Ann Thorac Surg 2009;88:1136-1137. doi:10.1016/j.athoracsur.2009.06.071
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Thomas F. Molnar, MD, PhD
Surgical Clinic, Department of Thoracic Surgery, University Medical School of Pecs, Ifjusag u. 13, Pecs H-7632, Hungary
We are presented with an innovative technology for the treatment of the oldest known general thoracic surgical entity: thoracic empyema . The inventor of the vacuum-assisted closure technique and the authors adjusting it to chest application deserve the merit for putting together a jigsaw puzzle. The known elements of basic and time-tested surgical rules of any empyema have now become systematically restructured. Although Celsus (2nd century, AC) adopted the rule of Hippocrates (ie, "ibi pus, ubi evacua," which means where you find pus, empty it), it was Herman Boerhave (1688–1738) of Leyden who laid down four basic principles of treatment. The success of the treatment depended on: (1) proper positioning of the patient (postural drainage), (2) suction through a drain, (3) local instillation, and (4) prevention of untimely closure of the hole in the chest wall. The influence of mild acidity (level of pH) on the environment of the cavity using irrigation (occasionally by wine) was a principle known since Guy de Chauliac (1300–1368). Drainage, which is the main pillar of the philosopy , was refined by using the microtubular effect of Penrose's drain introduced in abdominal surgery in 1890 . The principle of a permanent active evacuation obtained by continuous suction was born as a synthesis of the drainage techniques pioneered by the French Chassaignac (1805–1879) and von Bülau (1835–1900) of Hamburg by the late 19th Century. Actually the method adjusted to intrathoracic environment by the Dutch team (accidentally, also of Leyden) using microtubular foam and permanent evacuation of a closed collecting system is a mere result of a systemic analysis of previous experiences and proper application of the theory.
When the commentator warmly supports the wider application of the method, some limitations should be emphasized, highlighting the authors' own recommendations. Requirement of residual lung tissue seems to be important, as there is a need for expandable tissue to refill the empty space. Therefore, primary thoracic empyema and all kinds of postresectional thoracic empyema (except infected postpneumonectomy cavities) are candidates for this sort of treatment. As far as the pros and cos of this new technique, a pendulum movement is expected in the inclusion criteria. It will take time until this method settles down and consolidates into place. The next step in the consolidation is to avoid excesses (ie, application in an unsatisfactory environment). It can be foreseen that postpneumonectomy space with a significant bronchopleural fistula (BPF) is an unfavourable scenario, at least while a permanent supply of causative organisms are present. Another task is to implement this method into the chain of surgical decision making. It can be used either as an independent method or as a preparatory method prior to a second or third step procedure. The question is only how to optimize the combinations with other methods, as with the undeservedly forgotten chemical decortication using streptase, trypsin, or boric acid. Where the authors can explore still further elements, it is the pH value of the environment they provide. A mild acidity due to the wine flushing, suggested by the old barber surgeons, might have worked as a beacon of light coming from the distant past. The temptation of the usage of local antibiotics was resisted by the authors and they deserve merit for this attitude. History also teaches us of the dangers of antibiotic abuse. This is the way for the past to pave the way to teach the present , and how an old voice was listened to by the authors. The commentator is strongly convinced that if the authors and the strength of the market-seeking industry can practice common sense in self limitation, then thoracic surgery has definitely become richer by a useful method in the fight against a killing wolf in a sheep's skin, ie, thoracic empyema.
- Palmen M, van Breugel HNAM, Geskes GG, et al. Open window thoracostomy treatment of empyema is accelerated by vacuum-assisted closure Ann Thorac Surg 2009;88:1131-1137.[Abstract/Free Full Text]
- Molnar TF, Hasse J, Jeyasingham K, Rendeki SZ. Changing dogmas: history of treatment for traumatic haemothorax pneumothorax and empyema thoracis Ann Thorac Surg 2004;77:372-378.[Abstract/Free Full Text]
- Penrose ChB. Drainage in abdominal surgery JAMA 1890;14:264-266.
- Molnar TF, Lukacs L. Tolstoy's report of five cases with chest trauma and its relevance to contemporary military surgical experience World J Surg 2006;30:1400-1402.[Medline]
Open Window Thoracostomy Treatment of Empyema Is Accelerated by Vacuum-Assisted Closure
- Meindert Palmen, H. Nathalie A.M. van Breugel, Gijs G. Geskes, Arne van Belle, Jos M.H. Swennen, André H.M. Drijkoningen, Rene R. van der Hulst, and Jos G. Maessen
Ann. Thorac. Surg. 2009 88: 1131-1136.