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J Thorac Cardiovasc Surg 2000;120:270-275
© 2000 The American Association for Thoracic Surgery

General thoracic surgery

Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection

From Service de Chirurgie Thoracique et Vasculaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France.

Address for reprints: J. F. Regnard, MD, Service de Chirurgie Thoracique et Vasculaire, Hopital Marie Lannelongue, 135 Av de la Resistance, 92350 Le Plessis Robinson, France (E-mail: jf.regnard{at}ccml.com ).

	Abstract

Top Abstract Introduction Patients and methods Results Discussion References

 
Objective: Successful treatment of postoperative empyema remains a challenge for thoracic surgeons. We report herein our 12-year experience in the management of this condition by means of open window thoracostomy.
Methods: Open window thoracostomy was used in the treatment of 46 patients with empyema complicating pulmonary resection. A bronchopleural fistula was associated in 39 of 46 cases. Previous operations included pneumonectomy (n = 30), bilobectomy (n = 5), lobectomy (n = 9), and wedge resection (n = 2) performed for benign (n = 10) or malignant (n = 36) disease. In 10 patients open window thoracostomy was definitive because of patient death (n = 2), concomitant major illness (n = 2), tumor recurrence (n = 4), spontaneous closure (n = 1), or patient choice (n = 1). In 36 cases intrathoracic flap transposition was eventually performed. Muscular (n = 29), omental (n = 5), or combined muscular and omental (n = 2) flaps were used to obliterate the thoracostomy cavity and to close a possibly associated bronchopleural fistula. In 9 patients with postpneumonectomy cavities too wide to be filled by the available flaps, a limited thoracoplasty represented an intermediate step.
Results: Among patients treated with definitive open window thoracostomy, local control of the infection was achieved in all the survivors (8/8). After open window thoracostomy and subsequent flap transposition, success (definitive closure of the thoracostomy and, if present, of the bronchopleural fistula) was achieved in 27 (75.0%) of 36 patients. Four initial failures could be salvaged by means of reoperation (initial reopening of thoracostomy and subsequent muscular or omental transposition).
Conclusion: Open window thoracostomy followed by intrathoracic muscle or omental transposition represents a valid therapeutic option in patients with empyema complicating pulmonary resections.

	Introduction

Top Abstract Introduction Patients and methods Results Discussion References

 
Management of empyema complicating pulmonary resections still represents a challenge in thoracic surgery. Empyema is not uncommon as a complication of pneumonectomy, occurring in 2% to 16% of cases. ^1,2 Although more uncommon, it may complicate any kind of pulmonary resection. ³ It is a life-threatening condition with a mortality of approximately 40% in postpneumonectomy empyema. ^1-3 Empyema is frequently associated with a bronchopleural fistula (BPF) involving the stump of the main bronchus or of a lobar or a segmental bronchus; air leaks may originate also from more peripheral bronchi, as well as from bronchoalveolar fistulas. ³ The presence of a BPF obviously increases the morbidity and the mortality of empyema by providing a source of continuous contamination of the pleural space and promoting aspiration of infected pleural fluid in the remaining lung. ^1,4 Therefore, the optimal treatment of empyema complicating pulmonary resections should take into account the infectious state, the characteristics of the pleural space, and the presence of a fistula. ^1,5

Adequate drainage is the first step in the treatment of patients with postresection empyema. ^2,5-8 Closed tube drainage is generally used in the acute phase, and open drainage is carried out when clinical conditions are stabilized. ^2,5-7 According to other authors, optimal drainage of early postresection empyema is accomplished by reopening of the entire thoracotomy. ⁸ On the other hand, several controversies exist concerning the management of a concurrent BPF, as well as the modalities and the timing of definitive chest closure. ^2,5,7-9

In the present article we report our experience concerning the treatment of postresection empyema by using open window thoracostomy (OWT) followed by intrathoracic muscular or omental transposition. Such treatment was reserved for patients with persistent empyema after the initial closed drainage.

	Patients and methods

Top Abstract Introduction Patients and methods Results Discussion References

 
Patients
In the period from 1987-1998, 109 patients were treated in our department for a postoperative empyema; this empyema was associated to BPF in 97 cases.

