Empyema Cavity Research Articles

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.

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 intraoperative 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.

Facilitation of alternative one-lung and two-lung ventilation by use of an endotracheal tube exchanger for pediatric empyema during video-assisted thoracoscopy

Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for the management of postpneumonic empyema in children refractory to medical response. Alternative uses of two- and one-lung ventilations have been required during VATS. This study evaluated the efficacy of alternating one- and two-lung ventilation through intraoperatively through the same single-lumen endobronchial tube using a tube exchanger during a thoracoscopic procedure for pediatric empyema. Between May 1995 and August 2001, 62 consecutive pediatric patients undergoing VATS for evacuation of the loculated empyema cavity were studied. The same single-lumen endobronchial tube was used, with an indwelling endotracheal tube exchanger in place for readjustment of the tube position to provide alternation of one- and two-lung ventilations in a thoracosopic procedure. Duration of operation, heart rate, mean arterial pressure, peak airway pressure, an partial pressure of oxygen (PaO(2)) and carbon dioxide (PaCO(2)) changes during one- and two-lung ventilations were recorded. The quality of lung deflation and inflation was rated by the surgeon using direct visualization as excellent, fair or poor. The mean operating time was 90 min (range, 50-120 min). No differences were found in heart rate, mean arterial pressure, or PaO(2) during one- and two-lung ventilations. Peak airway pressure and PaCO(2) during two-lung ventilation were significantly higher than during one-lung ventilation. The quality of lung deflation and inflation was judged excellent for all the patients. The VATS procedure can be performed safely and effectively in children using proper anesthetic technique. Retention of a tube exchanger within a single-lumen endobronchial tube an easily provide alternative one- and two-lung ventilations without inducing any significant airway flow obstruction during the operation.

Persistent Gastric Stump–Pleural Fistula With Circumscribed Pleural Empyema: A Single Approach for a Twofold Problem

A 62-year-old woman was referred to our department for a gastric stump–pleural fistula after an Ivor-Lewis esophagogastrectomy that had been performed for esophageal cancer. A persistent circumscribed pleural empyema was still present after three consecutive percutaneous chest drainage procedures. Figure 1 is the computed tomography scan showing right-sided circumscribed pleural empyema. A new endoscopy study confirmed the fistula in the gastric stump. The hole was 5 mm in the maximum diameter, as shown on the endoscopic visualization (Fig 2A) by the black arrowhead.Fig 2View Large Image Figure ViewerDownload (PPT) We planned an endoscopic approach to attempt, with a single maneuver, to address both of the problems. A soft silicone 10F catheter was endoscopically inserted, under fluoroscopic control, on a steel wire guide positioned into the fistulous path (Fig. 2B) shows steel wire guide entering the fistula orifice [black arrow]) and into the pleural space up to the circumscribed empyema. Figure 3 is a chest roentgenogram showing the catheter path into the pleural space up to the empyema cavity. A prompt and complete collapse of the empyema cavity with the drainage of 40 mL of corpusculated fluid was obtained, confirmed by a computed tomography scan, as shown in Figure 4. The arrowhead points to the catheter and the arrow points to the stomach.Fig 4View Large Image Figure ViewerDownload (PPT) The catheter was then retracted in a four-step procedure over a 2-day interval, up to the complete extraction from the pleural space and from the gastric stump–fistula orifice. The subsequent outcome was uneventful. The fistula was radiographically and endoscopically confirmed to be completely closed. Pleural empyema did not recur, and the patient was discharged from the hospital 3 days after the catheter was extracted.

A simple solution for management of the postpneumonectomy empyema cavity

Postpneumonectomy bronchopleural fistula with empyema is a difficult problem. Once the fistula is healed, successful closure of the pleural space is associated with varying degrees of success, as well as the potential for major reconstructive surgery. My colleagues and I describe a simple approach for the definitive management of the open pleural space involving split-thickness skin grafts to marsupialize the pleural cavity.

