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Ann Thorac Surg 2000;70:1206-1207
© 2000 The Society of Thoracic Surgeons
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Discussion |
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 Top Discussion |
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DR SHIRAISHI: You mean how to dissect the empyema space?
DR SCHMIDT: Once you had done the pneumonectomy and you had the residual space that may or may not have been contaminated, how did you manage that space, or did you just close the chest in routine fashion?
DR SHIRAISHI: Before the chest is closed we painstakingly irrigate the empyema space with a large amount of saline and iodine and also antibiotic solution to prevent the occurrence of postoperative empyema.
DR JOE B. PUTNAM (Houston, TX): I was curious to know whether you used any special techniques to minimize your blood loss, as it was quite significant. We have used aprotinin in some of our large intrathoracic tumors where we expected a significant amount of blood loss during the extrapleural approach. The aprotinin seems to minimize blood loss, and I was curious whether you have tried this technique in your patient population.
DR SHIRAISHI: In the past we tried to remove the empyema as quickly as possible, and during that time blood loss was very high. But now we try to reduce the intraoperative blood loss using electrocautery, bipolar scissors, and argon beam coagulator, which minimizes the bleeding from the chest wall. With regard to the use of aprotinin, we have not used it yet.
DR GIUSEPPE CARDILLO (Rome, Italy): What is the percent of extrapleural pneumonectomy in the overall series of empyema that you have observed in your institution?
DR SHIRAISHI: That is a good point. Actually we are performing the operation for empyema on 20 and 30 patients per year. So about 10% to 20% of the total empyema patients have undergone an extrapleural pneumonectomy. Therefore, these patients are highly selected.
DR G. HOSSEIN ALMASSI (Milwaukee, WI): It appears that residual postoperative empyema after pneumonectomy is a bad actor and clearly patient survival is affected by that. Have you used or would you consider using additional adjunct measures in terms of the pleural cavity in those patients that you had contamination, either intentional or accidental, during extrapleural pneumonectomy to prevent that or minimize that other than antibiotic and iodine irrigation that you have been using, measures such as maybe thoracoplasty concomitantly or muscle flap at the same setting?
DR SHIRAISHI: Recently we have been liberally using muscle flap to prevent bronchopleural fistula and also to prevent postoperative empyema.
DR DANIEL L. MILLER (Rochester, MN): I have one question. Did any of these patients have a delayed closure? If we encounter gross contamination at operation we would leave the patient open and then we would come back at a later date and do a modified Clagett procedure. Are you planning in the future as you look back at your retrospective data to leave the patients open for a period of time as we do.
DR SHIRAISHI: In this group of patients, the chest was closed at the end of operation. We do not want to leave the chest open after the operation.
DR STEVEN D. HERMAN (Englewood, NJ): Your paper presents excellent outcomes in a horribly difficult clinical cohort. You are to be congratulated. Other than bronchopleural fistulas, were there any other factors causative to the incidence of your postoperative empyema complications? Perhaps the degree of contamination that you mentioned or the organisms responsible for the primary empyema, which precipitated your operation in the first place, may have had a role.
DR SHIRAISHI: Excuse me, I do not understand your question.
DR HERMAN: Other than bronchopleural fistula, were there any other factors that were common to your postoperative empyema complications?
DR SHIRAISHI: Reexploration was the only risk factor in this series.
DR RAYMOND A. DIETER JR (Glen Ellyn, IL): I noticed one injury to the esophagus and I wondered whether you had repaired that and if that healed or if that led to an esophagopleural fistula or contamination. That has always been one of our concerns in these types of patients.
DR SHIRAISHI: We had just one esophageal perforation in this series, as I showed you in the slides.
DR DIETER: Did you have a fistula?
DR SHIRAISHI: Yes. The patient was found to have an esophageal perforation 13 days after the operation. We reoperated on him and repaired that. But it failed, and the pleural cavity was contaminated. Eventually, the patient died of multiple organ failure.
Related Article
Ann. Thorac. Surg. 2000 70: 1202-1206.
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