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Original Articles: General Thoracic

Open Window Thoracostomy Treatment of Empyema Is Accelerated by Vacuum-Assisted Closure

^a Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
^c Department of Pulmonology, Maastricht University Medical Centre, Maastricht, the Netherlands
^d Department of Plastic and Reconstructive Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
^b Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, the Netherlands

Accepted for publication June 15, 2009.

^_* Address correspondence to Dr Maessen, Department of Cardiothoracic Surgery, Maastricht University Medical Centre, P. Debeyelaan 25, Maastricht 6202AZ, the Netherlands (Email: j.g.maessen{at}mumc.nl).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background: Recurrent thoracic empyema in the presence of residual lung tissue can be treated with an open window thoracostomy (OWT). Vacuum-assisted closure (VAC) of these large thoracic defects is a novel option.

Methods: Nineteen patients with residual lung tissue received an OWT for treatment of recurrent thoracic empyema. In this retrospective case series, 8 patients (aged 58 ± 20 years, all male) were treated conventionally, and 11 patients (aged 53 ± 17 years, 8 male) were treated with VAC.

Results: The application of the VAC system resulted in rapid debridement of the thoracic cavity and reexpansion of the residual lung tissue. The duration of OWT and VAC therapy was 39 ± 17 and 31 ± 19 days, respectively. All 11 patients were amenable for subsequent closure using pedicled muscular flaps. In 2 patients, VAC therapy alone resulted in complete closure of the OWT. The average duration of follow-up was 46 ± 19 months. All patients, except 1, have recovered well. One patient died of nonpulmonary causes. In the non-VAC group (n = 8), the OWT was managed conventionally by application of saline-soaked gauzes. In 2 patients, the OWT was eventually closed using pedicled muscular flaps (after 75 and 440 days, respectively). Four patients died of OWT-related complications (1 bleeding, 3 recurrent infections) during follow-up; 1 patient died of a cause unrelated to OWT. The average duration of OWT was 933 ± 1,422 days.

Conclusions: When compared with conventional management of OWT, VAC therapy accelerates wound healing and improves reexpansion of residual lung tissue in patients with OWT after empyema, allowing rapid surgical closure.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
The surgical management of thoracic empyema is still a controversial issue in the literature. Initial treatment consists of antibiotic therapy or chest tube drainage, or both. When these measures fail to cure infection, surgical drainage and debridement are indicated, either with or without decortication of pulmonary parenchyma, followed by closure of the chest and tube drainage for several days. However, when the infection cannot be eradicated with these standard techniques, open window thoracostomy (OWT) is often the last resort [1]. Although mutilating, this procedure results in continuous drainage of the thoracic cavity, and in general the patient can be discharged home with intensive outpatient wound management. Recurrent infections of the thoracic cavity are common, and mortality remains high [1]. When infection recedes, the OWT can be closed using omentum or pedicled muscular flaps [1, 2]. Recently, several large series of patients have been described demonstrating the safety and efficacy of these procedures using different surgical closure techniques [3].

The advent of vacuum-assisted closure (VAC) has revolutionized the treatment of infected wounds in various areas of the body [4]. In the field of cardiothoracic surgery, VAC therapy of infected sternal wounds is associated with rapid debridement and increased formation of granulation tissue, combined with enhanced mobility and reduced morbidity [5]. However, the application of VAC for chest wall defects and wounds has seldom been described in the literature [6].

In this paper, we describe the efficacy of VAC of an OWT in the presence of residual pulmonary parenchyma. This therapy was compared with the conventional treatment of patients with OWT.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
We retrospectively analyzed all 242 patients with thoracic empyema in the presence of residual pulmonary parenchyma who were admitted to our department since 1990 (study period is 19.5 years). In 19 patients (7.9%), empyema reoccurred despite adequate surgical drainage and antibiotic therapy, necessitating the creation of an OWT. The VAC group consisted of 11 patients (5 after resectional empyema, 6 with primary empyema without pulmonary resection; Table 1) who received VAC treatment, using the Vacuseal system (KCI Medical B.V., Houten, the Netherlands). The non-VAC group consisted of 8 patients (3 after resection empyema, 5 with primary empyema without pulmonary resection; Table 1) who received conventional treatment. In the VAC group, 9 of the 11 patients underwent prior surgical debridement before creation of the OWT, and 6 of the 11 underwent prior surgical decortication of pulmonary parenchyma; in 3 of the 11 patients, talc was used to treat recurrent pneumothorax. In the non-VAC group, 7 of the 8 patients underwent prior surgical debridement, and 4 of the 8 underwent surgical decortication; in 1 of the patients, talc was used to treat pneumothorax.

