Postpneumonectomy Empyema Research Articles

Surgical Treatment of Pleural Empyema: Changing Priorities

The surgical management of pleural empyema and post-traumatic clotted haemothorax is described. The study included 15 cases of post-thoracotomy empyema, 23 of empyema of other aetiology and five of post-traumatic haemothorax. Chest-tube drainage was the first measure in most cases. Post-pneumonectomy empyema was treated with partial thoracoplasty plus omentoplasty (8 cases) or plus myoplasty (1 case). Empyema after lobectomy or bilobectomy (4 cases) or after failed decortication (1 case) was managed with thoracoplasty or, in cases of concomitant wound infection, with open-window thoracostomy followed by thoracoplasty. Empyema after subclavian artery reconstruction (1 case) was cleared by removal of a previously unrecognized foreign body. For early empyema of other aetiology or haemothorax (10 cases in total), treatment comprised debridement by video-assisted thoracoscopic surgery (VATS). VATS was also used to establish suitable pleural drainage prior to elective thoracotomy (2 cases). Decortication and partial parietal pleurectomy were performed for organizing-stage empyema (16 cases). Three of the 15 patients with post-thoracotomy empyema died perioperatively, one died two months postoperatively and one had recurrence of bronchopleural fistula during follow-up. One patient with VATS debridement subsequently required thoracotomy and lobectomy for lung abscess. All the others with VATS or decortication recovered without complications. During follow-up there was no mortality or recurrence of empyema.

Pleural space irrigation and modified clagett procedure for the treatment of early postpneumonectomy empyema

Objective: The incidence of postpneumonectomy empyema is 5% to 10%. Approximately half of postpneumonectomy empyemas occur within 4 weeks of pneumonectomy. A bronchopleural fistula is found in more than 80% of the patients. The classic treatment of postpneumonectomy empyema includes parenteral antibiotics, drainage of the pleural space, removal of necrotic tissue, and open pleural packing for many weeks followed by obliteration of the empyema space with antibiotic fluid or muscle. This approach results in prolonged hospitalization, repeated operations, and significant morbidity. As a possible means of decreasing morbidity with the classic treatment of postpneumonectomy empyema, we studied the use of pleural space irrigation in these patients. Method: In a 5-year period, we treated 22 patients with early postpneumonectomy empyema. All patients had a bronchopleural fistula. All patients underwent emergency drainage of the pleural space followed by thoracotomy, debridement of necrotic tissue, closure of the bronchial stump with absorbable monofilament suture, and pleural space irrigation. After a negative Gram stain from the pleural fluid, the pleural space was filled with 2 L of debridement antibiotic solution (DAB solution) (gentamicin 80 mg/L, neomycin 500 mg/L, and polymyxin B 100 mg/L), and the irrigation and drainage catheters were removed. Results: Twenty patients had negative Gram stains on day 9, and 2 patients had a negative Gram stain on day 16. The mean duration of hospitalization was 12.9 ± 3.4 days. There was no recurrence of empyema or a bronchopleural fistula. Conclusions: Pleural space irrigation followed by obliteration of the pleural space with an antibiotic solution required one surgical procedure and resulted in significantly shorter hospitalization and decreased morbidity in patients with early postpneumonectomy empyema. (J Thorac Cardiovasc Surg 1998;116:943-8)

Childhood chronic pleural empyema: a continuing surgical challenge in developing countries.

Surgical treatment may be necessary in childhood chronic pleural empyema. Over a 21-year period 642 children with pleural empyema were hospitalized and 104 of them underwent surgical treatment. The records of the children who underwent surgery for the treatment of empyema were retrospectively reviewed to describe the role, indications, and results of surgical treatment of childhood chronic pleural empyema. Etiologic diseases or conditions leading to empyema were pneumonia in 69 patients, tuberculosis in 13, hydatid cyst in eight, postpneumonectomy empyema in five, and other causes in nine patients. Indications for surgery were severe pleural thickening in 54 cases (51.9%), trapped lung in 36 cases (34.6%), loculated empyema in eight cases (7.7%) and broncho-pleural fistula in six cases (5.8%). Operations performed were decortication in 90 patients, pulmonary resection and decortication in seven, muscle flap closure in five, and pneumonectomy in two. Success rates in the treatment of nonspecific and tuberculous empyema were 93% and 54%, respectively. Surgical treatment is still necessary in childhood pleural empyema in developing countries, and success rates are very high in nonspecific pleural empyema and acceptable in tuberculous pleural empyema.