During the same period, 3889 pulmonary resections were performed in our department. OWT was performed in 46 patients after an initial closed tube drainage for a persistent empyema.

Previous operations included pneumonectomy (n = 30), bilobectomy (n = 5), lobectomy (n = 9), and wedge resection (n = 2). Indications for pulmonary resection had been lung cancer (n = 36) or benign diseases (n = 10). Among patients with lung cancer, the final pathologic stage was I in 6, II in 19, and IIIA in 11 patients. Delay between resection and empyema ranged from 5 days to 45 years (median, 32 days). A BPF was present in 39 of 46 patients (Table I). Pseudomonas aeruginosa , Staphylococcus aureus , and Proteus mirabilis represented the microorganisms most frequently isolated from empyema fluid specimens.

Pleural drainage
In all patients, closed chest tube thoracostomy was initially performed to drain the purulent collection and, in patients with BPF, to prevent aspiration by the other lung. In the majority of cases, tube thoracostomy, appropriate antibiotics, and supportive care allowed a gradual improvement of clinical conditions.

In case of failure of closed drainage, OWT was planned to achieve optimal pleural drainage and to allow hospital discharge of patients. The delay between pulmonary resection and OWT ranged from 7 days to 45 years (median, 67 days). The site of OWT was selected on the basis of imaging studies, with the aim of correctly draining all purulent collection. Care was taken to limit the injury to chest wall muscles. Two to four rib segments (generally not more than 10 cm long) were resected to widely expose the empyema cavity. The skin was advanced and brought down to the parietal pleura. Pus and necrotic debris were gently removed, and the cavity was filled with povidone iodine–soaked gauze. The dressings were initially changed once daily and, after discharge, every 2 days. Mean hospital stay after OWT was 8 days. Elimination of gangrenous material and reduction of the pleural cavity were achieved in all the cases; in 21 of 39 patients, spontaneous closure of BPF occurred (Table II).

Flap transposition
The OWT was not closed by the second step of the Clagett procedure (ie, obliteration of the pleural cavity with an antibiotic solution and skin closure by direct approximation of edges). ¹⁰ In the presence of a BPF, such an approach is not feasible; furthermore, in the absence of a BPF, the risk of empyema recurrence is high. ⁷ We preferred to use intrathoracic flap transposition to close the OWT. It was considered possible if no sign of suppuration existed and abundant granulation tissue was present. The presence of a persistent BPF (as observed in 14/36 cases) did not represent a contraindication for closure. Satisfactory clinical conditions and, for patients previously operated on for lung cancer, no evidence of tumor recurrence at restaging were also mandatory. The timing of closure was also influenced by the patient’s preferences. Delay between creation and closure of the OWT ranged from 1 to 36 months (median, 6 months).

Intrathoracic muscular transposition was the procedure of choice for closure of OWT and was carried out in 29 patients. If sufficient muscular bulk was available, an omental flap was used alone (n = 5) or in association with muscular flaps (n = 2).

When a postpneumonectomy pleural space was judged too large to be filled by the available flaps, a limited extraperiosteal thoracoplasty represented an intermediate step. It was necessary in 9 patients and carried out through a posterolateral incision, thus always preserving the pectoralis major muscle, as well as the serratus anterior muscle.

To perform the muscular flap transposition, we used an incision that included in its trajectory the previous thoracostomy; skin flaps adequate for closure were obtained whenever possible. The muscles to be used for transposition were chosen by taking into account anatomic considerations, as well as the entity of damage caused by previous operations. Single or double muscular flaps were prepared (Table III); extreme care was used to avoid injuries to the principal vascular pedicles of the selected muscles. The flaps were passed into the cavity through the thoracostomy. If a bronchial fistula was still present, it was closed by suturing the muscle at its edges. In most cases the muscular flap was sufficient to obliterate the cavity entirely.

	Results

Top Abstract Introduction Patients and methods Results Discussion References

 
Outcome after OWT alone
OWT was definitive and flap transposition never performed in 10 of 46 patients. The transposition was not carried out because of patient death (one myocardial infarction and one pulmonary embolism, occurring at 1 and 3 months, respectively), concomitant major illness (n = 2), locoregional (n = 2) or metastatic (n = 2) tumor recurrence, or patient choice (n = 1). In 1 case spontaneous closure occurred. With the exception of the patient who had a spontaneous closure, the survivors were managed indefinitely on an outpatient clinic basis by local care. Local control of the infection was satisfactory in all the patients, and septicemia occurred in no one. Spontaneous closure of BPF occurred in 5 patients.

