Management Of Postpneumonectomy Empyema Research Articles

Management of postpneumonectomy empyema and bronchopleural fistula

: Although the number of pneumonectomies performed worldwide is decreasing due to epidemiological changes in lung cancer, increased awareness of postoperative complications of pneumonectomy plays a major role in the proper clinical management and ultimately in the quality of life and survival rate of patients. Postpneumonectomy empyema is a rare but serious complication of pneumonectomy. The prognosis of postpneumonectomy empyema patients mainly depends on when the complication appears and the presence or absence of a bronchopleural fistula (BPF). The majority of empyema will occur within the first 3 months after surgery. The management of postpneumonectomy empyema is a challenge to thoracic surgeons due to the number of surgical approaches available and a lack of consensus as to the best approach. It can vary from a simple rib resection and open drainage to a complete thoracoplasty. Unfortunately, after pneumonectomy, patients who develop BPF and empyema will present prolonged hospitalization and are at risk of high morbidity and mortality rates. Consequently, successful therapy might be difficult to achieve, that is why is so important to well select your strategy. Though this remains an area of controversy in the field of thoracic surgery, accurate and expedited diagnosis is critical to achieve a cure. Regardless of the technique adopted for treatment, adequate pleural drainage, definitive closure of the BPF, sterilization of the pleural cavity, and obliteration of residual space are the key factors to favorable outcomes. In this article, the authors aim to discuss in detail the management strategy based on the clinical evolution of patients with postpneumonectomy empyema and BPF.

Post-pneumonectomy Empyema Due to Necrosis and Perforation of a Herniated Stomach

Pleural complications after pneumonectomy occur not only in the early postoperative period but also several years after surgery. Post-pneumonectomy empyema (PPE) is such a possible complication that must be recognized and adequately treated. Sometimes the management of PPE can be extremely challenging because of an abnormal disease presentation and the critical condition of the patient. Herein, present you a unique case of an incarcerated diaphragmal hernia with stomach perforation and necrosis in a post-pneumonectomy patient with development of PPE.

Experience with Vacuum-Assisted Closure in the Management of Postpneumonectomy Empyema: An Analysis of Eight Cases

The treatment of postpneumonectomic empyema is challenging. The aim of this study was to test the efficacy of vacuum-assisted closure (VAC) in the treatment of patients with open window thoracostomy (OWT). Between January 2010 and April 2014, eight patients developed empyema following pneumonectomy for malignant diseases in our department and then underwent an OWT with subsequent VAC therapy; their cases were retrospectively studied. Each session of VAC therapy lasted 72 hours, and therapy was completed after approximately 6 sessions. OWT in six patients resulted in either decreased size or complete closure after VAC treatment. Five patients had a bronchopleural fistula (BPF), which was closed either with a tracheal stent (three patients), primary suture, or omentoplasty. The BPF in one of these patients closed during VAC therapy. The treatment failed in two patients due to the microfistula becoming obvious in one and persistence of the fistula in the other. We believe that the use of VAC in the treatment of postpneumonectomy empyema is effective, except for patients with BPF.

Application of Vacuum-Assisted Closure Device in Management of Postpneumonectomy Empyema

A 57-year-old man was diagnosed with lung cancer and underwent pneumonectomy and mediastinal lymph node dissection. He was discharged without acute complications, but on a regular outpatient follow-up, he was readmitted with postpneumonectomy empyema. He was successfully treated with a vacuum-assisted closure device and for 1 year period of outpatient follow-up, there was no recurrence of empyema or lung cancer.

Reply to Krueger et al.