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.

Pneumonectomy for tuberculosis.

Surgery for tuberculosis has been of major concern because of its associated morbidity and mortality, particularly with respect to pneumonectomy. Over a period of 11 years, between January 1985 and December 1995, pneumonectomy was performed for 20 patients with documented history of mycobacterium tuberculosis (TB). There were 12 male and eight female patients with an average age of 28.7 years. All patients had productive cough for an average duration of 12.8 years, while ten (50%) had an additional hemoptysis for an average duration of 3.9 years. Four patients (20%) were still with positive acid-fast bacilli due to drug resistance and four (20%) had aspergilloma complex. Preoperatively, all patients showed radiological evidence of unilateral destroyed lung with no perfusion. Among the 20 patients with post-tuberculosis lung destruction, 16 had left lung destruction and four had the right lung destroyed. In this series, there was no mortality and morbidity accounted for 15% (n = 3). Two patients required re-exploration for bleeding, while one patient developed post-pneumonectomy empyema without bronchopleural fistula, for which drainage with rib resection was performed. All patients were found to be symptom free during the follow up period which averaged 93.7 +/- 23.9 months (range between 12 and 124 months). In this series of 20 patients, pneumonectomy for TB and post-tuberculosis lung destruction was performed with no mortality and acceptable morbidity. Meticulous surgical technique is mandatory to avoid operative complications. Persistent positive sputum for acid-fast bacilli should not be considered as contraindication in symptomatic patients.

Modern morbidity following pulmonary resection for postprimary tuberculosis.

Between January 1991 and March 1996, a total of 28 patients with postprimary tuberculosis underwent resection for disease progression (n = 8), multidrug resistance or noncompliance to the medical treatment (n = 11), parenchymal sequelae (n = 3), suspected cancer (n = 5), and for the correction of postpneumonectomy bronchopleural fistula and empyema (n = 1). On admission, eight patients presented with sputum positivity (28.6%). Similar to previous series, tubercular predilection for upper lobes was confirmed (21/28, 75%); accordingly, upper lobectomy through an extrapleural approach was the most common procedure (16/28, 57.1%). Atypical segmental resections or segmentectomies were performed in seven patients (25%), whereas a bilobectomy was necessary in another three patients (10.7%) and a completion pneumonectomy in one (3.6%). Additional procedures were an open-window thoracostomy with transpericardial closure of the main bronchus and a tailored thoracoplasty. No operative mortality was reported. Healing was achieved in 26 patients (93%). Bleeding, either from the chest wall or hilar dissection, was the only reported intraoperative complication. Median blood loss, inclusive of early postoperative collections from chest tubes, reached 1330 ml (range 100-3700 ml). Major postoperative complications included recurrent disease (2/28, 7%) in sputum-positive patients and segmental pulmonary embolism (3.5%). Causes of minor morbidity were air leaks resulting in residual space undergoing spontaneous resolution (18%), wound breakdown (14%), and, fever (11%). This limited series confirms the therapeutic value of the surgical treatment of postprimary tuberculosis, provided that correct indications, adequate pre- and post-operative medical coverage, and meticulous technique are applied.