Outcome after OWT and subsequent flap transposition
Thirty-three of 36 patients were alive 6 months after the completion of the treatment and available for assessment of treatment success. The causes of the 3 deaths were recurrent empyema with septicemia (treatment failure) in 2 patients and cancer progression in 1 patient. All the deaths occurred more than 1 month after the completion of the treatment and discharge from the hospital. Neither flap necrosis nor other major complications were observed. One wound infection occurred, which was successfully managed by drainage and antibiotics.

In 27 (75.0%) of 36 patients, the intrathoracic flap transposition was successful; no infection recurred, and definitive closure of thoracostomy was achieved. Independent of the size of the residual pleural space at the time of flap transposition, in 9 (25.0%) cases empyema recurred, and reopening of the OWT was necessary. Four of these patients were eventually successfully treated by further intrathoracic muscular (1 patient) or omental (2 patients) transposition; in another patient a thoracoplasty followed by omentopexy was used with success. In the remaining 5 patients no further attempt for closure was possible because of persistent infection and the OWT was definitive. The overall success rate was 86% (31/36; Table IV).

	Discussion

Top Abstract Introduction Patients and methods Results Discussion References

 
Adequate pleural drainage remains the cornerstone of the initial treatment of empyema complicating pulmonary resections. Tube thoracostomy allows empyema drainage and prevents aspiration in the controlateral lung if a BPF is present. ^2,5,7 In our series, as well as in the experience of several authors, ^2,5-7 closed chest tube drainage represented the initial part of management of postresection empyema and allowed for stabilization of the patients’ clinical conditions. However, closed drainage often fails to completely drain the cavity with subsequent unsatisfactory control of the infection; in these cases open drainage is performed. ^2,5-7 Furthermore, open drainage allows for management of patients on an outpatient clinic basis much more easily than closed drainage. In our series, mean hospital stay after OWT was 8 days.

In our study, OWT was carried out according to the standard technique ⁵; the entity of rib resection was as limited as possible to ensure adequate drainage and easy changes of dressings. In these severely ill patients we preferred to limit the surgical trauma as much as possible, and therefore no attempt was made to close a BPF when present. This approach is probably responsible for the low incidence of complications observed in the present series. Furthermore, similar to others’ experience, ⁵ in 53.8% of cases, the BPF closed spontaneously after OWT, probably because of improvement (or resolution) of the infective condition of the pleural cavity. Other authors have advocated a more aggressive management of early postresection empyema and BPF, as well as different modalities of OWT closure. ^6,8,11 Pairolero and colleagues ⁸ suggested immediate open pleural drainage by reopening of the entire thoracotomy incision. In the presence of BPF they performed restapling of long bronchial remnants (if present) or complete reopening and resuture of short stumps. Immediate muscular transposition is used to protect the suture line or to cover the fistula if resuture is not possible. ⁸ They suggested OWT closure with the second stage of the Clagett procedure. ¹⁰ By using this approach, Pairolero and colleagues ⁸ reported a successful outcome in 26 (57.8%) of 45 patients; 6 (13.3%) operative deaths were also observed, and a mean of 5 surgical procedures were necessary. It is noteworthy that the second stage of the Clagett procedure was followed by empyema recurrence in 5 (16.1%) of 31 evaluable patients. ⁸ On the other hand, several authors have used the 2-step Clagett procedure (without flap transposition) in the treatment of postresection empyema. This technique is possible only in the absence of BPF, and the results are very variable in different authors’ experience. In the series of Stafford and Clagett, ¹² sterilization of empyema and definitive closure of the OWT were accomplished in 11 (61%) of 18 patients at the first attempt. Goldstraw ² reported successful results in 17 (77.3%) of 22 patients in whom the entire procedure could be completed, whereas in the experience of Shamji and colleagues, ⁷ in only 2 of 5 patients who underwent the second step of the procedure was a permanent closure of the OWT achieved.

