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Ann Thorac Surg 2000;70:1720-1721
© 2000 The Society of Thoracic Surgeons

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Case report

Management of empyema complicating lobectomy with superior vena cava replacement

^a Service de Chirurgie Thoracique et Vasculaire, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France

Address reprint requests to Dr Regnard, Service de Chirurgie Thoracique et Vasculaire, Centre Chirurgical Marie Lannelongue, 133 Av de la Resistance, 92350 Le Plessis Robinson, France
e-mail: jean-francois.regnard{at}htd.ap-hop-paris.fr

	Abstract

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We present the case of a 49-year-old man with right upper lobe adenocarcinoma invading the right brachiocephalic vein and the origin of the superior vena cava. En bloc resection of right upper lobe with the involved venous segments was carried out through a median sternotomy. Venous pathway was reestablished with a Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) prosthesis. Postoperative course was marked by right pneumonia complicated by empyema. The patient underwent thoracotomy with completion pneumonectomy and latissimus dorsi transposition to cover both the prosthesis and the bronchial stump, as well as to fill the cavity. A favorable outcome was observed and long-term survival achieved.

	Introduction

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Management of empyema complicating lung resection with superior vena cava prosthetic replacement represents a major challenge. The aim of this article is to report such a case and to propose a therapeutic strategy.

A 49-year-old white man, current heavy smoker, presented for mild right chest pain and body weight loss. Chest x-ray film revealed a right-sided paratracheal opacity. Fiberoptic bronchoscopy showed no abnormalities. Thoracic computed tomographic (CT) scan confirmed the presence of a solid mass in the right upper lobe in close contact with the right brachiocephalic vein and superior vena cava (SVC). There were no enlarged mediastinal lymph nodes. Brain CT scan, bone scintigraphy, and abdominal ultrasonography revealed no distant metastases. Thoracic magnetic resonance imaging (MRI) (Fig 1) and phlebocavography suggested tumoral invasion of the right brachiocephalic vein as well as the origin of SVC.

View larger version (174K): [in this window] [in a new window]   Fig 1. Magnetic resonance imaging showing the right upper lobe tumor invading the right brachicephalic vein and the origin of the superior vena cava.

Postoperative course was initially favorable. On the 10th postoperative day, fever and a mild dyspnoea appeared. Chest x-ray film was consistent with right pneumonia. Fiberoptic bronchoscopy showed a healing right upper bronchial stump. Laboratory examinations showed leukocytosis. Cultures of bronchial aspirate and blood were sterile. An antibiotic treatment was started (Amoxicillin–Clavulanate [SmithKline Beecham, Philadelphia, PA] and, subsequently, in the absence of clinical improvement, Sparfloxacin [Bristol-Myers Squibb, Princeton, NJ] and Ornidazol [Roche, Basel, Switzerland]). Patient’s conditions and chest x-ray results improved allowing the discharge on the 21st postoperative day. Despite continuing antibiotherapy, 3 days later, a new hospitalization was necessary for the worsening of clinical conditions. Thoracic CT scan revealed a destroyed right lung parenchyma with a pleural effusion and an hydroaeric level.

A reoperation was decided in this obvious empyema. At thoracotomy the lung parenchyma was almost entirely condensed; a localized empyema occupied the superior part of the hemithorax, the prosthesis soaked in the pus. The cavity was carefully debrided and washed with antiseptic solution. A completion pneumonectomy was necessary in the presence of a destroyed lung. A latissimus dorsi flap was mobilized, passed through the third intercostal space, and used to cover both the stump of main bronchus and the prosthesis, as well as to partially fill the cavity.

Postoperative course was uneventful, apyrexia was observed on the 2nd postoperative day. Cultures of specimens of empyema grew E coli and E faecalis. Based on in vitro sensitivity tests, Imipenem–Cilastatin [Merck, Sharp & Dohme, Whitehouse Station, NJ] and Amikacin [Rhone-Poulenc Rorer, Paris, France] were administered for 14 days. No pleural space irrigation was performed. A chest tube was maintained in the immediate postoperative course, and repeat gram stains from the pleural fluid were performed daily. As all these gram stains were negative, the chest tube was removed on day 5. On the 15th postoperative day, the patient was discharged home. No recurrence of infection occurred. Regular follow-up revealed no relapse of lung cancer, and patency of prosthesis 4 years later.

	Comment

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Massive invasion of SVC by lung tumors has been considered as a definitive surgical contraindication for many years [1]. In the last 15 years, suitable graft material became available for replacing the vessel [2]. The observation of very poor prognosis with treatment by chemotherapy or radiotherapy led some groups to perform lung resections with SVC replacement [3–5]. Results reported by different groups show that long-term survivals can be achieved in patients with no mediastinal node involvement [3–5].

