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Ann Thorac Surg 1998;65:818-822
© 1998 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Open-Window Thoracostomy and Thoracomyoplasty to Manage Chronic Pleural Empyema

Thoracic Surgery Service, University Hospital, Valladolid, Spain

Accepted for publication September 30, 1997.

Dr García-Yuste, Thoracic Surgery Service, University Hospital, Avda Ramón y Cajal s/n 47003 Valladolid, Spain.

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
Background. The purpose of this study is to report our 15-year experience treating chronic empyemas after pulmonary resection and tuberculosis.

Methods. Open-window thoracostomy and thoracomyoplasty were used to treat 40 patients with chronic pleural empyema characterized by residual empyematic cavity, bronchopleural fistula, and persistent pleural infections that were secondary to tuberculosis (n = 22) or pulmonary resection (n = 18). Between 2 and 7 months after thoracostomy, thoracomyoplasty was performed to eliminate a persistent pleural cavity. In 2 patients with postpulmonary resection empyema and a large bronchopleural fistula, intrathoracic transposition of the latissimus dorsi flap and open-window thoracostomy were performed simultaneously to close the fistula.

Results. The pleural space was eliminated per primam intentionem in 21 of 22 patients with tuberculosis and in 14 of 18 with a postpulmonary resection empyema. Another myoplasty was performed in an additional 3 patients to eliminate the pleural space. During open-window thoracostomy, the latissimus dorsi muscle was preserved with minimal injury to the anterior serratus muscle. One patient died postoperatively.

Conclusions. Successful treatment of chronic pleural empyema requires adequate timing of surgical procedures. Our two-procedure technique is relatively simple and safe.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
Although the incidence of pleural empyema has recently declined, some types of the disease can cause significant problems that are difficult to resolve. Such is the case with post–pulmonary resection and posttuberculosis chronic empyemas, in which three pathologic conditions normally occur regardless of the cause: persistent empyema cavity, cavity infection, and bronchopleural fistula (BPF).

Various procedures have been developed that combine therapeutic efficacy and cause minimal anatomic and functional damage. The most widely used have been different modalities of thoracoplasty, Clagett’s conservative method, and, most recently, intrathoracic transposition of the extrathoracic skeletal muscle or the pedicled omental flap, performed individually or in combination.

The purpose of this article is to report our 15-year experience treating empyemas using thoracomyoplasty after preparatory open-window thoracostomy. We published our preliminary results in 1991 [1], but our recent experience allowed more precise analysis of the indications and results.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment References

 
From March 1979 to June 1994, 40 consecutive patients (34 men, 6 women), ranging in age from 14 to 74 years, were treated at the Thoracic Surgery Service of the University Hospital of Valladolid. All patients had pleural empyema and presented with a cavity not reducible by closed thoracic drainage, BPF, and persistent infection.

Twenty-two patients presented with posttuberculosis chronic empyema with a clinical history ranging from 5 months to 44 years. No sign of active tuberculosis was present in any patient. Eleven patients had an active BPF; in the other 11, the BPF was found intraoperatively under thick pleural calcifications. Restrictive deterioration of respiratory function (forced expiratory volume in 1 second of 35% to 55%) and poor muscular condition of the affected hemithorax were common in these patients.

The other 18 patients presented with post–pulmonary resection empyema. Sixteen pneumonectomies and two lobectomies had been performed to treat pulmonary neoplasia (n = 12 cases), carcinoid tumor (n = 1), and posttuberculosis deterioration of pulmonary anatomy and function (n = 5). The time between pulmonary resection and empyema onset was less than 1 month in 12 patients, 2 years in 2, 3 years in 2, and 12 and 14 years in 2 patients who had undergone pneumonectomy for posttuberculosis pulmonary deterioration. An active BPF was found in all patients.

The most significant clinical signs in the 29 patients with an active BPF were symptoms of sepsis and purulent expectoration. In 2 patients who underwent pneumonectomy with early empyema onset (freedom from specific symptomatology <30 days), the BPF was wide and respiratory function was severely affected.

