Ann Thorac Surg 1996;62:1037-1038
© 1996 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Marvin Pomerantz, MD
General Thoracic Surgery Section, Division of Cardiothoracic Surgery, University of Colorado, Health Sciences Center, 4200 E 9th Ave, #C310, Denver, CO 80262
See also page 1033.
Doctor Massard and his colleagues have reported 25 patients undergoing pneumonectomy for chronic infection. Two of these patients died, 8 had postpneumonectomy empyema, and 3 patients had bronchial stump dehiscence. This high mortality and complication rate emphasizes the morbidity of chronic pulmonary infections requiring pneumonectomy. Nine of the 23 survivors eventually underwent thoracoplasty to obliterate the pleural space or to close the bronchopleural fistula.
Our experience includes 112 patients undergoing pneumonectomy for mycobacterial disease. Sixty-six had multidrug-resistant tuberculosis, 42 had mycobacterial infections other than tuberculosis, 3 had pneumonectomy for drug-sensitive tuberculosis, and 1 had a pneumonectomy for Mycobacterium bovis infection. Thirty-eight of the patients underwent completion pneumonectomy. As in Massard and associates' series, left-sided lung destruction has been more common for multidrug-resistant tuberculosis but was not more common in the other patients. For multidrug-resistant tuberculosis we have had only three bronchopleural fistulas with no other empyemas occurring, whereas in patients with mycobacterial infections other than tuberculosis, we had two empyemas without bronchopleural fistula and nine with bronchopleural fistula. Based on this series of patients we now advocate an extrapleural pneumonectomy as the procedure of choice whenever dense pleural adhesions exist. Furthermore, we employ the liberal use of muscle flaps for the following indications: positive sputum for acid-fast bacili at the time of operation, preoperative bronchopleural fistula, and polymicrobial contamination. Our muscle of preference is the latissimus dorsi muscle, which is sutured to the main bronchus and packed into any infected area. We do not use the serratus because it causes a winged scapula, which is often disabling to these patients. The use of omental flaps is advocated in patients undergoing right pneumonectomy for mycobacterial infections other than tuberculosis in instances where there has been a previous thoracotomy and latissimus dorsi is not available and when a left or right pneumonectomy is performed in the presence of massive contamination. In these latter patients we also now perform an Eloesser procedure, which can later be closed using the Claggett procedure. We perform very few thoracoplasties and prefer to try to close the bronchopleural fistula by other means such as rotating the pectoralis muscle into the chest or through a transmediastinal approach. Employing all of the above techniques, our operative mortality has remained at approximately 3%.
Doctor Massard and his colleagues should be congratulated for bringing a difficult problem of pneumonectomy for infection to our attention. The high complication rate they report should make one wary to operate on these patients without the use of muscle or omental flaps. One should also consider the use of Eloesser flaps when considerable contamination is present at the time of operation.
Related Article
-
Pneumonectomy for Chronic Infection Is a High-Risk Procedure
- Gilbert Massard, Ahmad Dabbagh, Jean-Marie Wihlm, Romain Kessler, Pierre Barsotti, Norbert Roeslin, and Georges Morand
Ann. Thorac. Surg. 1996 62: 1033-1037.
[Abstract]
[Full Text]
