48 - Embryology and Anatomy of the Diaphragm
Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.
Title: General Thoracic Surgery, 6th Edition
Copyright 2005 Lippincott Williams & Wilkins
> Table of Contents > Volume I - The Lung, Pleura, Diaphragm, and Chest Wall > Section XI - The Pleura > Chapter 59 - Postsurgical Empyema
Chapter 59
Postsurgical Empyema
Joseph I. Miller Jr.
Following pulmonary infection, the second most frequent cause of empyema is the development of infection in the pleural space after surgery of the esophagus, lungs, or mediastinum (Table 59-1). Postsurgical empyema accounts for 20% of all cases of empyema. It most frequently follows pneumonectomy, occurring in 2% to 12% of patients. It may occur in 1% to 3% of patients after lobectomy. LeRoux and associates (1986) report that in 8% to 11% of patients, the preceding lesion causing an empyema thoracis is an unrecognized subphrenic abscess in the patient who has undergone an abdominal, urologic, or pelvic operation. Empyema may occur secondary to a spontaneous pneumothorax with a persistent bronchopleural fistula, it may occur after parasitic infection or secondary to retained foreign bodies in the bronchial tree, or it may have a number of miscellaneous causes. The etiology of empyema in 215 patients is given in Table 59-2. Factors that may promote the development of a postsurgical empyema are listed in Table 59-3.
NONRESECTIONAL POSTSURGICAL EMPYEMA
The development of nonresectional thoracic surgical empyema is related to the predisposing cause. It may follow esophageal surgery with resultant leak into the pleural space. It may develop after subdiaphragmatic surgery on the stomach, pancreas, or spleen with the accumulation of fluid in the subdiaphragmatic space. It may occur after rupture of an infected pleural bleb or secondary to lung abscess.
Infection in the pleural space unrelated to a pulmonary resection generally can be treated in the same manner as a nonsurgical empyema, with correction of the underlying cause, appropriate antibiotics, and drainage with closed tube thoracostomy.
EMPYEMA AFTER RESECTION
Empyema that complicates pulmonary resection must be considered separately from empyema that occurs spontaneously or after trauma. When empyema complicates a pulmonary resection that is less than a pneumonectomy, the ability of the remaining lung to fill the pleural space after management of the empyema by drainage or decortication, and thereby to obliterate the pleural space, depends on the state of the remaining lung and its location, apical or basal. Empyema after upper lobectomy nearly always requires more than simple drainage, which nearly always suffices after lower lobectomy. After pneumonectomy, the empyema space is inevitably large and nearly always permanent. In these circumstances, alternative methods of treatment include sterilization, permanent drainage, thoracoplasty, and obliteration of the space by muscle flap transposition.
The incidence of empyema after pulmonary resection varies with the indications for the resection (inflammatory or neoplastic disease), with or without preoperative radiation. With resection for pulmonary tuberculosis, sputum conversion having been achieved, the incidence of bronchopleural fistula with empyema in the series Lynn (1958) reported was 6.7% after lobectomy. When sputum results were still positive for acid-fast organisms, Teixera (1968) reported it was 10%.
With pneumonectomy, as opposed to lesser resections, LeRoux and associates (1986) reported that the incidence of empyema varies from 2% to 13%. When pneumonectomy is completed through an empyema, the incidence of continued pleural infection is 45%.
Although empyema may occur at any time postoperatively, even years later, most empyemas develop in the early postoperative period. The pleural space may be contaminated at the time of pulmonary resection with the development of a bronchopleural or esophagopleural fistula, or from blood-borne sources. After pulmonary resection that is less than a pneumonectomy, empyema occurs more often when the pleural space is incompletely filled by expansion of the remaining lung, mediastinal shift, and elevation of the diaphragm. Symptoms and signs vary, and if resection was performed for neoplastic disease, they may be difficult to distinguish from those caused by dissemination of tumor. The possibility of empyema must be considered in any patient with clinical features of infection after pulmonary resection. Expectoration of
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serosanguineous liquid and purulent discharge from the wound or the drain sites are almost diagnostic. On radiography of the chest, usually a pleural opacity is seen, with or without a fluid level, when resection has been less than a pneumonectomy. After pneumonectomy, a decrease in the fluid level early postoperatively, or the appearance of a new fluid level when the pneumonectomy site was uniformly opaque, strongly suggests an infected pleural space with bronchopleural fistula. The timing of surgical intervention and the type of operative procedure undertaken are tailored to the individual patient. An algorithm for the management of postresectional empyema is given in Fig. 59-1.
