Ann Thorac Surg 2007;84:1023-1025
© 2007 The Society of Thoracic Surgeons
Case Reports
New Modality of Collapse Therapy for Pulmonary Tuberculosis Sequels: Tissue Expander
François Bertin, MDa,*,
Louis Labrousse, MDa,
Virgile Gazaille, MDb,
François Vincent, MDb,
Antoine Guerlin, MDa,
Marc Laskar, MDa
a Department of Thoracic and Cardiovascular Surgery and Angiology, Centre Hospitalier Universitaire Limoges, Limoges, France
b Department of Pulmonary Diseases, Centre Hospitalier Universitaire Limoges, Limoges, France
Accepted for publication April 2, 2007.
* Address correspondence to Dr Bertin, Department of Thoracic and Cardiovascular Surgery and Angiology, Centre Hospitalier Universitaire Limoges, 2 Avenue Martin Luther King, Limoges, 87042, France (Email: francois.bertin{at}chu-limoges.fr).
 |
Abstract
|
|---|
Classical collapse therapy with extrapleural Lucite balls placement used for tuberculosis sequelae is associated with long term complications, such as migration of the foreign body. We report a new modality of collapse therapy for tuberculosis cavitation which may avoid this complication and which uses percutaneous tissue expanders. Postoperative course was uneventful and mid term follow-up confirmed the functional improvement without recurrence of the infection. This new modality of post-tuberculosis collapse therapy may allow treatment with fewer physical and physiologic sequelae of the residual cavities, and should reduce long term complications such as migration.
|
Introduction
|
|---|
Classical collapse therapy with extrapleural Lucite balls placement used for tuberculosis sequelae is associated with long term complications, especially migration of the foreign bodies [1–4]. We report a new modality of collapse therapy for tuberculosis cavity which might deal with this complication and which uses percutaneous tissue expanders.
In May 2004, a 29-year-old man from West Africa was admitted in the department of pulmonary disease for dyspnea, cough, and pulmonary infection. His past history included a multi-drug resistance mycobacterial infection treated in 1996. The chest x-ray films showed multiple large left pulmonary cavitations which were confirmed by computed tomographic scan (Fig 1) and involved the superior and part of the inferior left lobe. Cultures were negative for mycobacterium tuberculosis, but positive to multi-resistant Pseudomonas aeruginosa and aspergillus. Ventilation-perfusion scintigraphy showed only a little residual pulmonary function on the left side (Fig 1) estimated at about 10%.
View larger version (110K):
[in this window]
[in a new window]
|
Fig 1. Preoperative pictures. (A) Chest x-ray films. (B) Ventilation-perfusion scintigraphy. (C) Thoracic computed tomographic scan.
|
|
Extrapleural collapse therapy was planned, but instead of Lucite balls, we considered the use of a tissue expander. The Perthese tissue expander (Perthese [Laboratoire Pérouse Implant, Bornel, France]) consists of an inflatable silicon elastomer envelope connected via a silicon tubing to a remote internal valve (Fig 2). The valve is made-up of a self sealing silicone filling port in the shape of a hemispherical dome facilitating its location. The implant is fitted with a stainless steel connector enabling the tubing length to be adapted to a given situation. Usual indications for these expanders are tissue flaps in plastic and reconstructive surgery, especially for treatment of scars, burns sequelae or post mastectomy reconstruction.
View larger version (96K):
[in this window]
[in a new window]
|
Fig 2. Percutaneous tissue expander (Perthese [Laboratoire Pérouse Implant, Bornel, France]). Inset: Operative view with the two expanders in place.
|
|
The procedure included a left lateral thoracotomy. Meticulous care in the surgical dissection was taken to obtain a pure extrapleural space in order to avoid septic contamination from the cavitations. Once the extrapleural pneumolysis was achieved, two Perthese percutaeous tissue expanders (Laboratoire Pérouse Implant) were implanted inside the cavity and inflated with saline serum (one with 1 L, the other with 700 mL) to obtain a total exclusion of the cavity (Fig 2). Both valves were kept in place under the skin at the anterior-axillary line level. Primary closure of the thoracotomy was performed, and two chest tubes were left in the cavity and removed on postoperative day 4. Total bleeding was 640 mL. Antibiotic therapy included cefazolin (Bristol-Myers Squibb, Rueil Malmaison, France) for the perioperative period (48 hours).