Confirmation of the empyema and BPF was based on thoracic roentgenograms, computerized tomography, and bronchoscopy. Pleural exudate cultures, performed at the time of diagnosis, confirmed the presence of Staphylococcus aureus, Enterococcus faecalis, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Serratia marcescens, and Acinetobacter anitratus, alone or in combination, in 18 patients with post–pulmonary resection empyema and in 17 patients with posttuberculosis empyema. In two of the latter, Koch’s bacilli also were detected.

Attempts to control BPF by pleural aspiration wash and topical endoscopic treatment (AgNO₃, laser photoresection of endobronchial granulomas, and endoscopic treatment using fast-setting materials such as fibrin glue) failed in all cases.

Treatment was carried out in two stages using open-window thoracostomy and thoracomyoplasty.

Open-Window Thoracostomy
All patients underwent open-window thoracostomy that involved resection (5 to 6 cm in length) of two to three segments of ribs in the lateral portion. The latissimus dorsi muscle was always avoided, and the most posterior fibers of the anterior serratus muscle were separated so as to provoke minimal lesions in the muscle. This permitted pleural cavity debridement and the search for and exploration of the BPF.

The 2 patients who had undergone pneumonectomy with early development of a large BPF underwent the same intervention, and the BPF was closed by intrathoracic transposition of a muscular flap through a small additional axillary costal resection. The latissimus dorsi muscle was transposed in 1 patient and the anterior serratus muscle in the other, after approximation of the borders of the bronchial stump with noncontinuous polydioxanone sutures.

Wet dressings of povidone iodine (solution diluted 20:1) were changed once daily or two to three times daily if the suppuration was excessive, thus allowing elimination of gangrenous matter, pleural cavity reduction, and BPF control.

Thoracomyoplasty
After 2 to 7 months (average 4.3 months), when the functioning BPF was virtually or totally eliminated, the pleural cavity was stabilized and reduced to a capacity of less than 250 mL. If no sign of suppuration was observed, thoracomyoplasty was performed in the following steps: (1) creation of a posterolateral incision, which includes in its trajectory the previous thoracostomy, following at its level the border between skin and pleura so as to obtain skin flaps adequate for closure; (2) dissection of the selected muscles for cavity elimination, respecting the principal vascular pedicle; (3) resection of the costal bony extremities of the thoracostomy borders, this being minimal for the costal arch segments that form the cavity top; (4) closure of the persistent minimal BPF with noncontinuous polydioxanone sutures and intrathoracic transposition of extrathoracic skeletal muscle; and (5) drainage of the different planes and incision closure.

Fifty-two muscles were used to perform the 40 intrathoracic transpositions (Table 1). The muscles used for the obliteration of the residual pleural space were chosen by taking into account, for each case, the damage caused to them by previous operations.

	Results

Top Abstract Introduction Material and Methods Results Comment References

Results were highly satisfactory in 14 of the 17 surviving patients with post–pulmonary resection empyema (as mentioned previously, one patient died 21 days after the operation). In the other 3, partial necrosis of the muscular flap caused BPF and empyema persistence. In 2 of these patients, a new open drain and myoplasty using the musculus pectoralis major was curative; an open drain was maintained in the third patient because of a poor muscular and functional state.

The average hospital stay after the first surgical procedure was 12 days (range, 7 to 21 days). Daily wet dressings of povidone iodine for the residual cavity were applied for an average of 4.3 months (range, 2 to 7 months). The average hospitalization period after thoracomyoplasty was 9 days (range, 7 to 13 days) in the 35 per primam intentionem closure cases. In the 4 patients who required a second open drain (with an additional myoplasty in 3), the postoperative hospitalizations were less than 10 days in length.

One patient (2.5%) died in the postoperative period. The number of operations per patient for the 39 in whom treatment was completed was two for 35 patients and three for the other 4.

Long-Term Results
Survival and functional results were evaluated after a follow-up period ranging from 4 to 187 months (Table 3). Of the 22 patients treated for posttuberculosis empyema, 21 are alive with no symptoms of relapse. One patient died 4 months after the operation because of chronic renal insufficiency with no objective symptoms of empyema relapse. No patient has presented with symptoms of respiratory insufficiency, and spirometry improved over previous values in all cases, although the forced vital capacity and forced expiratory volume in 1 second are still 10% to 15% lower than normal values. Pulmonary gammagraphy showed a decrease of the same proportion as the pulmonary perfusion on the affected side.