Table 59-1. Etiology of Postsurgical Empyema | |
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General Principles of Treatment
When the diagnosis of postresectional empyema, with or without a bronchopleural fistula, is made, surgical drainage by closed tube thoracostomy and institution of appropriate antibiotic therapy are crucial. Once adequate drainage has been established and the patient is stabilized, usually in 10 to 14 days, the course of management can be determined. If a bronchopleural fistula is present, the fistula should be closed by a myoplasty or omentoplasty, followed by single-stage muscle flap closure of the remaining space. If the patient is medically unstable, the closed tube thoracostomy can be converted to open drainage by Eloesser's procedure.
Table 59-2. Etiology of Empyema in 215 Patients | |||||||||||||||||||||||||||||||||
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Table 59-3. Factors That Promote Development of Postsurgical Empyema | |
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If the patient has only an empyema space without a bronchopleural fistula, the cavity is sterilized by irrigation with the appropriate antibiotic solution, as determined by the antibiotic sensitivities of the chest tube drainage, and a single-stage muscle flap closure of the remaining cavity is performed. A complete discussion of muscle flap closure is given later in this chapter. If the patient is medically unstable, closed tube thoracostomy can be converted to an open Eloesser's flap.
Postpneumonectomy Empyema
Postpneumonectomy empyema remains a problem. It is associated with a bronchopleural fistula in approximately 40% of patients, and in only 20% of patients does the bronchopleural fistula close spontaneously. One of the most important advances in the treatment of this complication was the report by Clagett and Geraci (1963), in which they described rib resection with antibiotic irrigation and closure of the space in 6 to 8 weeks. Stafford and Clagett (1972) reported a success rate of 75% to 88% using this method for sterilization of the empyema and permanent closure. My experience with this method has not achieved that success rate. When the offending organism is Staphylococcus aureus, a fair chance of success exists, but when multiple bacterial organisms are present, the rate of success is only approximately 20%.
Figure 59-2 presents an algorithm for treatment of the postpneumonectomy empyema space. Once the diagnosis of postpneumonectomy empyema, with or without bronchopleural fistula, has been established, prompt pleural drainage by closed tube thoracostomy is mandatory. Tube thoracostomy is continued until the mediastinum becomes stabilized, generally requiring approximately 2 weeks. Thereafter, open drainage or another modality of therapy for the empyema space can be undertaken safely without shift of the mediastinum. Once the patient is medically stable and has entered into the chronic phase at 3 to 4 weeks, if no bronchopleural fistula is present, a modified Clagett's procedure is performed. A second small chest tube is inserted into the second intercostal space, and a continuous
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inflow outflow irrigation system is established through the pleural cavity. The irrigant is based on antibiotic sensitivities to the pleural drainage. This is generally 2 g of cephalosporin in 500 mL of 5% dextrose in water, running at a rate of 50 mL/hour through the inflow catheter, with continuous drainage through the outflow catheter. Occasionally, if Gram-negative organisms are present, I use 0.25% neomycin as the irrigant. This method achieves sterilization of the space in approximately 50% of patients. If the method is successful and the return irrigant is negative on 3 consecutive days after 2 weeks of irrigation, the chest tubes can be removed, and pleural fluid is allowed to reaccumulate to fill the remaining space. If the modified Clagett's technique fails, a complete muscle flap closure of the pneumonectomy space can be performed.
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Fig. 59-1. Management of postresectional empyema. |
If a patient with a postpneumonectomy empyema has a bronchopleural fistula, it is likewise treated during the acute phase with closed tube thoracostomy, with conversion to open drainage at the appropriate time when mediastinal stabilization has occurred. If the fistula closes, one can attempt the aforementioned modified Clagett's sterilization of the cavity. In the patient in whom the bronchopleural fistula persists, the fistula and space are then managed by transposition of muscle flaps into the empyema space, as the author and associates (1984) reported.
Muscle Flap Closure of the Postpneumonectomy Empyema Space
I believe that the best way to treat a postpneumonectomy space is single-stage muscle flap closure, completely obliterating the pneumonectomy space by the transposition of the thoracic skeletal muscles.
Abrashanoff (1911) reported extrathoracic muscle transposition for closure of a bronchopleural fistula. Since then, muscle flaps have been used to obliterate spaces, close a bronchopleural fistula,
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and reinforce tracheobronchial and esophageal anastomosis. In the late 1970s, our group used extrathoracic muscle flaps to close bronchopleural fistulae and postlobectomy empyema cavities, but not until 1980 did we attempt to fill an entire pneumonectomy space with muscle flaps.
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Fig. 59-2. Treatment of postpneumonectomy empyema space. |
Because of their excellent blood supply and ability by pedicle flap to reach almost any location in the pleural space, muscle flaps are ideal tissue to fill a contaminated space. The extrathoracic muscle flaps used in various combinations in our patients (1984) in order of frequency are the latissimus dorsi, serratus anterior, pectoralis major, omentum, and rectus abdominis. The percentage of coverage of normal pneumonectomy space in the adult by each flap is as follows: latissimus dorsi, 30% to 40%; serratus anterior, 10% to 15%; pectoralis major, 20% to 30%; pectoralis minor, 0% to 2%; omentum, 5% to 15%; and rectus abdominis, 5% to 15%. These figures are based on clinical estimation of coverage at the time of operation and cadaver studies.