We thank Krueger et al. for their interest in our paper [1, 2]. The Lausanne group uses the Pairolero’s modification of the Clagett’s procedure [3, 4]—only with vacuum assisted closure VAC in lieu of repeated dressing changes [3]. In the past, we have used and still use this time-honoured approach for critically ill patients. However, we wanted to verify the possibility of managing stable (i.e. >1 month after primary surgery) post-pneumonectomy patients in an outpatient setting, and we opted for the openwindow thoracostomy (OWT) as per our previous experience published in 2006 [5]. Contrary to Dr Krueger’s interpretation, we did not suggest OWT and vacuum assisted closure (VAC) in an outpatient setting for the ‘critically ill’ [3]. In addition, in the Lausanne group’s series, there were only eight post-resectional empyemas [3]. Of these, only two occurred after primary pneumonectomy performed for mesothelioma and extended thymoma [3]. We suspect that applying VAC after primary pneumonectomy may be different from using VAC for somewhat smaller, contained, chronic areas of infection [5]. As to the OWT issue, contrary to Dr Krueger’s interpretation, OWT is obtained by refashioning the original thoracotomy without the need for additional incisions and repeated general anaesthesia [5]. If a broncho-pleural fistula (BPF) is identified, it is sutured and reinforced with a muscle flap [5]. In fact, we were successful in 1 patient despite several techniques used for bronchial closure (Table 1) [2]. The closure of the thoracostomy is done by an approximation of the myocutaneous edges after obliteration by granulation tissue and Clagett solution or additional intrathoracic viable tissue transposition [5]. Accordingly, to include, among the advantages of VAC therapy via thoracotomy, the ‘preserved integrity of the chest wall’ is at least questionable. We do not think that VAC should not be considered an alternative to OWT [5]. We believe that OWT is, rather, an alternative approach to redo thoracotomy under general anaesthesia [5]. Possibly, both could be considered in different stages of the management of postpneumonectomy empyema (PPE). Nevertheless, VAC can be used through the OWT despite the adverse effects observed in our patients [2]. We feel that soaking the foams with local anaesthetic, avoidance of the vagus nerve and the interposition of gauzes on the mediastinum may easily improve our learning curve [3]. Similarly to our experience, the lack of exposure upon removal or the application of the VAC foam directly on the mammary vein may have caused a similar incident in the series from Lausanne [2, 3]. In conclusion, we think that two different categories of patients and two—not necessarily alternative— approaches are compared to manage PPE [2, 3]. In fact, OWT and VAC can speed up recovery in stable pneumonectomy patients, thus avoiding psychologically burdensome and costly prolonged hospitalizations. However, the jury is still out as to the role of VAC in the closure of BPF. Conversely, for critically ill PPE patients whose condition obviously mandates a high level of care, the use of VAC instead of repeated dressing changes via the Pairolero-Clagett’s procedure may be a reasonable alternative to accelerated treatment of PPE [6].

Open Window Thoracostomy and Thoracoplasty to Manage 90 Postpneumonectomy Empyemas

Postpneumonectomy empyema (PPE) is a serious complication. The treatment options are similar to the management of any abscess, with drainage, ideally open, often of critical importance. After infection control, many techniques for space obliteration have been described. This study summarizes a 10-year experience in the management of PPE in our center. From 2000 to 2010, 90 patients (83 men) with PPE were treated. Median follow-up was 5.3 years. Once the diagnosis of empyema was confirmed, chest drainage was performed through open window thoracostomy (OWT), with ensuing extramusculoperiosteal thoracoplasties if healthy tissue was present. Pneumonectomy was performed in 72 patients with lung cancer. Mortality after PPE was 2.2%. OWT achieved infection control in 89 patients. Seven OWT spontaneously healed, and 24 were never closed. The remaining 59 patients with OWT underwent thoracoplasty. Mortality after thoracoplasty was 5%. Empyema recurred in 3 patients. Overall success rate of PPE control after pleural obliteration was 91.5%. Thoracoplasty is a reliable filling procedure. It has a significantly higher success rate and a lower mortality rate than the other techniques. We believe that this procedure has a part to play in the future management of PPE.

Diagnosis and Management of Postpneumonectomy Empyema With an Eloesser Flap

Postpneumonectomy empyema (PPE) is an uncommon and devastating complication of pneumonectomy, with substantial morbidity and mortality. The condition is characterized by pleural cavity infection and inflammation. This article focuses on the management of complicated and persistent PPE with a procedure called Eloesser flap placement, a type of open-window thoracostomy.

Free Anterolateral Thigh Combined Flap for Chronic Postpneumonectomy Empyema

Management of postpneumonectomy empyema has always been a challenging task. Local flaps or free muscle flaps are options for recalcitrant cases when traditional therapeutic attempts fail. This report presents 2 patients with chronic postpneumonectomy empyema who were treated with an anterolateral thigh combined flap consisting of vastus lateralis and rectus femoris muscles. This method showed promising results for reconstruction of large empyema defect.

