Ann Thorac Surg 1997;63:1494-1496
© 1997 The Society of Thoracic Surgeons
How To Do It
A Dedicated Prosthesis for Open Thoracostomy
Luiz T. B. Filomeno, MD,
José M. de Campos, MD,
Antonio W. de Almeida, MD,
Eduardo de Campos Werebe, MD,
Fábio B. Jatene, MD,
Adolfo A. Leirner, MD
Division of Thoracic Surgery and Bio-Engineering Laboratory, Department of Cardio-Pneumology, Faculty of Medicine of the University of São Paulo, Brazil
Accepted for publication December 17, 1996.
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Abstract
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Due to our dissatisfaction with the mutilation caused by the skin-lined open thoracostomy, we have developed a dedicated prosthesis that is expected to avoid or to substitute for the classic operation. The prosthesis is a corrugated silicone tube with an oval flange at one end (to fix it internally) and a mobile ring on the other (to fix it externally). It is inserted at the bottom of the empyematic cavity after 3 cm of a rib is removed. We have used it in 20 patients whose empyema was secondary to pneumonia (12) or complications of pneumonectomy (4), lobectomy (2), decortication (1), or pleuroscopy (1). Six of those patients have already been cured and their prosthesis removed after 54 to 305 days. In 1 with a persistent postpneumonectomy bronchopleural fistula the device was removed after 299 days and the patient was submitted to a limited thoracoplasty. Six other patients still have unresolved cavities and have been using the prosthesis for 63 to 302 days. Seven patients died of their underlying disease (bilateral pneumonia, 2; acquired immunodeficiency syndrome, 2; mesothelioma, 1; heart failure and pulmonary embolism, 1; unknown, 1) after using the prosthesis for 11 to 160 days. In those patients from whom the prosthesis already has been removed, the scar looks like those commonly seen after removal of an ordinary chest tube. Based on these early favorable results we feel most encouraged to persist in this research. Nevertheless, we are aware that a larger number of patients and a longer follow-up will be necessary before we may make definitive recommendations.
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Introduction
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Skin-lined open thoracostomy is undoubtedly an invaluable procedure in the management of particular cases of chronic empyema. Infected postpneumonectomy or postlobectomy spaces and residual infected spaces after pneumonia in patients with nonexpandable lung or in those who are not fit for a pulmonary decortication are the major indications.
Although there must be some exceptions (as always), the way that operation has been done in many different countries is basically the same. Most authors have reported they usually remove sizable segments (10 to 15 cm) of two to four ribs and then mobilize the skin around the incision to suture its borders to the thickened pleura [1–7]. The result is a "nice" (large) thoracostomy that allows one to thoroughly clean and pack the empyema cavity thereafter. As a matter of fact, we never felt comfortable in doing such a mutilating operation, and most of our patients (and referring doctors too) were usually shocked and quite unhappy with the appearance of the thoracostome.
Because of these sound complaints by patients, but also because a large skin-walled open thoracostomy can be a time-consuming operation, we devised a dedicated prosthesis that is now being presented. It is intended both to simplify the technique and to improve the cosmetic result of the conventional thoracostomy, whether open or healed.
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Technique
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The prosthesis is a corrugated silicone tube (10 x 2.5 cm) 2.0 cm in internal diameter. It has an oval plate at one end, to fix it against the pleura, and an external mobile ring at the other end, to fix it against the skin (Fig 1
). For its insertion the patient is usually positioned in the lateral decubitus position with the affected hemithorax up. After anesthesia has been induced (general, or even local) and towels have been applied, the first step is to determine the bottom of the empyematic cavity. Considering that virtually all of these patients have a chest tube at the time of the operation, after this tube is removed we try to find the bottom of the cavity by introducing the middle finger through the tube's port. If this proves unsuccessful, we use the videothoracoscope or, more often, Carlen's mediastinoscope (easier to set up) to accomplish that important aim. As soon as we have found the right place, a perpendicular skin incision of 4 cm is made over the rib encountered at this level, and 3 cm of this rib is resected. Once the cavity is entered, it is thoroughly cleansed by suction, saline irrigation, and, most importantly, dry folded gauzes mounted on long forceps. If the empyematic cavity is too deep or too large to be completely explored with the naked eye, we simply take advantage of Carlen's mediastinoscope or the videothoracoscope to assure complete debridement of the empyema and abrasion of the whole internal surface of the cavity. The prosthesis is finally inserted through the gap in the rib and a few stitches are placed to reapproximate the skin, if necessary (Fig 2). Next, the excess tube is trimmed away (leaving two or three rings out of the incision), the external ring is positioned against the skin, and a colostomy bag is attached to the tube.