Exclusion Criteria for VAC
Until 8 years ago, all patients with OWT received conventional treatment, whereas after this period, most patients received VAC treatment. In 1 of the first patients, VAC therapy was not instituted because of a large esophagopleural fistula. This patient was included in the non-VAC group. In addition, all patients with a pneumonectomy were excluded from VAC therapy. These patients present with a large bronchopulmonary fistulae (BPF), and therefore no effective vacuum can be obtained using VAC. For this reason, these patients have been excluded from this study.

Preoperative Condition
Patient characteristics are described in Table 1. Patients included in this study were in a poor clinical condition. The majority of patients already had a previous (sometimes repetitive) thoracotomy and debridement to treat the empyema at the time of formation of the OWT. In the VAC group, 4 of the 11 patients had chronic obstructive pulmonary disease Gold III, 4 patients had insulin-dependent diabetes mellitus, 1 patient had a history of drug abuse, and 3 patients were in the intensive care unit for more than 1 month (duration of ventilatory support more than 30 days). In the non-VAC group, chronic obstructive pulmonary disease Gold III was diagnosed in 2 of the 8 patients, and 1 patient had diabetes. In addition, 3 of the 8 patients were in the intensive care unit and had had ventilatory support for more than 1 month. Two patients had metastasized malignant disease (1 patient had hypopharyngeal carcinoma, 1 patient had testicular carcinoma).

Technical Aspects of Treatment
After creating the OWT in the operating theater, according to the methods described by Eloesser and colleagues [7, 8], saline-soaked gauzes were applied in the thoracic cavity. In the VAC group, a Vacuseal system was applied in the following days by two specialized nurse technicians. Not only the defect in the thoracic wall (Fig 1), but also the space in the thoracic cavity was filled with tailored polyurethane sponges (V.A.C. GranuFoam; KCI Medical B.V., Houten, the Netherlands), because the lung parenchyma is often still compressed at this stage (Fig 2A). Suction was applied (125 mm Hg) directly onto the pulmonary tissue (without covering gauze dressings) using the ATS-V.A.C. The system was changed on the surgical ward without anesthesia once every 3 to 5 days, or more frequently when indicated by increased purulent secretions or increased infection. When the pulmonary parenchyma had reexpanded (Fig 3A and B), the wound was granulating adequately (Fig 2B), and infection determinants had decreased (C-reactive protein levels less than 70 mg/L), the plastic and reconstructive surgeons performed surgical closure of the defect using either a pedicled latissimus dorsi muscular flap (n = 8) or a free rectus abdominal muscle flap (n = 1). After closure, the patients were monitored on the ward, and the drains were removed when production had diminished to less than 30 cc in 24 hours. Both groups received standard culture-guided antibiotic treatment during the first 5 days after creation of the OWT.

View larger version (118K): [in this window] [in a new window]   Fig 1. The vacuum-assisted closure (VAC) system is shown sealing the open window thoracostomy in a patient with right-sided empyema.

View larger version (61K): [in this window] [in a new window]   Fig 2. (A) With open window thoracostomy after debridement before vacuum-assisted closure (VAC) treatment, the lung is compressed. (B) With open window thoracostomy after 12 days of VAC treatment, the pulmonary parenchyma has reexpanded.

View larger version (48K): [in this window] [in a new window]   Fig 3. (A) Computed tomography scan demonstrates recurrent empyema after conservative treatment with saline-soaked gauzes and compression of pulmonary parenchyma. (B) Full expansion of pulmonary parenchyma occurred after debridement and 2 weeks of vacuum-assisted closure treatment.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
In the VAC group, the OWT was created 58 ± 119 days after the diagnosis of the empyema had been made. The total duration of OWT and the duration of VAC therapy were 39 ± 17 and 31 ± 19 days, respectively. No adverse events were reported with application of the sponge to the lung parenchyma (namely, bleeding or parenchymatous defects). All 11 patients (aged 53 ± 17 years; 8 male) were successfully treated and were amenable for subsequent surgical closure of the OWT. In 8 patients, the OWT was closed using a pedicled latissimus dorsi muscular flap, whereas in 1 patient, a free rectus abdominus muscular transposition flap was used. In 2 patients, VAC alone resulted in complete closure of the OWT. The length of hospital stay after closure was 21 ± 34 days (and 60 ± 41 days after creation of the OWT), and all patients were discharged from hospital. Cumulative follow-up was 469 months, with an average duration of follow-up of 46 ± 19 months. During follow-up, 1 patient was readmitted because of recurrent empyema and BPF, requiring formation of a new OWT. The recurrence of empyema and BPF was due to failure of the pedicled muscular flap, requiring removal of the graft. This patient was eventually treated by residual pneumonectomy through median sternotomy. All patients survived to 1 year of follow-up (Fig 4). At latest follow-up, 10 patients were doing well and did not demonstrate any recurrent infection. One patient died during follow-up (after 19 months) from a nonpulmonary cause.

