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234 Postpneumonectomy empyema
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After incision of the muscular attachment
6d
at the scapular tip, the scapula is elevated.
6d
Now, the muscular attachments on the costal
6e
distal to proximal. Again, the most proximal attachment
should be preserved. At the end of this step only the vascular
pedicle is left. The most cranial insertions on the first two ribs
and the upper part of the costal surface of the scapula should
be preserved to avoid winging of the scapula.
surface of the scapula are divided with cautery from
6e
Between 5 and 10 cm of the
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6f
in the midaxillary line as a portal of
entry into the thorax.
second or third rib are resected
Operation 235
THE OMENTUM FLAP
The disadvantage of omentopexy is the lack of bulk and the
necessary laparotomy. The greater omentum may not be
available if prior abdominal surgery has been performed, particularly gastric or colonic procedures.
The right gastroepiploic artery is larger than the left one
6f
and, therefore, should be preserved. However, in left-sided
fistulas it is sometimes beneficial to preserve the left gastroepiploic artery. The omentum is brought up into the thoracic cavity through an opening made around the costal
origin of the diaphragm. Rib resection may be necessary to
prevent compression.
236 Postpneumonectomy empyema
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After a superior subcostal
7a
reflected over the stomach. The
posterior fold of the omentum is
released from the colon.
incision, the omentum is
7a
The omentum is returned
7b
cavity, and the anterior fold is
released from the greater curvature of the stomach, preserving
the gastroepiploic arch. Depending on the side of the fistula,
the contralateral gastroepiploic
artery is divided and the flap
mobilized. On the right side the
omentum is mobilized to within
5cm of the gastric pylorus to preserve the blood supply of the
antrum. On the left side immobilization is performed to within
3 cm of the avascular zone.
to the inferior abdominal
7b
Operation 237
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7c
An opening at the diaphragmatic
insertion is created.
7c
238 Postpneumonectomy empyema
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The omentum is pushed into the
7d
stump, the mediastinum, and the diaphragmatic gap with interrupted sutures.
thorax and fixed to the bronchial
Open window thoracostomy
This method is the procedure of choice to control sepsis originating from empyema. Even debilitated patients may
undergo this minor operation. Window thoracostomy may
also be combined with muscle flap closure of a bronchopleural fistula. In the latter case the initial rethoracotomy
is left open (modified Clagett procedure).
7d
Two ribs are resected over a
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8a
racic cavity is opened and debrided. The
opening should be big enough to allow
insertion of wet dressings up to the apex
thoracis once or twice a day, until the
pleural space granulates.
length of 10–12 cm, and the tho-
Operation 239
8a
The skin is then sutured to the
8b
the inner surface of the postpneumonectomy space. The rib stumps should be
short enough so that they can also be covered with skin fixed to the inner surface of
the thorax.
thick fibrous layer that covers
8b
240 Postpneumonectomy empyema
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At the end of the operation the thoracic cavity is packed
with gauze dipped in an antiseptic solution. The dressing is
changed once or twice a day depending on the severity of
infection, and this procedure can be performed in bed with
anesthesia. When infection has subsided, the thoracostomy
can be closed.
THE CLAGETT PROCEDURE
The Clagett procedure requires open window thoracostomy
with daily change of dressings until infection subsides and the
thoracic cavity starts to granulate. After filling the hemithorax
with an antibiotic solution, the thoracostomy is closed.
Although very popular in the United States, the Clagett procedure has the disadvantage of a long duration of treatment,
the need for a second surgical intervention and a high recurrence rate of 40%. When multiple bacterial organisms cause
the infection, the success rate is about 20%. Up to a third of
all patients will not be amenable to chest wall closure because
of tumor recurrence or respiratory failure.
POSTPNEUMONECTOMY EMYPEMA WITHOUT
BRONCHOPLEURAL FISTULA
If BPF is ruled out, a less aggressive approach is justified.
Simple drainage with antibiotic irrigation
After chest tube drainage, the tube is irrigated with antibiotics
according to culture sensitivity between two and three times a
day. After instillation, the drain is clamped for several hours.
One major drawback of simple irrigation is the fact that
debridement of the empty hemithorax is not achieved. Even if
infection has subsided, the remaining intrathoracic debris
still harbors organisms as a potential source for late recurrence. Additionally, antibiotic irrigation of the postpneumonectomy space can be a lengthy procedure until sterility of
the thoracic cavity is achieved.
Videothoracoscopy
Videothoracoscopic debridement of the postpneumonectomy space is a simple procedure which is well tolerated by
any patient. Videothoracoscopy alone does not allow the
exclusion of a fistula diagnosis, as the bronchial stump is
often covered with a thick layer of granulation tissue, making
visual localization impossible, especially if the fistula is small.
Therefore, bronchoscopy is mandatory before videothoracoscopy. If a fistula is diagnosed, open operation should be
performed.
Videothoracoscopy is performed in the supine position. A
camera port and a working port are inserted cranially to the
thoracotomy scar. Intrathoracic debris is mobilized and
removed with a long plastic suction unit, endoscopic forceps,
a swab on a stick, or with a sharp spoon. The pleural space is
rinsed at the end of the procedure, and a chest tube is inserted
at the most caudal point of the thorax. If videothoracoscopy
or irrigation fail, infection is controlled by open wide
debridement, total thoracoplasty, or muscle plombage of the
postpneumonectomy space.