Empyema resulting from a true colopleural fistula complicating a perforated sigmoid diverticulum

Empyemas developing after traumatic rupture of intraabdominal organs have been previously reported. We report a case of a true nontraumatic colopleural fistula following surgery for spontaneous rupture of a sigmoid diverticulum. The diagnosis was suspected by the presence of an air-containing tract seen in a computerized tomogram of chest and abdomen and was established with a contrast study. The empyema cavity was initially drained, followed by a laparotomy and fistulectomy with primary large bowel anastomosis and loop ileostomy. Although rare, colopleural fistulas present a diagnostic challenge and delayed management can lead to increased morbidity.

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.

Twenty-six years of experience with the modified eloesser flap

Background Empyema thoracis is a common thoracic problem with a multitude of therapeutic options. The modified Eloesser flap (MEF) is one means of dealing with this problem in selected complicated patients. The purpose of this study is to report our 26-year experience with the MEF. Methods A review of 78 patients who had a MEF from 1975 to 2001 was performed. Results There were 52 males (67%) and 26 females (33%). Mean age was 59 ± 14 years. The overall length of stay was 26 ± 27 days, while mean postoperative length of stay was 16 ± 17 days. Microbiology of the empyema cavity revealed a predominance of gram-positive organisms. Before a modified Eloesser flap, all patients failed initial conservative interventions and 23 patients (29%) failed surgical interventions. Operative indications were as follows: parapneumonic effusions, 35 patients (45%); postresectional, 23 patients (29%); tuberculosis related, 7 patients (9%); malignant effusion, 4 patients (5%); esophageal fistulas, 4 patients (5%); abdominal sepsis, 3 patients (4%); and hemothorax secondary to trauma, 2 patients (3%). The inverted-U incision was performed in all patients. Average rib resection was 3 ± 1 ribs. There were no intraoperative complications and adequate drainage was achieved in all patients. Thirty-day morbidity/mortality was 4 patients (5%): 3 died of sepsis and 1 died of metabolic encephalopathy; although long-term follow-up (mean: 109 ± 141 months) revealed no additional morbidity related to the MEF. Conclusions We demonstrate that MEF can be performed as a safe, definitive surgical procedure for the treatment of chronic empyema thoracis. The MEF remains an important option in the surgical treatment of chronic, complicated empyema thoracis.

Thoracoscopic-assisted management of postpneumonic empyema in children refractory to medical response.

Empyema frequently complicates the hospitalization of children; and in advanced stages, it often requires surgical intervention. In this study, we investigated the use of video-assisted thoracic surgery (VATS) for the management of postpneumonic empyema in children who have had an unsatisfactory medical response. We did a retrospective review of the medical records of 51 consecutive patients with loculated empyema (mean age, 5 years; range, 2 months to 15 years) hospitalized at Chang Gung Memorial Hospital between 1995 and 2000. All patients underwent debridement of the necrotic lung tissue and evacuation of the loculated empyema cavity using a VATS approach. The mean operating time for the 51 patients was 90 min (range, 50-210); mean blood loss was 70 cc. Fever subsided within 72 h postoperatively in all patients. On average, chest tubing was removed on the 7th postoperative day (range, 4-18 days). However, in one patient who suffered from a prolonged air leak, the chest tube was not removed until day 18. The mean postoperative stay for all patients was 13.7 days (range, 9-23). No deaths occurred, and all of the children made a good recovery. A follow-up revealed that one of the 51 children patient suffered a left upper lung abscess 7 months after discharge. Left upper lobectomy was performed in this case, and the patient was discharged uneventfully 10 days after the operation. VATS is a safe and effective treatment for pediatric empyema. Thoracoscopic-assisted surgery facilitates visualization, evacuation, and debridement of the necrotizing lung tissue. Early surgical intervention can avoid lengthy hospitalization and prolonged intravenous antibiotic therapy, and it can accelerate clinical recovery.

Empyema necessitatis into the retroperitoneal space

Empyema necessitatis is a rare complication of tuberculous empyema. We present a very rare case of empyema necessitatis into the retroperitoneal space through the diaphragm. The fistula between the thoracic empyema cavity and the retroperitoneal abscess was clearly identified by magnetic resonance imaging.