View larger version (10K): [in this window] [in a new window]   Fig 4. One-year survival after creation of an open window thoracostomy in the presence of residual pulmonary parenchyma for vacuum-assisted closure (VAC) treated patients (upper graph) and conventionally treated patients (lower graph) is shown, along with the number of patients at risk at different time intervals.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
In the literature, the use of VAC therapy as part of the surgical treatment of chest wall defects has rarely been described. In a different population, O' Connor and coworkers [6] described VAC treatment of several patients with (infected) chest wall defects and empyema. Two of these patients suffered from thoracic empyema in the presence of residual pulmonary tissue. Two of these patients had rib resections, and none had a classical OWT. The bony thorax was closed in all patients before applying the VAC system, and the VAC sponge was therefore not applied inside the thoracic cavity, as is the case in our current study. In a recent case report, Matzi and associates [9] inserted the VAC device after pneumonectomy without the presence of a BPF, with good results.

VAC Results in Eradication of Infection and Reexpansion of Pulmonary Parenchyma
The advent of VAC for infected wounds in various areas of the body has revolutionized the closure of these defects. In cardiothoracic surgery, the success of this treatment modality in deep sternal wound infections is unequivocal [5]. The obliteration of dead space between layers of infected tissue and the removal of bacteria-loaded interstitial fluids induces rapid angiogenesis and accelerates the granulation process [4]. As demonstrated by our results, the principle of VAC is also applicable inside the thoracic cavity. One of the critical steps for successful treatment is to completely fill the thoracic cavity with the polyurethane sponge, to prevent reoccurrence of empyema. In addition to accelerating tissue granulation (Fig 2A and B), VAC in this setting also improves expansion of residual pulmonary parenchyma (Fig 3A and B), which would have remained compressed when treated conventionally with saline-soaked gauzes. Therefore, VAC may not only reduce the time needed for surgical closure and reduce OWT-related complications, but it may also improve pulmonary function. This is underlined by the observation of 2 patients with OWT, but without VAC, who had a problem weaning from ventilatory support in the intensive care unit. After implementing VAC therapy, these patients could be weaned from ventilatory support.

Our center had several years of experience with VAC in the treatment of deep sternal wound infections before this technique was applied to patients with an OWT. The presence of specialized and dedicated technicians is required for the successful treatment of these patients, and a specific level of knowledge is therefore needed. Early collaboration between the thoracic surgeon and the plastic and reconstructive surgeons is mandatory for planning surgical closure. Above all, VAC for OWT is about teamwork.

Efficacy and Safety of VAC Therapy
The VAC system effectively seals the OWT and makes it more manageable (Fig 1). We did not observe any VAC-related complications, while preexistent alveolopleural fistulae (as a result of decortication) gradually receded with the use of VAC. In all VAC patients, the OWT was closed within a month, using pedicled muscular transposition flaps. In 2 cases, surgical closure of the OWT was not necessary because of adequate overgrowth of granulation tissue with VAC therapy alone. In 1 patient, a pneumonectomy was performed after empyema due to graft failure reoccurred. All patients but 1 are doing well.

In contrast, in the non-VAC group, morbidity and mortality were high and comparable to results reported in literature [1]. Four patients died of OWT-related complications within the first year after formation of the OWT. In a quarter of all patients, the OWT could eventually be closed, but the time needed to safely perform surgical closure was much longer.

VAC Reduces OWT-Related Mortality and Morbidity
Molnar [1] recently reported high mortality and morbidity rates in patients with an OWT, and a high rate of OWT-related complications. One explanation may be that these patients are in a poor clinical condition and are therefore more susceptible to infection and bleeding. That also holds true for both our patient groups. The duration of hospital admission reflects the poor clinical condition of the patient population and significant comorbidity. Comorbidity and clinical condition are comparable in both the VAC and non-VAC treated patient groups, but the outcome (in terms of mortality and morbidity) is superior in the VAC group. Despite the small number of patients studied, our observations indicate that VAC enables rapid eradication of infection and subsequent surgical closure. That might reduce OWT-related mortality and morbidity.