Postoperatively, whether in the hospital or at home, there is no need for special care, except changing the bag when it becomes dirty. Yet, it is perfectly possible to irrigate and suction the cavity through the prosthesis and even make a complete reevaluation of the cavity by introducing a telescope lens through the prosthesis on any postoperative day.
When the lung reexpands and fully replenishes the pleural cavity, the prosthesis is manually removed (with a rotary movement and traction) with the patient under light sedation (meperidine, 100 mg intramuscularly).
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Results
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Between April 1995 and September 1996, 20 patients with chronic empyema (parapneumonic, 12; postpneumonectomy, 4; postlobectomy, 2; postdecortication, 1; postthoracoscopy, 1) were treated by this method. Of those, 6 (postpneumonectomy, 1; parapneumonic, 5) have already been cured of their empyema and have had their prosthesis removed after 184, 54, 56, 67, 115, and 305 days. Six other patients have also been cured of their pleural suppuration after using the prosthesis for 48, 63, 200, 279, 304, and 312 days, but because they still have residual cavities they are required to use the prosthesis until those spaces disappear or are surgically closed. Two patients presented postoperative complications: 1, with pneumonia and a postlobectomy bronchial stump fistula, aspirated infected material to the other lung and eventually died of bilateral pneumonia and septic shock on the 15th postoperative day. The other had small but persistent bleeding after the operation, which was controlled during a reexploration of the chest wall next morning. While still using the prosthesis 6 patients have died because of their primary diseases: bilateral pneumonia, 1; diffuse mesothelioma, 1; acquired immunodeficiency syndrome, 2; heart failure and pulmonary embolism, 1; and unknown, 1. In those last patients the prosthesis had been in place for 11 to 156 days. Finally, 1 of the patients with postpneumonectomy empyema and an 8-mm bronchopleural fistula had his prosthesis removed after 299 days and was successfully managed by a limited thoracoplasty.
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Comment
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Although open drainage of empyema goes back at least to the Hippocratic era [8], the first article about skin-walled open thoracostomy in the English-language literature is credited to Samuel Robinson, who reported the use of this operation for chronic empyema as early as 1915, according to the very nice and recent historical review by Jacques and Deslauriers [5]. His technique consisted of a U-shaped skin incision, partial resection of some ribs, suture of the latissimus dorsi muscle inside the empyematic cavity, and suture of the borders of the skin to the respective edges of pleura. This report, however, seems to have gone unnoticed, because the first skin-lined open thoracostomy is usually attributed to Eloesser [9], who actually described a surprisingly similar operation 20 years later in 1935.
Nonetheless, it is our impression that the type of open thoracostomy currently in use today derives mainly from the one described by Clagett and Geraci [1] in 1963 for the management of postpneumonectomy empyema. Since that time, this operation has remained, but the original technique has undergone a series of modifications regarding the site and design of the incision, the number and extent of resected ribs, and the issue of the inclusion of chest wall and intercostal muscles together with the rib resection. It is not within the scope of this report to make a comprehensive review on this matter, but to sustain our argument we will mention a few examples: Weissberger (from Israel) [7] resects 15 cm of each of the four ribs to create the thoracostome. Eerola and associates (from Finland) [2] also create a similar large stoma and later, instead of closing it, they cover all surfaces of the cavity with free skin flaps. Galvin and colleagues (from Ireland) [3] proposed a three-armed incision ("Mercedes-Benz" symbol). Postmus and co-workers (from the Netherlands) [6] make a thoracostomy very similar to but larger than originally described by Clagett and Geraci [1]. Hurvitz and Tucker (from the United States) [4] and Jacques and Deslauriers (from Canada) [5] make a large thoracostome (resection of 10 cm of two ribs) through an H-shaped skin incision. All of those operations, although highly effective in treating chronic empyema, are also quite deforming and mutilating in our point of view. They create a rather extensive area of chest wall depression with a wide and deep hole in its center, which gives the patient an unsightly profile.