Gharagozloo and colleagues ¹³ have recently reported a surprisingly high success rate (100%) in patients with early postpneumonectomy empyema associated with BPF. They suggested a procedure based on emergency tube drainage followed by thoracotomy, debridement of necrotic tissue, bronchial stump resuture, and immediate closure of the thoracotomy. Postoperative pleural irrigation and obliteration of the space by antibiotic solution constitute the final part of the treatment. The authors speculated that in most patients in their population a technical error in handling the bronchus at the time of initial thoracotomy was probably responsible for the occurrence of the BPF, and therefore they considered a technically satisfactory reclosure of the bronchus of paramount importance in the management of such patients. On the basis of these considerations, we think that presently the approach suggested by Gharagozloo and colleagues should be considered only in a very selected subset of patients.

In our experience after OWT, intrathoracic muscular or omental transposition was used to obliterate the pleural space and, at the same time, to close a possibly associated BPF. It has been reported that both omentum ^14,15 and muscle ^5,16,17 flaps may play an important role in infection control. Furthermore, both stimulate neoangiogenesis of ischemic bronchial stumps. ^18-20 In the present study a satisfactory success rate was also observed among patients with persistent BPF at the time of flap transposition.

The choice of muscles for transposition depends on the location of the space to be filled, as well as on previous operations. Pectoralis major is the muscle of choice for filling anterior cavities because of its bulk and integrity after a posterolateral thoracotomy. It is a general policy in our institution to respect the serratus anterior in all thoracotomies, and therefore this muscle is almost always available for transposition. The latissimus dorsi has also been used in several instances in our series. If it had been preserved at the time of the initial operation—if an anterior thoracotomy or a muscle-sparing lateral thoracotomy had been carried out—it can be mobilized and transposed entirely. On the other hand, it is generally believed that a previously divided latissimus dorsi will survive in situ, but the entire muscle will not survive as a proximally based muscle flap. ²¹ Furthermore, when a single muscle is not sufficient, 2 or more muscles may be used, as in 8 patients in our series.

In 9 patients in our series a limited extraperiosteal thoracoplasty represented an intermediate step between OWT and flap transposition. We did not carry out the thoracoplasty and flap transposition at the same operative time to limit the surgical trauma in these weak patients. In our opinion, thoracoplasty should be discouraged as the definitive and only procedure for treatment of postoperative empyema. When used alone, extensive rib resection (full thoracoplasty) is generally required, with a subsequent high operative mortality ^22,23 and significant physiologic changes negatively affecting the function of the controlateral lung. ²³ Furthermore, the success rates reported are not completely satisfactory. Among 16 patients with BPF complicating resection for lung cancer, Peppas and colleagues ²² observed 4 hospital deaths and 2 treatment failures. Young and Ungerleider ²⁴ reported an operative mortality of 10% and 18% of survivors with persistent empyema, BPF, or both.

Our results are in agreement with those reported in previous studies in which similar techniques and timing were used in smaller series of patients. ^5,9 In particular, Cicero and colleagues ⁹ reported good results in 2 of 2 patients with postresection empyema treated by OWT followed by intrathoracic transposition of myocutaneous flaps; on the other hand, Garcia-Yuste and colleagues ⁵ reported a successful outcome in 21 of 22 patients with tuberculous empyema and in 14 of 18 patients with postresection empyema by using OWT followed by intrathoracic muscular transposition.

We believe that OWT followed by intrathoracic flap transposition is a safe and effective technique in the management of empyema complicating pulmonary resections. Compared with the second step of the Clagett procedure, in the absence of BPF at the time of OWT closure, intrathoracic flap transposition provided results similar to those reported by some authors ^2,12 but remarkably better than those shown by others. ⁷ Therefore, no definitive conclusion can be drawn. On the other hand, in the presence of a persistent BPF, the second step of the Clagett procedure is not feasible, and flap transposition represents a very effective tool.

	References

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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): Jean-François Regnard Pierre Magdeleinat Philippe Levasseur Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Regnard, J.-F. Articles by Levasseur, P. Search for Related Content PubMed PubMed Citation Articles by Regnard, J.-F. Articles by Levasseur, P.