Elective pneumonectomy for benign lung disease: Modern-day mortality and morbidity

This retrospective study of elective pneumonectomy for complicated inflammatory lung disease was done to define modern-day mortality and morbidity. One hundred twenty-four patients received elective pneumonectomy. Patient ages ranged from 6 months to 71 years. Past, recurrent, or new pulmonary tuberculosis was present in 107 patients (86.3%). Clinical presentation involved recurrent infections or severe suppurative sequelae (abscess, empyema). Forty-seven patients had chronic hemoptysis and 25 patients had past or recent massive hemoptysis (> 600 ml of hemoptysis fluid within 24 hours). Nutritional deficiencies were common. One hundred six patients (85.5%) had end-stage destroyed lungs. Evaluative bronchoscopy showed inflammatory endobronchial changes in 106 patients (85.5%), bronchial strictures in 4, and indolent endobronchial tumor in 2. Lung separation was by double-lumen tube in 96 patients, single lung-single tube in 6, bronchus blocker in 6, and prone posture in 9. Extrapleural pneumonectomy was done in 83 patients (66.9%). Fifty-seven of these procedures were left sided and 26 were right sided. Standard transpleural pneumonectomy was done in 41 patients (33.1%): 30 left sided and 11 right sided. Nine pneumonectomies were conducted with the patient in the prone position. Four patients had completion pneumonectomy. Hospital mortality was three deaths (2.4%). Morbidity included postpneumonectomy empyema in 19 patients (15.3%). Seven postoperative bronchopleural fistulas occurred. Empyema in most patients was managed by open pleural drainage (thoracostoma) and later space closure. Pneumonectomy proved effective therapy with low mortality but postpneumonectomy empyema posed serious morbidity.

Initial experience of video assisted thoracoscopic pneumonectomy.

Preliminary experience of video assisted thoracoscopic pneumonectomy in six patients with bronchogenic carcinoma is described. Four left and two right pneumonectomies were performed under video thoracoscopic imaging. Thoracoscopic instruments were passed through two separate stab incisions on the lateral chest wall and a separate 6 cm submammary incision was also created to allow further access for instrumentation and removal of the resected lung. In this initial experience resection was restricted to patients with bronchogenic carcinomas of less than 6 cm in diameter who had no involvement of the mediastinum. There were no operative deaths and no complications attributable to the technique. One patient developed postoperative atrial fibrillation and a small sacral sore and one patient was readmitted with abdominal pain and pyrexia which settled following exclusion of post pneumonectomy empyema. The remaining four patients made a rapid uncomplicated postoperative recovery with less pain and discomfort than that normally associated with a standard posterolateral thoracotomy. Postoperatively the mean (SD) patient controlled morphine consumption was 1.36 (1.90) mg per hour in the first 36 hours compared with the unit mean for open thoracotomy of 1.73 (1.68) mg per hour. The mean linear visual analogue pain score was 15.4 (15.6) in the first 24 hours compared with the unit mean for open thoracotomy of 34.5 (8.5). Video assisted thoracoscopic pneumonectomy can be performed safely in patients who have stage I and stage II bronchogenic carcinomas, up to 6 cm in diameter, with no mediastinal involvement on mediastinoscopy and thoracic computed tomographic assessment. This technique may result in less postoperative pain and discomfort and should allow a quicker return to normal activities.

Open window thoracostomy, myoplasty, and epiploplasty for treatment of postpneumonectomy empyema: CT evaluation.

To demonstrate the computed tomographic (CT) appearance of the postpneumonectomy space (PPS) after surgical treatment of postpneumonectomy empyema. The authors retrospectively reviewed 22 CT scans obtained in 15 patients after open window thoracostomy (OWT) (n = 4), myoplasty (n = 12), and epiploplasty (n = 1). After uncomplicated OWT, the retracted PPS contained air and/or gauze without residual pleural fluid. After uncomplicated myoplasty, marked retraction of the operated hemithorax was observed. CT allowed localization of transposed muscle flaps and fatty tissue within the PPS. A moderate amount of fluid and air was present during the 1st month after surgery. After uncomplicated epiploplasty, the retracted PPS contained homogeneous tissue with characteristic fatty attenuation. Complications including recurrent empyema, recurrent bronchopleural fistula, aseptic fluid collection, necrosis and fatty transformation of muscle flaps, and tumor recurrence were accurately demonstrated. CT is useful in follow-up after surgical treatment of postpneumonectomy empyema because it permits accurate evaluation of the PPS.