The use of a Dumon stent for the treatment of a bronchopleural fistula

We report the successful management of a bronchopleural fistula with bronchial stent placement combined with irrigation of the empyema cavity. A bronchopleural fistula occurred in a 67-year-old man after a right upper lobectomy for lung cancer. Resuturing of the bronchial stump plus omental wrapping and subsequent closure of the open stump with a pedicled flap of intercostal muscle were not effective. Consequently, we placed a Dumon stent in the right main bronchus to close the stump.

Intrathoracic transposition of a pectoralis major and pectoralis minor muscle flap for empyema in patients previously subjected to posterolateral thoracotomy.

The latissimus dorsi muscle flap cannot be used to eliminate an empyema cavity in patients who have previously undergone posterolateral thoracotomy, because of the division of this muscle. Moreover, thoracoplasty alone cannot sufficiently eliminate an empyema cavity that includes the thoracic apex, where space remains between the clavicle and the first rib. Therefore, we constructed a flap from the pectoralis major (P.Ma) and pectoralis minor (P.Mi) muscles to eliminate empyema cavities in five patients who had undergone lobectomy (n = 3) or pneumonectomy (n = 2) via posterolateral thoracotomy from 3 months to 40 years previously. All five patients had bronchopleural fistulae, and because of the previous upper lobectomy or pneumonectomy, they had large empyema cavities including the thoracic apex. Open-drainage thoracotomy was performed due to severe infection, and intrathoracic transposition of the P.Ma and P.Mi muscle flap with simultaneous thoracoplasty was carried out 7-124 weeks (mean 38 weeks) later. The P.Ma and P.Mi muscle flap easily reached the apex space with sufficient obliteration of the empyema cavity. All of the patients remained free of empyema 12-85 months after thoracic closure. The P.Ma and P.Mi muscle flap is useful for eliminating empyema cavities including the thoracic apex in patients who have previously undergone a posterolateral thoracotomy.

Experiences in stage-adapted therapy of pleural empyema

Up till now the phases adapted treatment of a pleural empyema unfortunately is still not obvious, but recently the operative spectrum has been widened in the field of video-assisted thoracoscopic surgery (VATS) of the pleural empyema. In the present study we examined all our patients with a pleural empyema and we followed them for a postoperative period of 4 years analysing our therapy-efficacy and our treatment concept of pleural empyema. 52 out of 102 patients--who suffered from a pleural empyema in the last 10 years--were reexamined postoperatively. In 96% of the 102 cases we found a phase II-III empyema. Initially all patients were treated with a closed-chest-tube drainage, followed by an operation in 78%. In 6 cases a video-assisted-thoracoscopic evacuation of the cavity with an early decortication was performed. All the 52 patients who were treated in an early phase showed the best functional results 4 years later. Especially in phase III the open operative revision of a pleural empyema is the method of choice. In the fibrinopurulent phase the drainage therapy may be sufficient. If the empyema cavity is divided we recommend the early video-assisted-thoracoscopic revision of the thoracic empyema.

