Ann Thorac Surg 2006;81:723-725
© 2006 The Society of Thoracic Surgeons
Case report
Management of Empyema Cavity With the Vacuum-Assisted Closure Device
Kimberly A. Varker, MD
a
,
*
,
Thomas Ng, MD, FACS
b
a Surgical Oncology, Roger Williams Medical Center, Providence, Rhode Island, USA
b Department of Surgery, Brown University Medical School, Providence, Rhode Island
Accepted for publication October 8, 2004.
* Address correspondence to Dr Varker, 424 Comprehensive Cancer Center, 410 West 12th Avenue, Columbus, OH 43210 (Email: varker-1{at}medctr.osu.edu).
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Abstract
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Management of empyema after pulmonary resection remains a challenging problem. Along with mandatory drainage of the thoracic cavity and investigations to rule out bronchopleural fistula, a reliable method of thoracic cavity closure is needed. The open thoracic window and Eloesser flap techniques rarely represent definitive therapy. Muscle flap and thoracoplasty procedures may provide well-vascularized tissue to close bronchopleural fistula and obliterate the empyema cavity, but they are quite complex and involve significant patient morbidity. We report a case of empyema without bronchopleural fistula after lobectomy in which the vacuum-assisted closure device was used to achieve complete wound healing after open drainage.
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Introduction
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After preexisting pulmonary infections, postsurgical procedure is the second most common cause of empyema [1]. The incidence of empyema after lobectomy is 1% to 3%, and after pneumonectomy as high as 12% [1]. Although postpneumonectomy empyema is associated with bronchopleural fistula in 75% to 80% of cases, postlobectomy empyema is usually due to prolonged parenchymal air leak with persistent pleural space [2].
Initial management of postlobectomy empyema includes tube thoracostomy drainage and systemic antibiotic therapy [1, 2]. Thoracoscopic adhesiolysis or installation of fibrinolytic agents may be useful in the early stages of empyema [3]. Failure of conservative management should prompt open drainage of the empyema space to promote control of sepsis and patient stabilization [2].
Options for management of the empyema space after open drainage have traditionally included muscle flap closure, thoracoplasty procedures, or delayed thoracic closure after sterilization (the Clagett procedure) [4, 5]. We believe that this is the first report of complete healing and closure of postlobectomy empyema space using the vacuum-assisted closure (VAC) device.
A 72-year-old man who had undergone a three-incision esophagectomy for T2N0 squamous cell carcinoma 13 months previously was found to have a new right lower lobe lung nodule on computed tomographic scan. Computed tomographic-guided biopsy revealed squamous cell carcinoma. Metastatic work-up, including computed tomography of the head and bone scan was negative.
The patient was taken to the operating room. Flexible bronchoscopic examination was normal, and cervical mediastinoscopy revealed no malignant involvement of mediastinal nodes. At thoracotomy, the lesion involved the chest wall, necessitating right lower lobectomy with chest wall resection, including portions of the sixth and seventh ribs. Reconstruction of the resulting 6 x 6 cm defect was accomplished with 2-mm thick expanded polytetrafluoroethylene graft. The final pathologic diagnosis was Stage IIB (T3N0M0) squamous cell carcinoma of the lung.
Three months postoperatively, the patient developed sinus tracts draining purulent material at the old chest tube sites. Chest roentgenogram revealed a thoracic space with an air-fluid level. The patient was returned to the operating room with the diagnosis of postlobectomy empyema. Flexible bronchoscopy confirmed that the bronchial stump was intact. The prior thoracotomy incision was reopened. Skin, subcutaneous tissue, and muscle were debrided down to the expanded polytetrafluoroethylene graft, which was then excised. There was no air leak from the empyema cavity (Fig 1), which was debrided and packed with saline gauze.
Cultures of the excised graft revealed Proteus mirabilis and Pseudomonas aeruginosa. The patient was placed on intravenous antibiotics guided by sensitivities. After several days of saline dressing changes to ensure a clean granulating cavity, the VAC device was applied to the wound.
After initial application, the VAC wound sponge was changed every 2 days. Within 2 weeks, an exuberant bed of granulation tissue had formed. The patient and his family learned to manage the wound with the VAC device at home. Four months postoperatively, the wound was completely healed with minimal alteration of chest wall contour (Fig 2). Computed tomographic scan confirmed no residual collection or cavity (Fig 3).
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Fig 2. Complete healing of the empyema space after 4 months of using the vacuum-assisted closure device.
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Comment
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Recently the vacuum-assisted closure (VAC) device emerged as a new method of control of wound drainage and acceleration of wound healing [6, 7]. The application of uniform subatmospheric pressure and evacuation of wound effluent has been shown to increase nutrient blood flow, accelerate granulation tissue formation, and decrease tissue bacterial levels [6]. Potential mechanisms include removal of excess interstitial fluid impairing local blood flow, improvement of tissue oxygenation, inhibition of anaerobic colonization, and stimulation of cell proliferation by mechanical deformation of the tissue [6, 7]. Use of the VAC device has been successful in acute, subacute, and chronic wounds [7].
Recent reports have proven the VAC device to be useful in the management of poststernotomy mediastinitis [8]. We believe that this is the first report of use of the VAC device in the treatment of postresectional empyema. Principles for managing postresectional empyema still hold true. Sepsis must be drained and bronchopleural fistula must be ruled out. To avoid recurrent empyema, the residual cavity must be obliterated by muscle flap procedures or sterilized and closed by the Clagett procedure. Our patient had complete healing of his empyema cavity using the VAC device alone and avoided the morbidity of subsequent chest wall procedures. We encountered no complications with the use of the VAC device for this indication.
We recommend that the VAC device be tried on all postresectional empyema spaces once bronchopleural fistula has been ruled out or closed, and once the cavity has been cleaned. Even if the wound fails to completely heal, the VAC device can diminish its extent, allowing a less extensive muscle flap or thoracoplasty procedure for final closure.
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References
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- Miller Jr JI. Postsurgical empyemaIn: Shields Jr TW, LoCicero III J, Ponn RB, editors. General thoracic surgery. 5th edit. Philadelphia: Lippincott Williams & Wilkins; 2000. pp. 709-715.
- Vallieres E. Management of empyema after lung resections (pneumonectomy/lobectomy) Chest Surg Clin N Am 2002;12(3):571-585.[Medline]
- Ferguson AD, Prescott RJ, Selkon JB, Watson D, Swinburn CR. The clinical course and management of thoracic empyema Q J Med 1996;89(4):285-289.
- Deslauriers J, Jacques LF, Gregoire J. Role of Eloesser flap and thoracoplasty in the third millenium Chest Surg Clin N Am 2002;12:605-623.[Medline]
- Regnard JF, Alifano M, Puyo P, Fares E, Magdeleinat P, Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection J Thorac Cardiovasc Surg 2000;120:270-275.[Abstract/Free Full Text]
- Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation Ann Plast Surg 1997;38:553-562.[Medline]
- Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience Ann Plast Surg 1997;38:563-577.[Medline]
- Luckraz H, Murphy F, Bryant S, Charman SC, Ritchie AJ. Vacuum-assisted closure as a treatment modality for infections after cardiac surgery J Thorac Cardiovasc Surg 2003;125:301-305.[Abstract/Free Full Text]
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Abstract
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