Utility of C-reactive protein measurements for empyema diagnosis after pneumonectomy

Serum C-reactive protein (CRP) leveis were studied serially during the postoperative period in 151 consecutive patients who underwent paeumonectomy. Virtually all patients who had a simple postoperative course (115 of 120), as well as 9 patients who had a bronchial infection of the remaining lung, 3 with a pulmonary embolus, and 2 who suffered postoperative bleeding requiring reoperation, demonstrated a similar postoperative evolution in their CRP values; a rapid postoperative rise until a peak or a plateau (mean peak value, 132 ± 25 mg/L) was reached within 3 to 6 days, followed by a progressive decline to a value of less than 75 mg/L on day 9, and less than 50 mg/L on day 12. Conversely, all 12 patients who suffered empyema poctoperatively, as well as 3 patients with bacterial pneumonia, 1 patient with chylothorax, and 1 patient with inflammatory pericarditis, demonstrated either a markedly persistent elevation in their CRP values or a secondary rise in the levels which exceeded 100 mg/L. Because of the high sensitivity (100%) and specificity (91.4%) of the CRP levels in detecting postpneumonectomy empyema, we recommend the routine use of this measure. Furthermore, a low CRP value after pneumonectomy (less than 50 mg/L) may help in deciding whether to confidently discharge a patient from the hospital in the absence of empyema. The negative predictive value of this method was found to be 100%.

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)

The pectoral muscle flaps in the treatment of bronchial stump fistula following pneumonectomy.

Between 1975 and June 1992, pneumonectomy was performed in 594 patients, of whom 33 (5.6%) developed bronchopleural fistulae postoperatively. Until 1989 25 cases were reoperated: 5 patients were treated by thoracoplasty primarily, 20 by repair of the stump with sutures and by covering the stump with pericardial tissue or intercostal muscle, of whom 10 suffered from empyema. In 5/20 patients (25%) chronic fistulae developed making further interventions necessary. Since 1989 seven patients with bronchial stump fistulae have been reoperated with a delay of less than 12 h after diagnosis. Surgery consisted of reclosure of the stump with sutures in five patients. In addition, every patient was treated with the intrathoracic transposition of a petiolated ipsilateral pectoral muscle graft, which was the only treatment in two patients. Neither recurrence of the bronchopleural fistula nor empyema was seen in this group of patients (0%). We conclude that bronchial stump fistulae in patients after pneumonectomy can be treated successfully by the use of pectoral muscle flaps either combined with a closure of the leak using sutures or as the only measure. The method proved to be simple, safe and without major impairment of the patient. In combination with early reintervention, postpneumonectomy empyema including a disfiguring thoracoplasty can thereby often be avoided.

Pleuropulmonary aspergilloma: Clinical spectrum and results of surgical treatment

From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.

血管閉塞用コイルを用いた気管支鏡下瘻閉鎖後に筋弁充填を行った肺摘除術後有瘻性膿胸の 1 例

血管閉塞用コイルを用いた気管支鏡下瘻閉鎖後に筋弁充填を行った肺摘除術後有瘻性膿胸の 1 例

Open-window thoracostomy in pleural empyema.

Open-window thoracostomy (OWT) was performed in 21 cases of empyema. The indications were postpneumonectomy empyema with (n = 6) or without (n = 1) fistula, early recurrent empyema after decortication (n = 6), chronical empyema in ill elderly patients with (n = 5) or without fistula (n = 2), and total unilateral lung gangrene with a large fistula of the main bronchus after radiotherapy and chemotherapy (n = 1). All cases presented with severe sepsis, eight of them with acute septic shock, and six with signs of multiorgan failure. Three to five ribs were resected, the muscles and skin were sutured to the ribs confining the window located at the lowest point of the empyema cavity, while the intercostal muscles of the resected ribs were used to close fistulae. The cavity was packed with dressings every day. In all cases, the sepsis subsided immediately after OWT. With the exception of one patient with postpneumonectomy empyema, who died of contralateral pneumonia on day 36, no surgery-related complications were seen. Four further patients died of unrelated causes 2, 4, 5, and 7 months, respectively, after OWT. In one of them, the OWT had been closed. Up to this time, obliteration and closure of the cavity has been carried out in 7 cases by using thoracoplasty (n = 2) or predicted muscle flaps (n = 5) either in the early course or after a delay of 11 to 23 months, with fair functional and cosmetic results. In one further case, operative closure has been planned. In seven of the eight remaining patients, four of whom declined further operations, the cavities closed spontaneously, despite their initial size after intervals of between 11 and 21 months.