Thoracoplasty in the New Millennium

Before the development of antituberculosis drugs in the mid-1940s, pulmonary resection and thoracoplasty stood as the primary therapies for the treatment of pulmonary tuberculosis. In the nineteenth century, Parker and Thompson described the use of pneumothorax to partially collapse an empyema cavity. This method, along with unilateral phrenic nerve division, plombage, and pneumonolysis, emerged as therapies for potential obliteration of tuberculous cavities during this period, but complications were common, and these operations were soon outdated.1Moran JF Surgical treatment of pulmonary tuberculosis.in: Sabiston Jr, DC Spencer FC ed 6. Surgery of the Chest. Vol 1. Saunders, Philadelphia, PA1995: 752-772Google Scholar In 1885, Poulet2Poulet Empyeme.Rev Chir Orthop Reparatrice Appar Mot. 1885; 5: 926Google Scholar treated a patient with tuberculous empyema by intercostal incision, rib resection, and pleural debridement with subsequent resolution of the cavity. In the last decade of the nineteenth century, several surgeons, including Estlander, 3Estlander JA Sur le resection des cotes dans l'empyeme chronique.Rev Mens. 1891; 8: 885-888Google Scholar Ransahoff, 4Ransahoff J Discussion of the pleura in the treatment of chronic empyema.Ann Surg. 1906; 43: 502Crossref PubMed Google Scholar and Schede, 5Schede M Die behandlung der empyeme.Verhandl Cong Innere Med Wiesbaden. 1890; 9: 41Google Scholar described thoracoplasty for the treatment of persistent empyema cavities. Estlander was the first to report such a procedure in 1877.3Estlander JA Sur le resection des cotes dans l'empyeme chronique.Rev Mens. 1891; 8: 885-888Google Scholar The surgeon Cerenville first reported the resection of the first rib allowing for a resection extended higher in the chest.6Somers J Faber LP Historical development in the management of empyema.Chest Surg Clin N Amer. 1996; 6: 403-418PubMed Google Scholar, 7Meade RH: Empyema, in CC Thomas (ed): A History of Thoracic Surgery. Springfield, IL, pp. 234–253, 1961Google Scholar Sauerbruch, a German surgeon, proposed the modern method of thoracoplasty and first popularized this procedure for the surgical treatment of tuberculosis in 1911.1Moran JF Surgical treatment of pulmonary tuberculosis.in: Sabiston Jr, DC Spencer FC ed 6. Surgery of the Chest. Vol 1. Saunders, Philadelphia, PA1995: 752-772Google Scholar John Alexander developed the modern extrapleural thoracoplasty procedure and described the safe application of this operation for pulmonary tuberculosis.8Alexander J: The collapse therapy of pulmonary tuberculosis, in Thomas CT (ed): The Collapse Therapy of Pulmonary Tuberculosis. Springfield, IL, 1937Google Scholar, 9Alexander J The Surgery of Pulmonary Tuberculosis. Lea & Febiger, Philadelphia, PA1925Crossref Google Scholar His cavity closure rate in 93% of survivors was coupled with a mortality rate of only 10%. This procedure had a significant effect on our ability to treat tuberculosis. The incidence of mortality from tuberculosis in the United States fell from 300 per 100, 000 in 1880 to only 69 per 100, 000 in 1937.1Moran JF Surgical treatment of pulmonary tuberculosis.in: Sabiston Jr, DC Spencer FC ed 6. Surgery of the Chest. Vol 1. Saunders, Philadelphia, PA1995: 752-772Google Scholar Today, thoracoplasty is rarely, if ever used to treat primary pulmonary tuberculosis. However, it remains a treatment option for tuberculosis and pneumonectomy complicated by bronchopleural fistula or empyema. Surgeons in developing countries continue to use thoracoplasty as a primary treatment of pulmonary tuberculosis complicated by empyema, bronchopleural fistula, and drug-resistant mycobacterial strains.10Dewan RK Singh S Kumar A et al.Thoracoplasty: An obsolete procedure?.Ind J Chest Dis All Sci. 1999; 41: 83-88PubMed Google Scholar Thoracoplasty is better tolerated in patients in poor medical condition who may not tolerate pulmonary resection. Unfortunately, the increased incidence of AIDS over the past decade has led to the resurgence of tuberculosis and atypical mycobacterial infections in immunocompromised, debilitated patients. These patients often respond poorly to the usual drug regimen and will not tolerate pulmonary resection. Therefore, thoracoplasty once again may play a role in the treatment of this select group of patients. Before performing thoracoplasty, the surgeon must carefully plan a detailed preoperative strategy. A traditional thoracoplasty removed up to 7 ribs. A modified or limited thoracoplasty removes only 4 or 5 ribs and may be indicated to close a small infected apical space after lung resection. The size of the cavity is the determining factor in planning the extent of resection. The planned resection must be of adequate size to completely close the affected pleural space. A quality posteroanterior chest radiograph will allow the surgeon to determine the inferior extent of the cavity. The deforming nature of this operation creates a significant and permanent loss of unilateral ventilatory capacity. Thus, pulmonary consultation and formal pulmonary function tests are vital in assessing the patient's ability to tolerate such a resection. Today, surgeons combine limited thoracoplasty with new plastic techniques to limit the extent of rib resection and chest wall deformity.