It was only after many years of dissatisfaction with the cosmetic and psychological consequences of the open thoracostomy that one of us (L.T.B.F.) came up with a less aggressive alternative to that disgraceful operation. The rationale for this proposition was (1) we do need a large and long-standing drainage tract to treat chronic empyema; (2) skin-lined thoracostomy is usually made too large because the small ones tend to close soon; and (3) with a dedicated prosthesis we could have a large-enough, self-restrained, and long-standing thoracostome, without mutilating and disfiguring the patient (Fig 3).
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Fig 3. . (A) Chest roentgenogram 1 month after insertion of the prosthesis (see on the right, at the costophrenic angle) in a patient with a primarily larger cavity after a postpneumonic empyema. (B) Same patient 1 month after removal of the prosthesis.
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In our opinion, the prosthesis we are now presenting could be compared to the traditional open tube only as far as both of them are tubes. The conventional open tube is not large enough, most of the time it does not stay at the most dependent part of the empyematic cavity, and it is hard to maintain it in place. Thus, it is not appropriate for long-term use.
Considering our early favorable results, we are most encouraged to continue the use of this dedicated prosthesis for the treatment of chronic empyema, instead of performing the conventional open thoracostomy. We agree that more observation time and a larger number of treated cases are necessary before we can draw final conclsions, however.
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Acknowledgments
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We thank Mrs Marina Maisato and Mrs Helena Oyama, engineers from our laboratory of Bio-Engineering, for their dedicated attention in the fabrication of our prosthesis. We also thank Ms Lenira Monteiro da Silva, who carefully made all the illustrations, and our secretary, Ms Gracia A. P. Cordeiro, for her kind dedication in the many times the manuscript had to be reviewed.
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Footnotes
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Address reprint requests to Dr Filomeno, Rua da Consolação 3726, ap 101, CEP 01416-000 São Paulo, SP, Brasil.
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References
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- Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 1963;45:141–5.
- Eerola S, Virkkula L, Varstela E. Treatment of postpneumonectomy empyema and associated bronchopleural fistula. Scand J Thorac Cardiovasc Surg 1988;22:235–9.[Medline]
- Galvin IF, Gibbons JRP, Maghout MH. Bronchopleural fistula: a novel type of window thoracostomy. J Thorac Cardiovasc Surg 1988;96:433–5.[Abstract]
- Hurvitz RJ, Tucker BL. The Eloesser flap: past and present. J Thorac Cardiovasc Surg 1986;92:958–64.[Abstract]
- Jacques LF, Deslauriers J. Open drainage. In: Pearson FG, Deslauriers J, Ginsberg R, Hiebert CA, McKneally MF, Urschel HC Jr, eds. Thoracic surgery. New York: Churchill-Livingstone, 1995:1136–40.
- Postmus PE, Kerstgens JM, Boer WJ, Homan JN, Koeter GH. Treatment of post-pneumonectomy pleural empyema by open window thoracostomy. Eur Resp J 1989;2:853–5.[Abstract]
- Weissberger D. Empyema and bronchopleural fistula: experience with open window thoracostomy. Chest 1982;82:447–50.[Abstract/Free Full Text]
- Haeger K, ed. The illustrated history of surgery. New York: Bell Publishing, 1990:42.
- Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935;60:1096–7.
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Abstract
Introduction