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
Drainage of the empyema cavity is essential to control the septic state and ultimately correct the process. Considering the inefficiency of the more conservative procedures used to treat this type of empyema, eg, closed drainage and pleural drainage-lavage, drainage capable of solving the problem must be instituted. The advantages of open-window thoracostomy, a form of pleural drainage introduced in 1915 [2] and corroborated as useful to treat postpneumonectomy pleural empyema in 1935 [3], have been progressively recognized [4][5]. It is currently the ideal drainage to control septic symptomatology in patients with post–pulmonary resection empyemas or after poor evolution of other disease processes, especially tuberculosis.

Thus, in all cases regardless of origin, the initial drainage with closed-chest tube thoracostomy and appropriate antibiotic therapy should be followed by open-window thoracostomy to control the septic state once the acute symptoms have subsided, and with postpneumonectomy empyema, when the mediastinum is stabilized.

The size and location of open-window thoracostomy allow diverse criteria. Resection of only one segment of rib of approximately 8 cm long [6] was expanded by most authors. Virkula and Eerola [7] proposed using two ribs (15 to 20 cm); Weissberg [8] preferred fragments of the same length from four ribs; and Shamji and associates [4] recommended from three to five ribs. We advocate that surgery be performed in the lower portion of the empyematic cavity with the smallest dimensions that allow BPF control and repeated povidone iodine dressings. This allows patient discharge in a maximum of 2 weeks after stabilization of the septic problem. Daily home-care dressings can be continued.

The postpneumonectomy BPF poses a special problem with open-window thoracostomy. Because of its dimensions, it involves severe respiratory insufficiency. Cavity wet dressings cannot control air leaks, and require that the BPF be eliminated when open-window thoracostomy is performed to ensure patient survival and posterior residual cavity obliteration. Muscular transposition is presently superior to that of omentum [9][10].

We believe that open-window thoracostomy controls the septic state, improves the patient’s general condition and the thoracic muscular state until closure, and achieves better results with BPF closure.

The decision regarding the optimum time to close the open-window thoracostomy and eliminate the pleural space and the BPF considers both the evolution of these pathologic events and the patient’s general condition. Shamji and colleagues [4] recommended an average interval of 160 days (range, 17 to 355 days) between window formation and closure; Miller and associates [11] considered that 3 months was appropriate for empyemas after benign processes and approximately 1 year for those arising from pulmonary resections for malignant processes. Our criterion, using open-window thoracostomy and thoracomyoplasty, is based on the earliest possible achievement of the objectives of open-window thoracostomy. This makes it possible to perform a thoracomyoplasty that ensures the ultimate elimination of the pleural space and BPF and prevents relapse. Likewise, in the case of empyema occurring after pulmonary resection for cancer, we recommend no less than 6 months between the two operations.

More than a century ago surgeons used thoracoplasty to eliminate the residual pleural space after empyema [12]. The pain, high mortality, and unsatisfactory results associated with the procedure led to technical modifications [13] to lower the risk of BPF and persistent suppuration and lessen the esthetic and functional damage. At present, although there are proponents of this technique [14][15], the accumulated experience has demonstrated its drawbacks, eg, postoperative mortality, pleurocutaneous fistulas, residual cavities, high percentage of scoliosis and secondary respiratory restriction, and antiesthetic consequences. These factors, and the proven efficacy of other procedures, make thoracoplasty advisable only under highly specific conditions [16]: appropriate patient selection, resection of few costal arches, and in combination with other techniques to reduce residual pleural space, such as the intrathoracic transposition of extrathoracic skeletal muscle.

In 1963, Clagett and Geraci [6] described a new therapeutic method. By this method, once the residual cavity is sterilized by open-window thoracostomy, a closure was performed after having filled the empyema cavity with an antibiotic solution. In 1972, Stafford and Clagett [17] achieved optimal results in more than 80% of patients and attributed the failures to persistent or recurrent BPF.