Before the VAC era, patients needed daily wound care. Changing of saline-soaked gauzes often had to be preceded by the administration of analgesics or sedatives [6]. Patients were discharged home with intensive daily wound care by specialized nurse technicians. In this study, the average duration of OWT was approximately 3 years. During this period, patients had to visit the outpatient clinic frequently. Several patients experienced recurrent infections of the thoracic cavity necessitating antibiotic treatment, readmission to the hospital, and sometimes (n = 2) even intensive care unit admission owing to sepsis. In contrast, changing of the VAC system was performed on the ward by two specialized nurse-technicians once every 3 to 5 days, without administration of extra analgesics. When progression of wound healing after surgical closure was satisfactory, patients were discharged without additional wound care, and were followed up in the outpatient clinic. When wound healing was complete, patients were monitored on a yearly basis. In the outpatient population, no recurrent infections were reported. We, therefore, conclude that VAC therapy diminishes the duration of OWT and wound care, in addition to accelerating surgical closure. In this respect, the proposed VAC treatment strategy may improve the quality of life in this population.

Study Limitations
Fortunately, the number of patients presenting with this severe complication is limited. Even in our center (being a tertiary referral center for treatment of thoracic empyema), we were only able to collect 19 patients who had required an OWT and who had residual pulmonary parenchyma in the past 19.5 years. Because of these small numbers of patients, this study is merely a series of case histories and not a randomized trial. In addition, we describe a very heterogeneous group of patients. Therefore, patients of both groups may not have been adequately matched. Nevertheless, the effects of VAC in the presence of an OWT are striking. Because of the small number of patients, however, randomized trials will be difficult to conduct. Furthermore, because of the results that we obtained with this therapy, we would have ethical considerations not treating OWT patients with VAC in the presence of pulmonary parenchyma.

Future Perspectives
In the past, patients with recurrent empyema often received multiple surgical interventions to avoid formation of an OWT. When morbidity and mortality after OWT are taken into account, this may have been the treatment modality of choice [1]. This paper described the possibility of VAC in this patient category, allowing rapid debridement and accelerated surgical closure. Although the indication for formation of an OWT does not change with the advent of VAC, the surgeon might feel more comfortable creating an OWT in the knowledge that it may be closed with reduced morbidity and possibly improving the patients's quality of life. In the near future, patients with an OWT and VAC treatment will be discharged home with VAC therapy and managed in the outpatient clinic until surgical closure is possible, as is the case with VAC-treated patients with sternal defects after cardiac surgery. Despite the use of extra materials for the VAC system, this therapy may reduce hospital stay and therefore reduce costs.

In conclusion, patients with OWT after thoracic empyema can be successfully treated with VAC therapy. The presence of residual pulmonary parenchyma is no contraindication for VAC therapy. In fact, VAC therapy accelerates wound healing and improves expansion of residual lung tissue, accelerating subsequent surgical closure using pedicled muscular flaps. Vacuum-assisted closure may thereby reduce morbidity and mortality in this challenging group of patients.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

1. Molnar TF. Current surgical treatment of thoracic empyema in adults Eur J Cardiothorac Surg 2007;32:422-430.[Abstract/Free Full Text]
2. Miller JI, Mansour KA, Nahai F, et al. Single stage complete muscle flap closure of the post-pneumonectomy empyema space; a new method and possible solution to a disturbing complication Ann Thorac Surg 1984;38:227-231.[Abstract/Free Full Text]
3. Widmer MK, Krueger T, Lardinois D, et al. A comparative evaluation of intrathoracic latissimus dorsi and serratus anterior muscle transposition Eur J Cardiothorac Surg 2000;4:435-439.
4. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation Ann Plast Surg 1997;38:563-576.[Medline]
5. Segers P, de Jong AP, Kloek JJ, et al. TNP in wounds after cardiothoracic surgery: successful experience supported by literature Thorac Cardiovasc Surg 2006;54:289-294.[Medline]
6. O' Connor J, Kells A, Henry S, Scalea T. Vacuum-assisted closure for the treatment of complex chest wounds Ann Thorac Surg 2005;79:1196-1200.[Abstract/Free Full Text]
7. Eloesser L. An operation for tuberculous empyema Surg Gynaecol Obstet 1935;60:1096-1097.
8. Desauliers J, Jacques LF, Gregoire J. Role of Eloesser flap and thoracoplasty in the third millennium Chest Surg Clin North Am 2002;12:605-623.[Medline]
9. Matzi V, Lindenmann J, Porubsky C, et al. Intrathoracic insertion of the VAC device in a case of pleural empyema 20 years after pneumonectomy Ann Thorac Surg 2007;84:1762-1764.[Abstract/Free Full Text]

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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): Gijs G. Geskes Jos G. Maessen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Palmen, M. Articles by Maessen, J. G. Search for Related Content PubMed PubMed Citation Articles by Palmen, M. Articles by Maessen, J. G. Related Collections Pleura Related Article