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Video-Assisted Thoracoscopic Management of Post-Pneumonectomy Empyema

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Video-Assisted Thoracoscopic Management of Post-Pneumonectomy Empyema JSLS Video-Assisted Thoracoscopic Management of Post-Pneumonectomy Empyema Francis J. Podbielski, MD, Ari O. Halldorsson, MD, Wickii T. Vigneswaran, MD ABSTRACT INTRODUCTION Background: Post-pneumonectomy empyema is a major Post-pneumonectomy empyema occurs in a small percent- therapeutic challenge in thoracic surgery. The presence or age of patients and continues to be a major therapeutic chal- absence of a concomitant bronchopleural fistula directs lenge. Etiology of this problem includes bronchopleural fis- treatment of this condition. When there is no bron- tulae, wound dehiscence, or a persistent nidus of colonized chopleural fistula the condition is classically treated with pleura. Clinical manifestations with spiking fever, purulent thoracostomy drainage, irrigation and antibiotic instillation sputum production, and generalized malaise are the prelude with closure. This approach is, however, associated with a to appearance of a new air-fluid level or loss of fluid level significant rate of primary failure. Alternative modified and/or loculation in a previously homogeneous hemithorax techniques involve opening the thoracic cavity widely with on chest roentgenogram. Patients rarely present with mild serial debridement followed by interval closure. Multiple constitutional symptoms and wound dehiscence or empye- surgical procedures often require a protracted hospital stay. ma necessitans. Methods: We describe a technique in three patients utiliz- The goals of treatment are control of infection, closure of ing video-assisted thoracoscopic surgery for debridement the bronchopleural fistula if present and obliteration of the and closure of the pneumonectomy cavity. cavity. Treatment algorithms segregate post-pneumonecto- my empyema into those with versus those without con- Conclusion: Advantages of this technique include comitant bronchopleural fistula. Early infections with bron- debridement under direct visualization, low morbidity, and chopleural fistula are managed by debridement of the potential for a shorter hospital stay. bronchial stump with closure and reinforcement of the repair with vascularized tissue.1 Once the pneumonectomy Key Words: Post-pneumonectomy empyema, Video- space is clean it is filled with antibiotic solution and closed. assisted thoracoscopic surgery (VATS) Failure of this technique necessitates filling the cavity with muscle tissue transposition with or without thoracoplasty.2 Patients without bronchopleural fistula have been treated successfully with open drainage, irrigation, and instillation of antibiotic solution with closure. Stafford and Clagett ini- tially described this technique in 16 patients.3 Alternatively, closed drainage with continuous irrigation and interval clo- sure upon achieving sterile fluid cultures as suggested by Rosenfeldt and colleagues4 has also been successfully employed by others.5 A primary failure rate of up to 40% has been reported for these techniques, perhaps secondary to inadequate debridement of potentially infected fibrinous debris and non-viable tissue. Video-assisted thoracoscopic surgical (VATS) drainage and debridement of the pleural cavity allows complete removal of all devitalized tissue. This approach can significantly increase the probability of successful management of this University of Illinois Division of Cardiothoracic Surgery, Chicago, Illinois problem with irrigation and antibiotic instillation. We report three cases of post-pneumonectomy empyema managed Address reprint request to: Francis J. Podbielski, MD, Department of Surgery, Columbus Hospital, 2520 N. Lakeview Avenue, Chicago, IL, 60614, USA. Telephone: using VATS techniques; two without evidence of bron- (773) 388-6787, Fax: (708) 396-9869 chopleural fistula and one with a healed fistula. JSLS (1997)1:255-258 255 Video-Assisted Thoracoscopic Management of Post-Pneumonectomy Empyema, Podbielski F. CASE 1 pital one month later with fever, dyspnea, and a large amount of brownish sputum. Chest radiograph showed a A 66-year-old man presented with a right Mar mass con- drop in the previous fluid level in the right hemithorax. A firmed on bronchoscopy to be moderately differentiated bronchopleural fistula was suspected and tube thoracosto- adenocarcinoma. Following a negative mediastinoscopy, my yielded over 600 cc drainage of cloudy fluid. Pleural exploratory thoracotomy revealed a right lower lobe tumor fluid cultures grew Staphylococcus aureus. Bronchoscopy with direct inferior mediastinal invasion and deemed unre- confirmed a small area of bronchial stump dehiscence with- sectable at that time. The procedure was aborted and the out signs of tumor recurrence. Rib resection with an