Management of Postpneumonectomy Empyema Using Free Flap and Pedicled Flap

Treatment of empyema after pneumonectomy is challenging. We treated 4 patients with postpneumonectomy empyema using a free rectus abdominis myocutaneous flap together with a pedicled pectoralis major muscle flap. The pectoralis major flap was used to fill the apical portion of the cavity, while the rectus abdominis flap was used to fill the caudal portion and occlude any bronchial fistula present. All empyemas were treated successfully without recurrence. This method has the advantage of filling apical and caudal parts of the space at once, making effective use of the combined volume of the two flaps.

Invited Commentary

We are more familiar with the management of post-pneumonectomy empyema than with post-lobectomy or post-segmentectomy empyema. The latter has not been addressed well in thoracic surgical literature, and the authors should be commended for bringing a new contribution to an uncommon problem. Although the number of patients is small, the material and methods are correctly described, and the results are clearly expressed. The late occurrence of empyema in this series [1Massera F. Robustellini M. Della Pona C. Rossi G. Rizzi A. Rocco G. Open window thoracostomy for pleural empyema complicating partial lung resection.Ann Thorac Surg. 2009; 87: 869-874Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] is bothersome. Empyema developed in 12 of 19 patients (63%) at more than 3 months after pulmonary resection, and it is wondered if this is because of missed or delayed diagnosis, indolence of organism, or residual or recurrent tumor at the stump [1Massera F. Robustellini M. Della Pona C. Rossi G. Rizzi A. Rocco G. Open window thoracostomy for pleural empyema complicating partial lung resection.Ann Thorac Surg. 2009; 87: 869-874Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]. The authors believe the reason for delayed occurrence is probably due to hematogenous spread of bacteria to the pleura or from other parts of the body. In dealing with post-pulmonary resection empyema, two problems must be considered: (1) the treatment of infection, and (2) the obliteration of the infected space. To treat infection, drainage must be established. Chest tube drainage should be considered in early cases. The authors suggested that early performance of open window thoracostomy, in their hands, was more effective and instrumental in early eradication of infection. It was a significant predictor of healing, whereas prolonged chest tube drainage failed to control the infection in “late onset empyema,” especially in patients with an entrapped lung, and we are in total agreement. In regard to obliteration of the residual space, certain principles should be considered at the time of initial pulmonary resection that hopefully may cut down on the incidence of postoperative empyema. Measures such as the application of a pleural tent, phrenic nerve crush, or institution of pneumoperitoneum are good examples. The authors expressed their opinion regarding bronchopleural fistula as a cause of persistence of drainage. If bronchopleural fistula persists, the intrathoracic interposition of muscle flaps will help with obliteration of the residual space. In the absence of bronchopleural fistula, the use of the Clagett procedure with antibiotic irrigation was effective in their hands. At our institution, we use the transaxillary approach for the Eloesser flap, in which no muscles need to be cut, and therefore it is cosmetically attractive. In regard to muscle flaps for the obliteration of the space we use the serratus anterior, the latissimus dorsi, and occasionally the pectoralis major muscle for post-upper lobectomy empyema and the omentum for post-lower lobectomy empyema and intercostal muscle to buttress the closure of a bronchopleural fistula. Open Window Thoracostomy for Pleural Empyema Complicating Partial Lung ResectionThe Annals of Thoracic SurgeryVol. 87Issue 3PreviewAlthough an open-window thoracostomy (OWT) represents the ideal method for drainage of postpneumonectomy empyema, several controversies exist concerning its application to pleural empyema complicating pulmonary resections less than pneumonectomy. Full-Text PDF

Thoracoplasty for the Management of Postpneumonectomy Empyema

Persistent postpneumonectomy empyema space is a difficult problem. Various operative procedures are described for its management. These include space sterilization procedures e.g. Clagett procedure, space filling with muscle flaps and space collapse procedures such as thoracoplasty. Andrew's thoracoplasty, originally used for cavitary pulmonary tuberculosis, is a valuable operative procedure in the management of persistent postpneumonectomy empyema space. We present a case in which a diagnostic radiological aspiration five years postpneumonectomy resulted in empyema in the postpneumonectomy space. Management of the patient involved involved a combination of space reduction and space filling with muscle flaps. This case highlights the risks of interventions in the post pneumonectomy space and the value of time-honored thoracoplasty.