A case of empyema developing thirteen years after a pneumonectomy treated using pedicled omentum which was followed by intestinal obstruction

Postpneumonectomy empyema is one of the most difficult complications for the thoracic surgeon to treat. We report herein a case of a 62 year old diabetic man who developed empyema 13 years after a pneumonectomy for cancer, which was successfully treated using an omental pedicle flap. Postoperatively, the chest would healed uneventfully, however, a bowel obstruction developed which was subsequently treated by removing the remnant omentum that had adhered to the bowel.

Late-onset post-pneumonectomy empyema manifesting as tracheal stenosis with respiratory failure

Late-onset post-pneumonectomy empyema manifesting as tracheal stenosis with respiratory failure

Occult tuberculous postpneumonectomy space empyema four years after lung resection

We describe a patient in whom a tuberculous postpneumonectomy empyema developed 4 years after resection for lung cancer. The clinical presentation was dominated by non-specific constitutional symptoms, without any chest complaints. A computed tomographic scan of the chest suggested inflammation in the postpneumonectomy space. Ultimately Mycobacterium tuberculosis was cultured from material aspirated by needle thoracocentesis. To our knowledge this is the first report of a tuberculous postpneumonectomy empyema complicating resection for cancer.

Treatment of Postpneumonectomy Empyema

Postpneumonectomy empyema with or without (bronchopleural) fistula is an infrequent but serious, and often life-threatening complication. In 20 of our patients postpneumonectomy empyema was discovered. The time interval between original operation and discovery of the empyema varied from 9 days to 9 years. In two cases, the empyema had been found and treated initially at another hospital but not adequately, so that at the time of treatment by us the bronchopleural fistula had already been present for 8 and 19 years. In 13 cases a bronchial stump fistula was discovered. In five patients the fistula was successfully closed endoscopically with glue. In one patient closure was performed by transmediastinal stump resection, in three patients with a fistula thoracoplasty was performed. In three patients we achieved closure by transposition of pedicled muscle flaps. In one of these patients a septic condition could be mastered by performing window thoracotomy. Two patients without fistula were successfully treated with irrigation, and two further patients with thoracostomy. In one patient recovery was achieved by medication after puncture. Two patients died of sepsis and after thoracoplasty. If a fistula is present, drainage with irrigation and endoscopical glueing should be the initial treatment. This should be followed by resection of the bronchial stump. If there is no fistula or if the stump is too short thoracostomy is the treatment of choice. If it is not successful thoracoplasty has to be performed.

Thoracoplasty: Current application to the infected pleural space

Thoracoplasty, once commonly used in the management of cavitary pulmonary disease, continues to find application in the obliteration of infected pleural spaces. This study reports a series of 13 patients receiving thoracoplasty between 1976 and 1989. Five patients had chronic apical empyema spaces without prior resection of lung tissue. Two of the empyemas were due to tuberculosis, two were due to atypical mycobacteria, and one was due to postpneumonic empyema. All patients had extensive destruction of upper lobe tissue. Eight patients had undergone prior pulmonary resection; 3 had persistent infected spaces in the early pestoperative period, 3 had development of empyemas and bronchopleural fistulas late (5 to 19 years) after pulmonary resection, and 2 had postpneumonectomy empyema. All patients had rigid cavity walls preventing space obliteration by rib removal alone and required concomitant resection of the thickened pleura and intercostal muscle tissues. Bronchopleural fistulas were present in 11 patients and were closed with adjacent nonintercostal muscle. All patients survived and had successful obliteration of the infected spaces with acceptable physiological and cosmetic results. We conclude that thoracoplasty remains a useful procedure in the management of the infected pleural space in select patients.