Management Strategies for Complex Bronchopleural Fistula

The management of complex bronchopleural fistula remains a major therapeutic challenge for the thoracic surgeon. Although the incidence of bronchopleural fistula following lung resection has decreased in recent years to 1% to 2%, when it occurs, it is associated with significant morbidity and mortality. Using illustrative cases, the epidemiology and pathophysiology of bronchopleural fistula are reviewed and operative strategies are discussed. Algorithms for the diagnosis and treatment are suggested on the basis of cases described in the literature. The best way to prevent a fistula is to rigorously follow the surgical techniques described, with minimal devascularization of the bronchus and prophylactic coverage of the stump in high-risk patients. Successful management of a fistula is combined with treatment of the associated empyema cavity. Definitive repair should be accomplished expeditiously, minimizing the number of procedures performed. When treatment is protracted, secondary complications are more likely and survival is adversely affected. The first step should be control of active infection and adequate drainage of the hemithorax, followed by timely repair of the bronchopleural fistula when possible and reinforcement of the stump with vascularized tissue. If a residual cavity is present it must also be obliterated with a pedicled muscle flap.

Reconstruction of Irradiated Postpneumonectomy Empyema Cavity with Chain-Link Coupled Microsurgical Omental and TRAM Flaps

Rand, Richard P. M.D.; Maser, Benjamin M.D.; Dry, Gavin M.D.; Vallieres, Eric M.D Author Information

Improved patient outcome after surgical treatment for loculated empyema

Reginald J. Franciose, MD (Denver, Colorado): I was particularly pleased to see that Dr. Powell supports our bias that empyema is a surgical disease. However, it seems to me that in 1999, the treatment of empyema is not a two-variable disease, medical versus surgical, but more a four-variable disease with multiple subvariables. There is medical treatment. There is fibrinolytic therapy, which can be directed by interventional radiologists or by the surgeon through chest tubes. That’s been in widespread use since 1989. There is small-catheter directed interventional radiology where they can then place devices inside the empyema cavity, break up the loculations, and theoretically, more specifically, drain the loculations. That would be a third variable. And fourth, there is surgery, which has three variables: open thoracotomy with decortication, VATS technology, which has been available since 1992, and the so-called minithoracotomy, which is assisted by the camera with just a small incision allowing you to work with your open instruments.

Microvascular vastus lateralis muscle flap for chronic empyema associated with a large cavity

Thoracic empyema can be disabling and may need microvascular free flaps in some intractable cases. After repeated failure of conventional thoracic surgical procedures, 2 patients with empyema were treated with microvascular free vastus lateralis muscle flaps for obliteration of the large empyema cavity. The reconstruction was successful in wound closure and eradication of infection. The donor site morbidity was minimal, and the patients resumed normal daily activities. Microvascular vastus lateralis muscle flap is the best option if free flaps are required for reconstruction of empyema.

Treatment of Empyema by Transposition of Contralateral Lower Trapezius Flap

We report the successful treatment of bronchopleural fistula and empyema using transposition of a contralateral lower trapezius musclocutaneous flap, which provided immediate obliteration of the middle-back empyema cavity. This technique is easy to perform without any intraoperative change of position and with little postoperative impairment of the back and shoulder movement.

Thoracic Surgery Techniques of Şerefeddi̇n Sabuncuoğlu in the Fifteenth Century

Şerefeddin Sabuncuoğlu (1385 to 1470?) is known to be the author of the first surgery textbook, namely Cerrahiyyet’ül Haniyye (Imperial Surgery), written in Turkish in 1465. It is the first book to contain colored illustrations of surgical procedures, incisions, and instruments in the Turkish-Islamic medical literature. He was the first man to illustrate and mention introduction of a tube into the pharynx and upper esophagus, removal of foreign bodies in the esophagus by special instruments of his own design, and use of a silver ringlet in a man after tracheotomy. He also described and illustrated reduction of sternal fractures, thoracic puncture through the intercostal space for drainage of empyema cavities, and treatment of rib fractures that have severed the diaphragm. He was a humble, curious, and intelligent surgeon, and also a calligrapher and a miniature artist.(Ann Thorac Surg 1997;63:575–7)