Ann Thorac Surg 2004;78:1107-1108
© 2004 The Society of Thoracic Surgeons
How to do it
A simple solution for management of the postpneumonectomy empyema cavity
Michael S. Kent, MDa,
Robert J. Korst, MDa,*,
Lloyd B. Gayle, MDb,
Jeffrey L. Port, MDa,
Nasser K. Altorki, MDa
a Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, New York, USA
b Department of Surgery, Division of Plastic Surgery, Weill Medical College of Cornell University, New York, New York, USA
Accepted for publication August 13, 2003.
* Address reprint requests to Dr Korst, Department of Cardiothoracic Surgery, Ste M404, Weill Medical College of Cornell University, 525 E 68th St, New York, NY 10021, USA
rjk2002{at}med.cornell.edu
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Abstract
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Postpneumonectomy bronchopleural fistula with empyema is a difficult problem. Once the fistula is healed, successful closure of the pleural space is associated with varying degrees of success, as well as the potential for major reconstructive surgery. My colleagues and I describe a simple approach for the definitive management of the open pleural space involving split-thickness skin grafts to marsupialize the pleural cavity.
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Introduction
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Postpneumonectomy bronchopleural fistula (BPF) with empyema is a particularly challenging problem. The thoracic surgeon is faced with the dilemma, in addition to fistula closure, of how to close the existing empyema space. If a window thoracostomy (Eloesser flap) has been performed, options have traditionally included local wound care followed by closure of the chest wall defect while simultaneously filling the space with an antibiotic solution [1]. Alternatively, the space may be obliterated by transposition of ipsilateral extrathoracic tissue, such as the latissimus dorsi, pectoralis major, rectus abdominus, or even omentum. These flaps can be harvested with minimal morbidity and rotated into the pleural cavity with proven effectiveness [2, 3]. In situations in which pedicled flaps are insufficient, the patient is faced with the prospect of a contralateral myocutaneous flap, necessitating a microvascular anastomosis. Although technically possible, such a procedure is lengthy and has a substantially higher failure rate [4].
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Technique
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A 58-year-old man presented to our institution for treatment of a recurrent postpneumonectomy BPF and empyema. The postpneumonectomy BPF had been initially managed with an Eloesser flap (resection of ribs 4 to 6), followed by transposition of the ipsilateral pectoralis major muscle into the chest to cover the bronchial stump and concomitant closure of the Eloesser flap. The fistula recurred 8 months after chest closure.
When the patient presented to our institution, the right bronchial stump was 1.5 cm long. Initial management consisted of reopening the Eloesser flap, followed by local wound care. Despite this, the existing pectoralis flap, as well as ribs 2 and 3, required resection to facilitate effective chest packing for what cultures proved to be a resistant fungal empyema. After several months of aggressive wound care, the pneumonectomy space eventually granulated; however, the patient had a persistent large BPF. My colleagues and I elected to close the BPF by using the transsternal and transpericardial approach [5]. The patient recovered well but was left with a large chest wall defect (Fig 1) and an insufficient supply of pedicled flaps to completely obliterate the empyema cavity.
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Fig 1. Computed tomography scan image of the large, right-sided, chest wall defect in a patient with recurrent postpneumonectomy bronchopleural fistula. The creation of this defect was necessary to facilitate packing of a persistent fungal empyema cavity.
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When presented with the prospect of a free myocutaneous flap, the patient refused, because he had already undergone multiple operations. As an alternative, a split-thickness skin graft was harvested and placed inside the chest to effectively marsupialize the residual pleural space. The defect was large enough to allow excellent visualization of the cavity for placing the grafts. Skin grafts were tacked to the cavity with absorbable sutures. The cavity was lined with petroleum jelly–impregnated gauze and further packed with dry gauze. The dressing was removed after 1 week. Three months after skin graft placement, the pleural space had completely healed (Fig 2) and required no additional care, and the patient had resumed a normal level of activity.
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Fig 2. The empyema cavity 3 months after skin grafting. Despite complete epithelialization, the grafts retained some of their meshed appearance at this time.
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Comment
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The use of autologous, pedicled muscle flaps to cover postpneumonectomy BPF and close the pleural cavity have allowed even large fistulas to be treated successfully [2, 3]. Unfortunately, the availability of these flaps may be limited in some patients. This is problematic, because more than 1 flap is usually required to obliterate the pneumonectomy cavity entirely.
In this situation, several options are available. The patient may simply continue with packing of the pleural space. This approach is usually not acceptable to most patients who wish to resume normal activity. Second, the use of a contralateral muscle flap with a microvascular anastomosis may be considered [4]. In this case, the patient refused this option because of the magnitude of the operation involved. Third, the open window thoracostomy may be closed over the chest wall defect while the chest is simultaneously filled with antibiotic solution [1]. This was not a viable option for our patient given the large size of the chest wall defect and the fungal nature of his empyema. Another strategy would be to use a deepithelialized rectus abdominis flap [6]. This is a straightforward technique that does not require a microvascular anastomosis; however, the patient did not wish to undergo a lengthy operative procedure. Furthermore, the rectus muscle was rather atrophic and did not have sufficient bulk to obliterate the pneumonectomy space entirely.
In this case, split-thickness skin grafts were harvested and used to provide immediate epithelial coverage of the pleural cavity. Two articles have reported on this technique in the international literature: 1 from Scandinavia and the other from Japan [7, 8]. The sole article in the English language dates from 1976, and we believe that the simplicity of the technique warrants reemphasis. Skin grafting permits the pleural space to be definitively treated, avoids considerable morbidity, and allows the patient to return to full activity within days of the procedure. In addition, this procedure does not preclude future attempts to close the cavity by using free flaps, should the patient wish to pursue this option.
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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;45:141–145
- Arnold PG, Pairolero PC. Intrathoracic muscle flaps: an account of their use in the management of 100 consecutive patients. Ann Surg. 1990;211:656–662[Medline]
- Pairolero PC, Arnold PG, Piehler JM. Intrathoracic transposition of extrathoracic skeletal muscle. J Thorac Cardiovasc Surg. 1983;86:809–817[Abstract]
- Al-Kattan K, Breach N, Kaplan D, Goldstraw P. Soft-tissue reconstruction in thoracic surgery. Ann Thorac Surg. 1995;60:1372–1375[Abstract/Free Full Text]
- Ginsberg R, Pearson F, Cooper J, et al. Closure of chronic postpneumonectomy bronchopleural fistula using the transsternal transpericardial approach. Ann Thorac Surg. 1989;47:231–235[Abstract/Free Full Text]
- Serletti J, Feins R, Carras A, et al. Obliteration of empyema tract with deepithelialized unipedicle transverse rectus abdominis myocutaneous flap. J Thorac Cardiovasc Surg. 1996;112:631–636[Abstract/Free Full Text]
- Yokoyama K, Takashima T, Nozaki M. A case of skin implantation in the residual pleural cavity after repeated thoracoplasty. Nippon Kyobu Geka Gakkai Zasshi. 1984;32:88–91 [In Japanese][Medline]
- Eerola S. Pedicle thoracoplasty and free skin transplantations in the treatment of open postpneumonectomy cavity after empyema. Scand J Thorac Cardiovasc Surg. 1976;10:175–178[Medline]
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Abstract
Introduction
