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J Thorac Cardiovasc Surg 2006;132:708-710
© 2006 The American Association for Thoracic Surgery
Brief Communication |
Department of Thoracic Surgery, Georges Pompidou European Hospital, Paris V University, Paris, France.
Received for publication March 23, 2006; accepted for publication May 9, 2006. * Address for reprints: Marc Riquet, MD, Service de Chirurgie Thoracique, Hôpital Européen Georges Pompidou, 20-40 rue Leblanc, 75908 Paris, France (Email: marc.riquet{at}egp.aphp.fr).
Postpneumonectomy empyema (PPE) is a serious complication in fragile patients. Usual surgical treatment ranges from pleural irrigation1
to aggressive management with open-window thoracostomy.2 This study reports a minimally invasive method combining antibiotic irrigation and videothoracoscopic debridement.
Clinical Summary
Between January 2000 and December 2005, 254 pneumonectomies were performed at our department. PPE confirmed by bacteriologic examination of the pleural fluid developed in 18 patients (7%), 16 men and 2 women with a mean age of 65.2 years. Clinical and bacteriologic characteristics are depicted in Table 1. Seven patients had a neoadjuvant therapy. Pneumonectomy was performed under antibiotic prophylaxis with a second-generation cephalosporin (cefamandole). The mean interval between surgery and PPE was 12 days (2-35 days). After bronchoscopic exclusion of a bronchopleural fistula and bronchial bacteriologic sampling, the protocol consisted of antibiotic irrigation for 10 days (according to culture sensitivity) through two 18F Monaldi chest tubes (Porges, Le Plessis Robinson, France) with simultaneous parenteral antibiotics. Antibiotic lavage was performed through an axillary chest tube twice per day every 12 hours (Figure 1). Aspiration of pleural fluid was performed through an anterior chest tube for 1 hour after lavage. Pleural pression was maintained constant because of the opening of the axillary drain with antibacterial filter during aspiration.
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Videothoracoscopy was performed after an instillation of 250,000 UI of streptokinase through a chest tube 2 hours before the surgical procedure. The patient was in a supine position. After removal of the chest tubes, the skin was excised around the drains to prevent chest wall sepsis and to allow the insertion of two 10-mm thoracoports. After pleural debridement and bacteriologic sampling, the bronchial stump was examined and tested with saline serum. A pleural lavage was performed at the end of the procedure.
The success rate of antibiotic lavage was 88.8% (n = 16/18). In 1 patient, videothoracoscopy diagnosed an asymptomatic bronchopleural fistula, which was treated immediately with an open-window thoracostomy. Systematic perioperative bacteriologic examination was also positive in 1 patient, who was treated with antibiotic irrigation for 7 more days.
The mean C-reactive protein level decreased from 236 (107-364) U/L to 53.5 (5-155) U/L after videothoracoscopy. The mean hospitalization stay after empyema diagnosis was 13.9 (13-27) days. One patient (5.5%) died of pulmonary edema during the treatment. There was no reoperation. No early or late recurrence was observed with a mean follow-up of 44.4 (12-71) months. Prosthetic material (polytetrafluoroethylene mesh n = 3, polyglactin mesh n = 3) was conserved in every cases.
Discussion
The 7% rate of PPE that we observed is in agreement with the 2% to 15% rate reported by Deschamps and colleagues.3 Our protocol is the combination of a standard treatment of PPE and a minimally invasive surgical approach. The videothoracoscopic exploration of the pleural cavity after antibiotic irrigation and fibrinolysis allows direct-control verification of effective tight bronchial stump closure. It also prevents recurrences by removing false membranes and debris, which are a potential source of late infection.
Management of PPE based on early thoracoscopic debridement is efficient but has a 27% recurrence rate when open-window thoracostomy is performed with no antibiotic irrigation4 and has a mean duration of thoracic drainage of 22 ± 9 days when antibiotic irrigation is performed after videothoracoscopy.5 Compared with these protocols, pleural antibiotic irrigation performed first, rather than videothoracoscopic debridement, provides satisfactory results in terms of hospital stay and number of sepsis recurrences.
Conclusion
The combination of antibiotic irrigation followed by thoracoscopic debridement is a minimally invasive and efficient method to treat PPE and conserve the prosthesis.
References
This article has been cited by other articles:
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  D. Schneiter, T. Grodzki, D. Lardinois, P. B. Kestenholz, J. Wojcik, B. Kubisa, J. Pierog, and W. Weder Accelerated treatment of postpneumonectomy empyema: A binational long-term study J. Thorac. Cardiovasc. Surg., July 1, 2008; 136(1): 179 - 185. [Abstract] [Full Text] [PDF]
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