy is accelerated and the chest closed within 1 week.
Mr D. Blyth (Durban, South Africa): I was very interested in what you have just said, and like the previous speaker, also our procedure is to repair, and I really wanted to ask you more about that. There is one thing, though, if you will allow me one comment.
I don't think that this problem is a procedure of high mortality, as you say in your abstract. I think it can be done with zero mortality, and we have shown that in a series of 46, many of those patients having active tuberculosis, the tuberculosis patients actually did better than others with inflammatory lung disease. But I accept your point that you probably are saving time in the end, but your series is very small and I will be very curious to see, if you extend it, what your results will then turn into.
Dr Schneiter: This is true, our series is relatively small, but we have another series of postpneumonectomy empyemas where we applied the same concept, and we had very good results in this group of patients as well.
Dr T. Grodzki (Szczecin, Poland): It is rather a comment than a question to David Blyth. It sounds a little bit strange for people who are accustomed to the Clagett procedure and so on, but due to our cooperation with Zurich, we adopted this method in our department, too, and it works, it really works.
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References |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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This article has been cited by other articles:
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  C.-A. Kerti, I. Miron, G. V. Cozma, O. N. Burlacu, C. P. Tunea, V. T. Voiculescu, E. F. Memu, and A. C. Nicodin The role of surgery in the management of pleuropulmonary tuberculosis - seven years' experience at a single institution Interactive CardioVascular and Thoracic Surgery, March 1, 2009; 8(3): 334 - 337. [Abstract] [Full Text] [PDF]
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 T. F. Molnar Current surgical treatment of thoracic empyema in adults Eur. J. Cardiothorac. Surg., September 1, 2007; 32(3): 422 - 430. [Abstract] [Full Text] [PDF]
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