Extrathoracic muscle flaps require a route of entry when transposed into the thoracic cavity. Segments of rib, determined by the blood supply of the muscles (Fig. 59-3), are resected to prevent kinking, constriction, and consequent swelling and ischemia of the muscle when the muscle is transposed into the pleural space.
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Fig. 59-3. Extrathoracic muscle flaps that can be used in closure of a postpneumonectomy empyema cavity. a, artery. From Miller JI, et al: Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 38:227, 1984. With permission. |
Specific Muscle Flaps and Omentum
Omentum
The omentum can be brought into the pleural space as a flap or a free graft. It is the flap of choice to cover an open bronchial stump because of the excellent vascular supply. Neovascularization is evident in the stump within 48 hours after placement of an omental flap around a closed stump. The omental flap is usually brought up through a separate anterior opening in the diaphragm and is laid over the bronchial stump; tacking sutures are placed around the flap (Fig. 59-4). Normally, I do not use this flap unless an open bronchial stump is present or not enough muscle is available to fill the space.
Pectoralis Major
The pectoralis major flap is one of the two most commonly used extrathoracic muscle flaps. It has a dual blood supply from the predominant thoracoacromial artery to the major pedicle, and from the internal mammary to the major pedicle and secondary pedicles. It can be used as a reverse
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turnover flap or placed directly into the wound. It requires a 5-cm rib resection for entry into the chest. It is the flap of choice for sternal infections and ranks after the latissimus dorsi and serratus anterior for the pleural space.
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Fig. 59-4. The omental flap is brought through an anterior opening in the diaphragm and placed over the bronchial stump. OG, omental graft. From Miller JI, et al: Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 38:227, 1984. With permission. |
Latissimus Dorsi
The latissimus dorsi flap is the most commonly used flap for thoracic defects. Its predominant blood supply is from the thoracodorsal artery. It can be used as a turnover flap or placed directly into the wound. It may be brought through the incision or through a separate small rib resection.
Serratus Anterior
The serratus anterior is my second choice of flap for filling a pneumonectomy space and is particularly good for filling a small space. The entrance into the chest is through the primary chest incision.
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Fig. 59-5. An entire pleural space filled with muscle flaps and their usual anatomic location. LD, latissimus dorsi; PM, pectoralis major; REC, rectus abdominis; SA, serratus anterior. From Miller JI, et al: Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 38:227, 1984. With permission. |
Rectus Abdominis
In general, the rectus abdominis is used for closure of the lowest one-third of sternal defects. It is held in reserve for problems involving the pleural space in case a residual space remains. It is generally the last flap applied.
Surgical Technique of Single-Stage Complete Muscle Flap Closure
Single-stage muscle flap closure is performed for a persistent postpneumonectomy empyema space at approximately 3 months for benign disease and 6 months to 1 year for malignant disease. The six basic steps for complete flap closure are as follows:
Appropriate antibiotics are given, based on the sensitivities of the pleural drainage.
The original incision is reopened.
The cavity is d brided widely so that good granulation tissue is present.
A bronchopleural fistula is identified, and if present, the edges are freshened, and the fistula is closed, if technically possible; an omental flap is brought up through the anterior diaphragmatic incision (see Fig. 59-4) and tacked around the fistula with 3 0 Prolene sutures.
Appropriate muscle flaps are then swung to fill the pleural space.
The procedure is begun with a latissimus dorsi flap and followed with any necessary flaps to fill the entire space, depending on the anatomic location and size of the space. The filling of the entire pleural space is shown in Fig. 59-5. Mathes and Nahai (1982) discussed in detail the technique of flap mobilization in their excellent work on muscle and musculocutaneous flaps.
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Fig. 59-6. Usual sites of rib resection for entrance of the pectoralis major (PM) and latissimus dorsi (LD) flaps into the pleural space. REC, rectus abdominis; SA, serratus anterior. From Miller JI, et al: Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 38:227, 1984. With permission. |
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Fig. 59-7. Treatment of postlobectomy empyema. |
All extrathoracic muscle flaps require a route of entry into the chest. The location of the opening is usually determined by the blood supply of the muscle and should be placed so that the blood supply is under no tension after transposition. Generally, 4 to 5 cm of the appropriate rib is all that must be resected to allow for flap entry. Figure 59-6 shows the typical site of entry for the pectoralis major and latissimus dorsi flaps. The sine qua non for success with single-stage complete muscle flap closure is that the entire space must be filled. If a space is left, it is usually just beneath the fifth or sixth rib in the midaxillary line and can be closed by a short resection of the ribs over it without cosmetic deformity. Following transposition of the muscle flaps, the wound is closed primarily, and chest tubes are connected to Pleur-evac suction for 7 to 10 days. Appropriate antibiotics are given.
