Ann Thorac Surg 2007;84:1762-1764. doi:10.1016/j.athoracsur.2007.05.052
© 2007 The Society of Thoracic Surgeons
Case Reports
Intrathoracic Insertion of the VAC Device in a Case of Pleural Empyema 20 Years After Pneumonectomy
Veronika Matzi, MD,
Joerg Lindenmann, MD*,
Christian Porubsky, MD,
Nicole Neuboeck, MD,
Alfred Maier, MD,
Freyja Maria Smolle-Juettner, MD
Division of Thoracic and Hyperbaric Surgery, Department of General Surgery, Medical University Graz, Graz, Austria
Accepted for publication May 18, 2007.
* Address correspondence to Dr Lindenmann, Division of Thoracic and Hyperbaric Surgery, Department of General Surgery, Medical University Graz, Auenbruggerplatz 29, Graz, 8036, Austria (Email: jo.lindenmann{at}meduni-graz.at).
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Abstract
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We report a 72-year-old man suffering from pleural empyema after pneumonectomy due to nonsmall cell lung cancer 20 years previously. Insufficiency of the bronchial stump was ruled out by bronchoscopy and bronchography. Thoracic computed tomographic scan of the thorax detected an abscess located in the subcutaneous tissue of the right ventrolateral chest wall originating from severe pyogenic osteomyelitis of the fifth and sixth ribs. Our surgical management included partial resection of the chest wall followed by insertion of the vacuum-assisted closure system into the thoracic cavity. The patient fully recovered and was discharged on postoperative day 32.
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Introduction
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Septic complications after lung resection are usually due to bronchopleural or pleuropulmonary fistulas, or both, with subsequent contamination of the pleural cavity and formation of pleural empyema associated with high morbidity and mortality. Empyema due to osteomyelitis of the ribs occurring 20 years after pneumonectomy is quite an exceptional complication that has never been described before.
We report a 72-year-old man who had undergone pneumonectomy due to nonsmall cell lung cancer (Union Internationale Contre le Cancer stage IIB) in November 1984. After surgery he had postpneumonectomy empyema develop, which was managed successfully by open window thoracostomy. When readmitted 20 years later, the scar of the closed thoracic window was painful and showed a serous putrid dehiscence of approximately 5 cm associated with the typical signs of locoregional inflammation without fever.
The computed tomographic scan of the thorax showed a 5 x 2 cm fistulating abscess located in the subcutaneous tissue in the area of the right ventrolateral chest wall (Fig 1). Bronchoscopy showed no evidence of bronchial stump insufficiency, which was confirmed by bronchography. The preoperative staging was completed by positron emission tomography and bone scan, which detected no evidence of local relapse or distant metastases, or both.
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Fig 1. Computed tomographic scan of the thorax. Note the fistulating abscess located in the subcutaneous tissue associated with pleural empyema after pneumonectomy.
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Re-thoracotomy and postoperative implantation of the vacuum-assisted closure (VAC) system was considered as treatment of choice. Fistulectomy associated with meticulous debridement and resection of the rough endothoracic granulation tissue together with the fifth and sixth ribs (according to the open window thoracostomy) were performed without any complications and were followed by temporary closure of the subcutaneous tissue of the right chest wall. Definitive histopathologic workup showed an unspecific fistulating abscess with partial rib destruction concomitant to chronic osteomyelitis, but no evidence of malignancy. A bacteriological swab of the thoracic cavity confirmed Staphylococcus aureus and specific antibiotic therapy was enhanced.
The second look on the first postoperative day consisted of repetitive lavages of the thoracic cavity with physiologic sodium chloride solution. Afterwards the VAC device was directed toward the mediastinal structures and the whole thoracic cavity was loosely filled with grey sponge without plastic film protection (Fig 2). Continuous suction of not more than 100 mm Hg was administered from the day of surgery. The VAC system was first changed on the third day after implantation. As the patient’s general condition improved (indicated by laboratory measurements and clinical appearance), the further dressing changes were set individually, whereby only the clinical measurements were taken into consideration. However, the VAC system was never left in situ for more than 4 days and the vacuum was always set at 100 mm Hg. Seven dressing changes (always in the operating room and under general intubation anesthesia) were required until definitive wound closure. Bacteriological smears were taken regularly, and from postoperative day 18 onward, pathologic bacterial colonization of the pleural cavity was not present.
The thoracic cavity was definitively closed on postoperative day 25 with moderate mobilization of the muscle layers and the subcutaneous tissue with direct closure of each layer. The repeated changes of the surgical dressing showed uncomplicated wound healing. The further course was uneventful and the patient was discharged on postoperative day 32 (Fig 3).
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Fig 3. Computed tomographic scan of the thorax before the patient’s discharge. The vacuum-assisted closure device was removed and the thoracostomy was closed.
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Comment
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The right surgical treatment of postoperative empyema still remains a therapeutic challenge. Surgical revision in the form of a re-thoracotomy is often inevitable and the general criteria for the treatment of open wounds in septic surgery apply. The creation of a temporary thoracostoma, a well-known form of pleural drainage, was first introduced in 1915 [1] and proven as a useful treatment for postpneumonectomy empyema [2], involves a number of problems.
Although VAC has become an established treatment for laparostoma, there is still a great deal of skepticism about its use with thoracostoma, and only case reports are available [3–5]. Intrathoracic application of the VAC device stabilized the thorax and improved wound healing by alleviating interstitial edema and increasing the local blood flow associated with enhanced tissue oxygenation. In addition it can increase proliferation of granulation tissue and inhibit anaerobic bacterial colonization [6, 7]. The wound area was clean and easy to care for, and maceration of the skin could always be avoided. As compared with conventional treatment options in the management of postoperative empyema, the VAC system was found to be advantageous.
The intrathoracic application of the VAC device is a safe and efficient supplement in the management of postoperative empyema. Furthermore it could increase patient comfort and shorten mean hospital stay, mortality, and morbidity.
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References
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- Robinson S. The treatment of chronic non-tuberculous empyema Collect Pap Mayo Clin Mayo Found 1915;7:618-644.
- Massera F, Robustellini M, Pona CD, Rossi G, Rizzi A, Rocco G. Predictors of successful closure of open window thoracostomy for postpneumonectomy empyema Ann Thorac Surg 2006;82:288-292.[Abstract/Free Full Text]
- Varker KA, Ng T. Management of empyema cavity with the vacuum-assisted closure device Ann Thorac Surg 2006;81:723-725.[Abstract/Free Full Text]
- Ditterich D, Rexer M, Rupprecht H. Vacuum assisted closure in the treatment of pleural empyema—first experiences with intra-thoracal application Zentralbl Chir 2006;131(Suppl 1):S133-S138(in German).[Medline]
- Matzi V, Lindenmann J, Porubsky C, Mujkic D, Maier A, Smolle-Jüttner FM. VAC treatment: a new approach to the management of septic complications in thoracic surgery Zentralbl Chir 2006;131(Suppl 1):S139-S140(in German).[Medline]
- 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]
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Abstract
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