The patient made an uneventful recovery and was discharged on postoperative day 10. A postprocedural pulmonary computed tomographic scan confirmed the efficiency of the procedure (Fig 3). At 30 months follow-up, the patient condition was improved with a normal physical aspect of the thorax and no sign of local or pulmonary infection. Note that no late additional saline injection was needed. Last, a new ventilation-perfusion scintigraphy performed at 2 years follow-up showed a residual function of the left inferior lobe similar to the preoperative one.
|
Comment
|
|---|
Different procedures have been developed over the years for collapse therapy of pulmonary sequels or active multi-drug-resistance mycobacteria. Surgical thoracoplasty is probably the more efficient procedure, but it is usually a two-stage procedure followed by postoperative pain, respiratory embarrassment, and nonaesthetic result [5].
Lung resection is an alternative procedure. However, due to the diffusion of the disease in this patient, only a left pneumonectomy could be expected. Also, there is a very high risk of contamination with multi-drug resistant microbes of the residual pleural cavity. Even in the case of isolated superior lobectomy, the expansion of the residual left parenchyma will probably be suboptimal with a residual pleural cavity prone to superinfection. Moreover, one of the main advantages of collapse therapy compared with pulmonary resection is the preservation of the unilateral noninfected residual parenchyma, which is confirmed in this case by the ventilation and perfusion scintigraphy performed at 2 years follow-up. Although the tissue expander was a foreign body, risk of its infection is limited by uniquely extrapleural dissection. Last, concern exists regarding hemorrhagic risks due to hypervascularization from bronchial arteries during lung resection, especially where dense and inflammatory adhesions make vascular control much more difficult.
Concerning the choice of the material used for extra pleural collapsus, plombage using acrylic resin balls (lucite ball) has been performed for a long time, but is associated with long-term complications such as erosion of major vessels, infection, and migration [1–4]. Advocated by Dov and Dorit Weissberg [2], but never published in this clinical setting, this new strategy should deal with part of these complications. Indeed, as only two devices are used to fill the cavity, the volume of each of them (700 and 1000 cc, respectively) prevents future migration. The design of the expanders with a flexible membrane allows the fit to be perfect with the ovoid aspect of the extrapleural cavity. The latter property leads to a very efficient crushing of the cavern by inducing a better distribution of the pressure on the tuberculosis cavern than lucite balls used to achieve. And as the valves of the expanders are in an accessible position, a new filling of the expanders could be proposed in the future in case of insufficient crushing of the lesions. Moreover, silicon elastomer is a well-known material used for many years by plastic surgeons, and it has a low rate of late infection and long-term tolerance. So if a secondary procedure should be planned in the future, the mild reaction secondary to silicon prosthesis in human tissue [6] will allow easy removal of these devices. Last, these expanders have been previously used in the same localization for postpneumonectomy syndrome with good midterm results [7, 8].
Although the follow-up of our patient was limited to 30 months, this new modality of post-tuberculosis collapse therapy might allow treatment with lower physical and physiologic sequelae of the residual cavitations, and might reduce long-term complications such as migration. Its use could be proposed for post-tuberculosis sequelae, but also as an additional treatment for multi-drug resistant M tuberculosis [2].
|
References
|
|---|
- Shepherd MP. Plombage in the 1980s Thorax 1985;40:328-340.[Free Full Text]
- Weissberg Dov, Weissberg Dorit. Late complications of collapse therapy for pulmonary tuberculosis Chest 2001;120:847-851.[Medline]
- Horowitz MD, Otero M, Thurer RJ, Bolooki H. Late complications of plombage Ann Thorac Surg 1992;53:803-806.[Abstract]
- Massard G, Thomas P, Barsotti P, et al. Long-term complications of extraperiosteal plombage Ann Thorac Surg 1997;64:220-224.[Abstract/Free Full Text]
- Barker WL. Thoracoplasty Chest Surg Clin N Am 1994;4:593-615.[Medline]
- Matturri L, Azzolini A, Riberti C, et al. C Long-term histopathologic evaluation of human expanded skin Plast Reconstr Surg 1992;90:636-642.[Medline]
- Wasserman K, Jamplis RW, Lash H, Brown HV, Cleary MG, Lafair J. Post-pneumonectomy syndromeSurgical correction using Silastic implants. Chest 1979;75:78-81.[Medline]
- Downey RJ, Trastek VF, Clay RP. Right pneumonectomy syndrome: surgical correction with expandable implants J Thorac Cardiovasc Surg 1994;107:953-955.[Free Full Text]
Top
Abstract
Introduction