To combine the good esthetic and functional results of this technique and eliminate the failures that result from BPF persistence, Pairolero and coworkers [9][18][19] reported their results using the intrathoracic transposition of extrathoracic skeletal muscle to control BPF and eliminate residual pleural space. This procedure was proposed by Robinson [2] in 1915 to treat chronic empyema after preparatory open-window thoracostomy, corroborated as useful by Eloesser [3], and used successfully in the 1960s [8]. However, Pairolero and associates [18] and Miller and coworkers [11] consolidated its application in these processes.

Some authors [11] resolve the problem by eliminating the residual pleural space using muscular transposition; others [9][19] use Clagett’s method and ensure by selective muscular transposition over the BPF that the method’s good esthetic and functional results are not negated by persistent or recurrent BPF. All these authors have shown that the thoracic wall muscles are an excellent material for correcting chronic empyema when correct transposition can ensure vascularization and survival in a previously infected area. Several [1][5][20] have supported these methods, using intrathoracic transposition of extrathoracic skeletal muscle to resolve post–pulmonary resection empyema and other types of empyema with chronic characteristics in which similar pathologic processes exist.

However, despite the high success rate achieved with the modifications of Pairolero and associates [9] of Clagett’s method, the procedure is not failure-free. Despite the open drain, the septic cavity conditions can lead to graft necrosis and require new muscular transpositions to control the fistula. However, occasionally the functional consequences of the fistula are minimal; alternatively, muscular transposition is not performed per primam intentionem, but when the residual cavity is free of gangrenous matter, thus ensuring graft viability and spontaneous progressive cavity reduction.

In our patients with post–pulmonary resection empyema, except in those in whom Clagett’s method was totally effective, we perform intrathoracic muscular transposition after an interval of 2 to 7 months and attempt to eliminate the residual pleural space and the BPF completely if they persist using a technique called thoracomyoplasty. In other empyema modalities, and particularly in chronic cases after tuberculosis, the possibility of persistent, undetected BPF as a cause of permanent contamination of the residual pleural space has led us to the double-treatment method.

We termed this second step thoracomyoplasty because during the procedure the thoracic wall undergoes modification, with satisfactory esthetic and functional results for the following reasons: the intrathoracic muscular transposition is performed on a residual pleural space that has progressively decreased in the period between the two operations; the open-window thoracostomy itself modifies the wall, although the costal resections are few and short; and the occasional supplementary entry for muscular flap transposition to the residual pleural space when this is forced through the previous window or its widening is necessary.

Intrathoracic transposition of the pedicled omental flap has also been used to eliminate the pleural space [10][21][22] in an attempt to duplicate the advantages of myoplastic techniques and further preserve respiratory and esthetic function. The transposition is easily done through a small diaphragmatic incision, ensuring the vascular supply by preserving the right gastroepiploic artery. This in principle avoids additional operations that alter the thoracic wall structure. However, difficulties arise in preserving good vascularization (as in patients who underwent a previous gastrointestinal operation) and reducing a possible imbalance between the residual pleural space volume and omentum, which necessitates additional myoplasties. Therefore, although we have used this method in 4 of the 40 patients, we believe that muscular transposition is more advantageous than using omentum, which we reserve for cases with insufficient thoracic muscles that have been compromised by a previous operation.

In conclusion, successful treatment of chronic pleural empyema requires logical spacing. To achieve low operative mortality and failure rates, the procedures should be limited to open-window thoracostomy and elimination of the residual pleural cavity.

The presence of a BPF with severe functional consequences, especially in patients with postpneumonectomy empyema, requires its elimination when the open-window thoracostomy is performed. This is the only way to ensure patient survival and later residual cavity elimination. Muscular transposition is presently considered superior to using omentum.

To achieve BPF control and residual pleural cavity aseptization and elimination using methods that best preserve function and esthetics, the surgeon must choose between Clagett’s method or intrathoracic transposition of either extrathoracic skeletal muscle or omentum. The decision must be made on a case-by-case basis, based on the advantages of each method to the patient’s locoregional and general conditions to achieve the final correction with the least risk and deterioration.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Guillermo Ramos José M. Matilla Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by García-Yuste, M. Articles by Matilla, J. M. Search for Related Content PubMed PubMed Citation Articles by García-Yuste, M. Articles by Matilla, J. M.