patient entered a course of chemotherapy and radiation. Eloesser flap 'window' was performed and the empyema Computed tomograms performed midway in the treatment space irrigated with antiseptic solution at his weekly out- protocol showed significant tumor regression. A repeat patient clinic visit. right posterolateral thoracotomy and pneumonectomy was then performed. The bronchial stump was reinforced with Four months later the patient was referred for further eval- an azygous vein and intercostal muscle pedicled flap. uation. Bacterial cultures of the drainage fluid from the hemithorax were sterile. Bronchoscopy demonstrated a The postoperative course was unremarkable until five healed bronchial stump and no evidence of tumor. Using months later when he presented to the clinic complaining the access provided by the Eloesser flap, a thorough VATS of a mass in the anterior aspect of his thoracotomy wound. debridement and irrigation of the hemithorax was per- The chest radiograph that had previously been homoge- formed. This procedure was repeated on four occasions in nous now showed a decreased fluid level with multiple loc- the ensuing ten days. In the intervening period the cavity ulations. A thoracostomy tube was placed and 800 cc of was continuously irrigated with antibiotic solution. At the turbid fluid drained over the next three days. conclusion of the ten-day course, satisfied with the debride- Bronchoscopy demonstrated an intact bronchial stump and ment of the pleural space, the hemithorax was filled with no evidence of tumor recurrence. After placement of a tho- the same antibiotic cocktail employed in Case 1 (except flu- racic epidural infusion catheter and a single lumen endo- conazole was substituted for nystatin due to a formulary tracheal tube, VATS exploration was performed through the change) and the subcutaneous tissue and skin closed in slightly enlarged thoracostomy site. Once in the pneu- one watertight layer. monectomy space, aggressive debridement of devitalized tissue was performed under direct vision. Two size 32 The patient did well for four months but developed a recur- French thoracostomy tubes were placed into the thoracic rence of the bronchial fistula. He underwent repeat thora- cavity and irrigated thrice daily with a bacitracin solution. cotomy, closure of the fistula, and reinforcement of the The patient was returned to the operating room on the sec- stump with a transposed serratus anterior muscle pedicle ond and fourth postoperative days and VATS debridement flap. Four days later the remaining cavity was obliterated repeated under epidural analgesia from the previously with a pedicle transfer of omentum and partial thora- placed catheter. Over the following two days the patient coplasty. Patient was well for six months but died subse- defervesced and the leukocyte count returned to normal quently of cerebral metastasis. with no left shift. On postoperative day six the cavity was filled with an antibiotic cocktail solution of bacitracin, gen- CASE 3 tamicin, kanamycin, and nystatin and the subcutaneous tis- sue and skin closed in one watertight layer. A 68-year-old man with a diagnosis of right upper lobe lung cancer underwent a right pneumonectomy at an outside At the six-month clinic visit the right thoracotomy wound institution. His immediate postoperative period was report- and thoracostomy sites were clean and well healed. Chest ed as uneventful. Six months after his pneumonectomy he roentgenogram demonstrated a small apical air collection presented to our institution with purulent discharge from with no evidence of subcutaneous emphysema. The right his wound and mild constitutional symptoms. The wound hemidiaphragm was elevated with shift of the mediastinum appeared superficial, but was suspicious for an underlying to the operative side. empyema. Skin dehiscence progressed and wound explo- ration confirmed communication with the thoracic cavity. CASE 2 No bronchopleural fistula or tumor recurrence was identi- fied on bronchoscopy. A 68-year-old man underwent a right pneumonectomy for a T2NO squamous cell lung cancer. The initial postopera- Under thoracic epidural analgesia and single lumen endo- tive recovery was uneventful, but he was readmitted to hos- tracheal anesthesia a two-centimeter length of exposed rib 256 JSLS(1997) 1:255-258 was resected for the exposure of the pneumonectomy cav- inhibitors gentamicin and kanamycin is recommended. ity. VATS examination of the space was performed and all Bacitracin provides broad spectrum Gram positive and neg- devitalized tissue and infected debris removed. The cavity ative coverage against commonly isolated organisms such was packed under direct vision with antibiotic soaked as Staphylococcus aureus and Escherichia coli. gauze rolls. Re-exploration, debridement and repacking were performed twice over the following four days,
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