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Ann Thorac Surg 1997;64:220-225
© 1997 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Long-Term Complications of Extraperiosteal Plombage

Department of Thoracic Surgery, University Hospital of Strasbourg, Strasbourg, and Department of Thoracic Surgery, Hôpital Sainte Marguerite, Marseille, France

Accepted for publication January 28, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. As soon as complications due to migration of extraperiosteal plombage material had been documented, early removal became the rule. Some patients who have escaped this rule may still present with long-term complications.

Methods. Since 1980, 14 patients aged 54 ± 10 years were admitted 28 ± 11 years after collapse therapy. Eight presented with signs of infection, 4 with hemoptysis, and 2 with periscapular pain. Vascular erosion, suspected in 3 patients, was demonstrated with angiograms in 1.

Results. Ablation of the material was combined with excision of the devitalized ribs in 13 patients. Femorofemoral bypass was used in 2 patients for repair of an aortic erosion. Single ablation of subcutaneously migrated material was performed in a poor-risk patient. Operative bleeding was moderate except in 2 patients; 1 of them died intraoperatively during repair of an aortic erosion. A second patient died postoperatively with a massive pulmonary embolus on day 11. Infection was diagnosed in 8 patients (Mycobacterium tuberculosis, 4; and pyogens, 4). Operative outcome was satisfactory in all 12 operative survivors. A single patient presented with an infected apical space at 1 year and underwent complementary resection of the first rib.

Conclusions. We recommend routine ablation of any residual plombage material whenever operative risk is acceptable because of the high incidence of spontaneous complications.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
See also page 224.

See also page 225.

Extraperiosteal plombage, the so-called birdcage operation, was developed during the era of collapse therapy for tuberculosis, mainly to avoid the burden of repeated injections of air as required for artificial pneumothorax. This operation further was employed instead of thoracoplasty to treat failures of pneumothorax, to avoid the cosmetic and functional sequelae of thoracoplasty in younger patients. The procedure was performed through a thoracoplasty incision in the paravertebral area, carried through the trapezius and rhomboideus muscles. Once the scapula had been lifted upward, the periosteum and intercostal muscles were stripped off the ribs, as for a thoracoplasty, and pushed inward. This extraperiosteal collapse was maintained through insertion of plombage material, which was packed between the denuded ribs and the surface of pneumolysis [1]. The rather tough layer of parietal pleura, periosteum, and intercostal muscles was thought to prevent erosion of the underlying lung by the material. Various materials such as rubber bags or sheetings, paraffin packs, Polystan sponges, and fiberglass had been used, but Lucite balls were elected as the preferred material. These were translucent methyl methacrylate balls with a diameter about 2.5 cm.

The enthusiasm for this procedure was greatest during the years 1948 to 1955, when the several advantages over thoracoplasty were convincing [2]. The birdcage operation could be performed in a single stage, whereas thoracoplasty used to be performed in two stages in fragile patients. Therefore, and in addition because there was no paradoxical respiration, the procedure could be extended to poor-risk patients, to aged patients, and to patients with bilateral disease. The collapse could be very selective, and the hospital stay could be reduced. However, these expectations were frustrated by a relatively high complication rate of at least 16%. These complications were mainly infection of the plombage space, hemorrhage through vascular erosion, and breach of the underlying parenchymal cavitation leading to an extrapleural spread of tuberculosis. Therefore, the rule was established that the plombage material should be removed on a routine basis. The removal of the plombage material required a combined thoracoplasty to obliterate the extraperiosteal space. Thus, the main advantage of the procedure, namely, avoidance of thoracoplasty, was eliminated. Eventually, major antituberculous drugs ended the hazards of collapse therapy [2].

Some rare patients did not undergo routine removal of the plombage material for various reasons and are still alive; their referral to the thoracic surgeon is usually mandated by acute complications [3]. This study was designed to review operative experience with these patients during the most recent years. Our data are expected to help out thoracic surgeons of the younger generation with operative decision-making in these rarely presenting, but challenging patients.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Patients
From January 1980 to December 1995, 14 patients presented with long-term complications after plombage thoracoplasty at our two institutions. These were 8 men and 6 women, with a mean age of 54 ± 10 years (range, 26 to 68 years; median, 56 years). The plombage procedure was right-sided in 6 and left-sided in 8 patients. The delay between the plombage procedure and the current referral averaged 28 ± 11 years (range, 5 to 48 years; median, 29 years). Most of the patients presented with findings suggestive of superinfection of the plombage space: 8 had a recent swelling of the supraclavicular area or along the thoracotomy scar, and Lucite balls were palpated beneath the skin in 4 of them; fever was noted in 5 patients. Needle aspiration disclosed pus in 6 of these patients; a seventh had a bloody effusion. Four patients had repeated hemoptysis, and 2 complained of periscapular pain.

Angiographic studies were performed in 6 patients with clinical findings suggestive of vascular involvement. Vascular erosion was suspected in 3 patients because of the immediate paraaortic location of one or more Lucite balls, together with a parietal hematoma in 1. In 1 patient, needle aspiration disclosed a hemorrhagic effusion with bright red fluid. A final 2 had severe hemoptysis. Angiographic studies were positive in a single patient with several intercostal arterial erosions.

Surgical treatment was indicated on a routine basis, either because symptoms were important (n = 12) or to prevent further complications (n = 2).