Posptneumonectomy empyema.

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. 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). 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%. 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.

Post-pneumonectomy empyema

Empyema remains a formidable complication following pneumonectomy, and compounds the mortality of such major surgery. Our experience of 41 cases of post-pneumonectomy empyema (PPE) is presented. There is no universally appropriate treatment and management depends upon the patient's general condition and the presence of associated fistulas. Initial management consists of drainage in all cases. This may be continued if the patient is unfit for further procedures or if there is any doubt about the possibility of an early relapse. Since 1979, we have treated 23 cases of PPE not associated with bronchopleural fistula (BPF) ("simple" PPE). All were treated by rib resection and open drainage. Subsequently in four patients, Portovac drainage eradicated the space and infection within 3 and 12 months. One patient died of pulmonary embolus one day after open drainage. Three patients were unfit for further treatment and one patient refused further treatment. One patient underwent Schede thoracoplasty and had no further infection. Thirteen patients were re-admitted after a period of open tube drainage (3-28 weeks), the infected space was irrigated to sterility and closed. This was successful in eight cases which have remained sterile 9 months to 9 years later. Five patients developed recurrent PPE and three patients have remained sterile following repeated irrigation and closure. The management of PPE is further complicated by concurrent fistulas. Since 1979, 18 patients have had PPE complicated by fistula ("complex" PPE), often recurrent following previous unsuccessful attempts at closure. Treatment has been individualized, and has often required further major surgery. Small BPFs closed with drainage and the space was obliterated with Portovac drainage in three patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Postpneumonectomy empyema: The role of intrathoracic muscle transposition

Forty-five patients (36 male and nine female) were treated for postpneumonectomy empyema. All were initially managed with the first stage of the Clagett procedure (open pleural drainage). In 28 patients with associated bronchopleural fistula the fistula was closed and reinforced with muscle transposition at the time of open drainage. Seven patients had multiple flaps. The serratus anterior muscle was transposed in 28 patients, latissimus dorsi in 11, pectoralis major in four, pectoralis minor in one, and rectus abdominis in one patient. After the fistula was closed and the pleural cavity was clean, the second stage of the Clagett procedure (obliteration of the pleural cavity with antibiotic solution and closure of the open pleural window) was done. The number of operative procedures ranged from 1 to 19 (median 5.0). Length of hospitalization ranged from 4 to 137 days (median 34.0 days). There were six operative deaths (mortality rate 13.3%), none in the patients who had both stages of the Clagett procedure. Follow-up of the 39 operative survivors ranged from 2.1 to 90.2 months (median 21.8 months). Eighty-four percent of patients in whom the Clagett procedure was completed (26/31) had a healed chest wall with no evidence of recurrent infection. The bronchopleural fistula remained closed in 85.7% of patients (24/28). There were 19 late deaths, none related to postpneumonectomy empyema. We conclude that the Clagett procedure remains safe and effective in the management of postpneumonectomy empyema in the absence of bronchopleural fistula and that intrathoracic muscle transposition to reinforce the bronchial stump is an effective procedure in the control of postpneumonectomy-associated bronchopleural fistula.

Open window thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula

Postpneumonectomy empyema, with or without bronchopleural fistula, remains an infrequent but serious complication of pulmonary resection. We reviewed our experience with the Clagett procedure in 31 patients with postpneumonectomy empyema. Seven had empyema alone and 24 had empyema with bronchopleural fistula. Ten patients died of metastatic disease without attempted closure of the thoracostomy window. In eight patients the total Clagett procedure was completed; window closure was permanent in two patients, but the remaining six had recurrence of empyema (four of whom had persistent occult fistulas). In eight further patients, persistent infection prevented attempted closure of the window. Five patients refused further surgical procedures. In only two of 31 patients were we able to achieve permanent closure of the thoracostomy window. Based on this experience, we conclude that open window thoracostomy provides adequate drainage and an excellent interim or permanent treatment of the infected pneumonectomy space. However, the presence of persistent bronchopleural fistula prevents successful completion of the total Clagett procedure. In our series, there were no deaths related to empyema or the surgical procedures performed for it.

The management of postpneumonectomy empyema

The management of postpneumonectomy empyema