The two predominant points in this surgical technique are that no residual space can be left and that a sufficient number of flaps must be available so that any intrathoracic space can be filled. To date, I have used this technique in over 35 patients, with only 6 failures (17.2%).
Two-Stage Alternative Technique
An alternative method of dealing with the infected postpneumonectomy space has been popularized by Pairelero
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and his colleagues at the Mayo Clinic. This is a two-stage procedure. The first stage consists of reopening the thoracotomy wound and leaving it open. If the cavity is markedly purulent, it is left alone until it starts to clear up, which generally requires 5 to 7 days. If the cavity is not too purulent and a bronchopleural fistula is present, the fistula is closed primarily and covered with a serratus anterior muscle. The wound is then left open and packed daily for 6 weeks to 3 months. The second stage is obliteration of the pleural space by filling it with an antibiotic solution and then closing the wound in layers.
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Fig. 59-8. A residual empyema cavity after a lower lobectomy. |
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Fig. 59-9. Flap closure of a lower lobectomy empyema cavity with the latissimus dorsi and serratus anterior muscles. |
Pairelero (personal communication, 1998) reported on 62 patients treated in this manner. The age range was from 29 to 77 years, with a mean age of 60. Hospitalization ranged from 4 to 137 days, with a median of 34. Thirty-eight patients had a bronchopleural fistula and 24 did not. There were 8 postoperative deaths (13%). Of the 38 patients with a bronchopleural fistula, 33 (87%) healed well and 5 (13%) failed to heal. In the total of 62 patients, 44 patients had their chest totally closed at a second stage. In this group, 34 patients healed completely, but 9 failed to heal and 1 was lost to follow-up.
In the total group of 62 who underwent the procedure, 17 never had the second stage performed and the chest was left open. Reasons for this were as follows: carcinoma (5), respiratory failure (5), recurrent bronchopleural fistula (3), cardiac hemorrhage (2), infarction (1), and refusal (1). This technique is a highly effective procedure but is associated with prolonged hospitalization and a significant mortality.
In summary, the principles of dealing with a pneumonectomy space are the same regardless of the technique used. The infected space must be drained and sterilized. A bronchopleural fistula, if present, must be closed and covered with autologous material. The space must then be obliterated with muscle or antibiotic solution.
POSTRESECTIONAL LOBECTOMY EMPYEMA
Our group's algorithm for the treatment of the postresectional empyema space after lobectomy is given in Fig. 59-7. The basic principles that apply to the pneumonectomy space apply to the management of the empyema space after resectional lobectomy. In general, a persistent lower lobectomy space (Fig. 59-8) can be easily closed and filled by application of the serratus anterior and latissimus dorsi flap. This is illustrated in Fig. 59-9. If a bronchopleural fistula is present, it is closed by myoplasty, using a pedicled intercostal muscle flap, followed by obliteration of the space with the latissimus dorsi and serratus anterior muscles. If an upper lobe space persists following lobectomy, with or without bronchopleural fistula, the fistula is closed with a pedicle intercostal muscle flap, followed by a reverse pectoralis major turnover flap into the superior space through the second intercostal space.
REFERENCES
Abrashanoff: Plastische Methode der Schliessung von Fistelgangen, welche von inneren Organen kommen. Zentralbl Cir 38:186, 1911.
Clagett OT, Geraci JE: A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 45:141, 1963.
LeRoux BT, et al: Suppurative diseases of the lung and pleural space. Part 1. Empyema thoracis and lung abscess. Curr Probl Surg 23:6, 1986.
Lynn RB: The bronchial stump. J Thorac Surg 36:70, 1958.
Mathes SJ, Nahai F: Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis: CV Mosby, 1982.
Miller JI, et al: Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 38:227, 1984.
Stafford EG, Clagett OT: Postpneumonectomy empyema: neomycin instillation and definitive closure. J Thorac Cardiovasc Surg 63:771, 1972.
Teixera J: The present status of thoracic surgery in tuberculosis. Dis Chest 53:19, 1968.
Reading References
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Eggers C: Radical operation for chronic empyema. Ann Surg 77:327, 1923.
Fowler GR: A case of thoracoplasty for the removal of a large cicatricial fibrous growth from the interior of the chest, the result of an old empyema. Med Record 44:938, 1893.
Graham EA, Bell RD: Open pneumothorax: its relation to the treatment of acute empyema. Am J Med Sci 156:939, 1918.
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