POSTOPERATIVE CARE
Postoperative pulse oximetry is mandatory. A decrease in
oxygen saturation may result from fistula recurrence with
consecutive aspiration and requires bronchoscopy and reoperation. The most probable reason for this complication is
flap necrosis due to kinking or tension, both technical flaws,
or progressive stump necrosis.
If the bronchial stump is tight, empyema may still recur or
persist. This situation is heralded by fever and a rise of WBC
and CRP and also requires reoperation.
In the ward the empty hemithorax is irrigated with antibiotic solution via the chest tube according to culture results
twice a day, starting on the first day after operation. After
instillation, the drain is clamped for 3 hours; and the patient,
if capable, is encouraged to leave bed. Repeated radiological
examination of the chest reveals pneumonia due to silent
aspiration and the development of multiple fluid levels in the
empty hemithorax, which may be an early sign of empyema
recurrence. The drainage volume is recorded every 24 hours.
A decrease of drainage volume indicates successful empyema
control.
Cultures should be obtained twice a week. After three consecutive negative cultures, the infection may be considered
eradicated, and the drain is removed. Thereafter, the patient
is kept in hospital for another week, CRP and WBC being
measured regularly. If no clinical signs of infection or fistula
recurrence exist and the blood results are within normal levels, the patient is discharged.
OUTCOME
If the patient escapes aspiration pneumonia, early BPF can be
successfully closed by muscle or omentum in 80–90% of
cases. In late fistulas the success rate by various treatments lies
within 60%.
The results of treatment of isolated PPE are difficult to
interpret, since very few cases are published. Wong et al
achieved permanent healing in eight of 13 patients after a
mean irrigation time of 12 weeks. Videothoracoscopic treatment of simple PPE was successful in five consecutive
patients without recurrence.
FURTHER READING
Hollaus PH, Lax F, El-Nashef B, Hauck HH, Lucciarini P, Pridun NS.
Natural history of bronchopleural fistula after pneumonectomy: a
review of 96 cases. Annals of Thoracic Surgery 1997; 63: 1391–7.
Further reading 241
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Hollaus PH, Lax F, Wurnig PN, Pridun NS. Videothoracoscopic treatment
of postpneumonectomy empyema. Journal of Thoracic and
Cardiovascular Surgery 1999; 117: 397–8.
Pairolero PC, Phillip GA, Trastek VF, Meland NB, Kay PP, Arnold PG.
Postpneumonectomy empyema: the role of intrathoracic muscle
transposition. Journal of Thoracic and Cardiovascular Surgery 1990;
99: 1958–68.
Smith DE, Karish AF, Chapman JP, Takaro T. Healing of the bronchial
stump after pulmonary resection. Journal of Thoracic and
Cardiovascular Surgery 1963; 46: 548
Wong PS, Goldstraw P. Post-pneumonectomy empyema. European
Journal of J Cardiothoracic Surgery 1994; 8: 345–50
Empyema, spaces and fistula. Chest Surgery Clinics of North America
1996; 6: 503–71.
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22
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Decortication of the lung
C. PETER CLARKE MB, BS, FRACS, FACS
Professorial Fellow, Department of Surgery, University of Melbourne; Senior Thoracic Surgeon, Austin Health, Heidelberg, Victoria, Australia
HISTORY
Jason of Greek mythology developed a fever and wasting and,
fearful of dying in bed, led his force into battle. An assailant
speared him in the chest, releasing a gush of pus, and with
renewed energy he ungratefully slew his nameless surgeon
and went on to make a complete recovery. Hippocrates
(460–377 BC) gave a remarkably accurate account of
empyema. He noted that if patients survived two weeks, they
should have dependent drainage and packing of the wounds.
Serefeddin Sabuncouglu (1385–1470) was a military surgeon
in the Persian Empire who had a good understanding of
empyema occurring after penetrating chest wounds and at
the age of 80 wrote a masterly text on surgery entitled
‘Imperial Surgery’.
After this promising start, surprisingly little progress was
made in the understanding and management of empyema
until the nineteenth century. In 1843, Trousseau introduced
the concept of thoracentesis by needle aspiration, and Hewitt
proposed closed pleural drainage in 1876.
In chronic situations when the lung was trapped and would
not re-expand, the initial approach was to manage the cavity
by open drainage or thoracoplasty. In 1893, Fowler reported
the first successful decortication for empyema. The term
decortication was popularized in 1896 by Delorme, who gave
a clear description of the procedure designed to remove the
thick parietal and visceral pleura, and allow the lung to reexpand to fill the thoracic space and the chest wall to regain
its mobility.
PRINCIPLES AND JUSTIFICATION
Decortication is most commonly performed for established
empyema or fibrothorax, and less commonly for trapped
lung in patients with an effusion and malignancy. The usual
cause of an empyema is parapneumonic infection, and an
empyema occurs in approximately 5% of cases of pneumonia
with an associated effusion. Other causes are trauma, complications of surgery, and specific infective situations, for example, tuberculous or a lung abscess. A hemothorax after
trauma, if undrained, eventually results in a trapped lung due
to a thick fibrous layer, the so called ‘fibrothorax’.
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