In our patient, both phlebography and MRI had suggested tumoral invasion of both SVC and right innominate vein. So the resection was performed through a median sternotomy due to the difficulty to correctly control the innominate vein through a thoracotomy. Venous pathway was reestablished by a graft interposition between the left innominate vein and the SVC stump. In fact, when the origin of the SVC is invaded, the revascularization of a single innominate vein is recommended; it is sufficient and provides a higher flow through the prosthesis than if both innominate veins are revascularized [4].

Infection represents a major complication of lung resection with SVC replacement [4]. When mediastinitis or empyema occur, the risk of a life-threatening graft infection is obviously enormous [4]. Due to the exiguity of published series, no consensus exists concerning the optimal management of this complication. Open window thoracostomy combined with progressive clamping of the graft and its subsequent removal has been reported; an unfavorable outcome was observed in this case [4]. On the other hand, a mediastinitis following a SVC replacement for recurrent thyroid cancer was successfully treated by epiplooplasty and antibiotherapy [4]. Closed pleural drainage with irrigation would represent another therapeutic option.

In our case, we decided to maintain the graft, to eradicate the source of infection (completion pneumonectomy), and to cover both the graft, the bronchial stump, and the formerly infected area with a latissimus dorsi flap. In fact, graft removal almost always provokes an acute SVC syndrome, a life-threatening condition in a severely ill patient.

Muscle flaps have been reported to successfully prevent bronchial fistulas in high-risk patients previously treated by high-dose radiotherapy [6]. Transposition of muscles is a well-recognized technique to fill thoracostomy cavities, also in the presence of residual infection [7]. Furthermore, it has been recognized that myoplasty for infected vascular graft in the groin is safe and effective [8]. Even if the flap did not completely filled the right hemothorax, we did not perform systematic pleural irrigation and, finally, we removed the chest tube on day 5 without filling the space with antibiotic solution because no positive gram stains were identified in the postoperative course. In our opinion, a favorable outcome was possible because it was a localized empyema and all the previously infected area could be covered by the muscle flap.

Empyema still represents a life-threatening complication of lung resection with SVC replacement. Muscular transposition could represent a useful tool in the management of this condition.

	References

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1. Moghissi K. Technical consideration in stage III disease. In: Delarue N.C., Echapasse H., eds. International trends in general thoracic surgery. Vol. 1. Lung cancer. . Philadelphia: WB Saunders, 1985:146-153.
2. Esato K., Shintani K., Yasutake S., Morita T. Experimental replacement of vena cava with expanded polytetrafluoroethylene graft. Int Surg 1981;66:227-232.[Medline]
3. Burt M.E., Pomerantz A.H., Bains M.S., et al. Results of surgical treatment of stage III lung cancer invading the mediastinum. Surg Clin North Am 1987;67:987-1000.[Medline]
4. Dartevelle P.G., Chapelier A.R., Pastorino U., et al. Long term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumors. J Thorac Cardiovasc Surg 1991;102:259-265.[Abstract]
5. Thomas P., Magnan P.E., Moulin G., Giudicelli R., Fuentes P. Extended operation for lung cancer invading the superior vena cava. Eur J Cardiothorac Surg 1994;8:177-182.[Abstract]
6. Regnard J.F., Icard P., Deneuville M., et al. Lung resection after high doses of mediastinal radiotherapy (sixty grays or more). Reinforcement of bronchial healing with thoracic muscle flaps in nine cases. J Thorac Cardiovasc Surg 1994;107:607-610.[Abstract/Free Full Text]
7. Arnold P.G., Pairolero P.C. Intrathoracic muscle flaps. An account for their use in the management of 100 consecutive patients. Ann Surg 1990;211:656-660.[Medline]
8. Maser B., Vedder N., Rodriguez D., Johansen K. Sartorius myoplasty for infected vascular graft in the groin. Safe, durable and effective. Arch Surg 1997;132:522-525.[Abstract/Free Full Text]

This article has been cited by other articles:

				L. Spaggiari, P. Solli, G. Veronesi, and U. Pastorino Intrathoracic myoplasty for prosthesis infection after superior vena cava replacement for lung cancer Ann. Thorac. Surg., October 1, 2002; 74(4): 1231 - 1233. [Abstract] [Full Text] [PDF]

				L. Spaggiari, P. Thomas, P. Magdeleinat, H. Kondo, G. Rollet, J. F. Regnard, R. Tsuchiya, and U. Pastorino Superior vena cava resection with prosthetic replacement for non-small cell lung cancer: long-term results of a multicentric study Eur. J. Cardiothorac. Surg., June 1, 2002; 21(6): 1080 - 1086. [Abstract] [Full Text] [PDF]

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): Pierre Magdeleinat Philippe Levasseur Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Alifano, M. Articles by Regnard, J. F. Search for Related Content PubMed PubMed Citation Articles by Alifano, M. Articles by Regnard, J. F.