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Ann Thorac Surg 1999;68:1121
© 1999 The Society of Thoracic Surgeons

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Correspondence

Bronchoperitoneal fistula secondary to Klebsiella pneumoniae

^a Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill, EH #215, Indianapolis, IN 46202, USA

To the Editor

We appreciate Dr Miller’s expertise on pulmonary and pleural space infections as well as his commentary on our case report [1]. Doctor Miller has clearly outlined the surgical options available to deal with large inferior-based pleural spaces. We would like to emphasize, however, that this was a very large cavity, which was not only intrapleural in location but in direct

communication with a subphrenic abscess through a necrotic defect in the central diaphragm. We therefore believed that surgical options involving diaphragmatic relocation or paralysis such as pneumoperitoneum, diaphragmatic elevation, or phrenic crush would have been of little value.

As stated in our article, we agree that muscle transposition could have been used; however, this technique would still have resulted in very large residual cavities both above and below the diaphram and therefore would have required some form of postoperative antibiotic irrigation. These residual cavities would also be potentially subject to recurrent late infections from sequestered bacteria, such as Klebsiella, which was the precise cause of this patient’s initial problem. We did use multiple chest tubes, above and below the diaphram, including right-angled tubes as suggested by Dr Miller. The negative pressure generated by these tubes, in addition to a limited thoracoplasty, ultimately allowed complete intrathoracic and subphrenic space obliteration, which occurred just before discharge at 22 days.

In summary, we agree that use of muscle flap transposition has greatly reduced the indications for thoracoplasty. We believe, however, there still remain occasional situations in which thoracoplasty, and in particular limited thoracoplasty, is a good surgical option. I am sure Dr Miller would agree that thoracic surgeons need to be aware of all surgical options available to deal with complex thoracic spaces, and carefully consider the advantages and disadvantages of each option in each individual situation that may present. In this regard, we believe that a limited thoracoplasty served this patient well.

References

1. Stockberger S.M., Jr, Kesler K.A., Broderick L.S., Howard T.J. Bronchoperitoneal fistula secondary to chronic Klebsiella pneumoniae subphrenic abscess. Ann Thorac Surg 1999;68:1058-1060.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kenneth A. Kesler Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kesler, K. A. Search for Related Content PubMed Articles by Kesler, K. A.