Methods
The charts were reviewed for operative details, microbiology, postoperative outcome, and long-term follow-up. Data were expressed as mean ± standard error, range, and median.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Surgical Procedure
In 13 patients, ablation of all material and thoracoplasty were performed as a standard approach. The surgical procedure was carried out through the previous thoracoplasty incision, which was extended anteriorly if required. After removal of the plombage material (13 to 36 Lucite spheres of varying sizes per patient), a formal thoracoplasty removing four to seven ribs was performed to obliterate the remaining space. The first rib was resected routinely in all but 1 patient. A common finding was that the ribs were fragile and decalcified, and on occasion partially interrupted. Intraoperative fluoroscopy was performed to ascertain that all material had been removed.

In 2 patients with aortic erosion, femorofemoral cardiopulmonary bypass was initiated; the aortic repair was performed under profound hypothermia with cardiocirculatory arrest. In a patient with several vascular erosions, a cutdown of the humeral artery was performed preoperatively; a Fogarty catheter was positioned at the take-off of the right subclavian artery in an attempt to reduce intraoperative blood loss. In a single poor-risk patient, ablation of subcutaneously migrated material was performed under local anesthesia.

Operative blood loss averaged 1,970 ± 3,199 mL (range, 250 to 11,000 mL; median, 1,125 mL) for the 11 patients who have undergone the full procedure without cardiopulmonary bypass. Massive intraoperative bleeding (11,000 mL) was encountered in a patient with multiple intercostal erosions, despite balloon occlusion of the right subclavian artery. One of the 2 patients operated on under cardiopulmonary bypass died intraoperatively of diffuse intravascular coagulopathy.

Microbiology and Pathology
Microbiologic examination disclosed an obvious infection in 8 patients: 4 had acid-fast bacteria, which were identified as Mycobacterium tuberculosis on culture, and 4 had pyogenic infections due to Staphylococcus aureus in 2, Klebsiella species in 1, and Streptococcus pneumoniae in 1. Two patients had a sterile exudate, and 3 patients had a sterile hemorrhagic effusion. There were no fungal superinfections.

Pathologic examination disclosed chronic inflammatory changes in all patients. None had undergone malignant change.

Mortality and Morbidity
There were two perioperative deaths. One of them occurred intraoperatively. This patient had an erosion of the aortic arch, whose repair had been attempted under profound hypothermia and circulatory arrest. Diffuse intravascular coagulopathy developed, and the patient eventually died of exsanguination. A second patient died with massive pulmonary embolism 11 days after the operation, following an initially uncomplicated outcome.

Chest tubes were maintained for 13 ± 9 days (range, 2 to 28 days; median, 10 days). When infection was assumed or proven, tubes were left for at least 7 days as a rule to perform lavages of the thoracoplasty space.

Postoperative hospital stay averaged 23 ± 13 days (range, 13 to 59 days; median, 20 days) for operative survivors. The length of the hospital stay was directly related to the duration of drainage; no further significant complication occurred.

Follow-up
All 12 operative survivors were seen at the outpatient clinic at 6 and 12 months postoperatively. Eleven patients had a satisfactory result, without any residual extrapleural space. The patient who had undergone a limited procedure under local anesthesia remained stable, without any findings suggestive of further migration of material or superinfection. An empyema developed in a residual cavity below the first rib, which had been left in place, in a final patient. This rib was resected 13 months after the initial procedure; outcome was satisfactory with 27 months of follow-up. Further follow-up was deferred to the referring physician, and data are incomplete except in 5 patients. Three were alive and well at the conclusion of this study. Two others had died with acute respirtatory failure at 37 months and 81 months respectively; 1 of them had posttransfusion hepatitis C with subsequent cirrhosis.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Spontaneous complications of plombage procedures such as superinfection, migration of material, and erosion of adjacent organs and structures have been well known and documented by surgeons dealing with tuberculosis during the 1950s and 1960s [1,4–6]. Usually, the stripped periosteum regenerated some osseous tissue at the floor of the collapse space. However, early after insertion of the material, the material could erode the relatively smooth pleural and muscular layers leading to early broncho-extrapleural fistulas; radiologic findings have been extensively described earlier [6]. In the long term, such complications became rare owing to osteogenesis.

Superinfection with Mycobacterium tuberculosis or common pyogenes has been the most frequent complication. In particular, tuberculous empyema is expected in those patients treated previously without any major antituberculous chemotherapy. In opposition to artificial pneumothorax, where sterile late exudative complications are common [7, 8], most patients have positive microbiological results.

The first sign usually is an acute onset of swelling of the collapse space (Fig 1). Owing to the intracavitary tension, the devitalized ribs offer little resistance to the plombage, which may directly erode the ribs. Mechanical osteolysis explains that the plombage material may appear in the superficial parietal layers and thus be palpable under the skin in many patients, either on the thoracoplasty scar or in the periclavicular area (Figs 2 through 5). The tract of migration is easily recognized at operation. Fistulization to the skin was precipitated when general surgeons unaware of this type of patients made incisions into "subcutaneous abcesses" [9].

View larger version (148K): [in this window] [in a new window]   Fig 1. . This posteroanterior chest view demonstrates an acute swelling of the extraperiosteal collapse space; Lucite balls lose contact owing to abundant fluid production.

View larger version (121K): [in this window] [in a new window]   Fig 2. . Coronal tomogram in a patient with bilateral extraperiosteal plombage. Note the slight erosion of the chest wall on the left side.

View larger version (91K): [in this window] [in a new window]   Fig 3. . Computed tomographic scan demonstrates costal erosion in the left subscapular fossa.

View larger version (117K): [in this window] [in a new window]   Fig 4. . Clinically obvious subcutaneous migration of plombage material as evidenced by computed tomographic scan.

View larger version (133K): [in this window] [in a new window]   Fig 5. . Magnetic resonance imaging study of the same patient as Figure 4 demonstrates Lucite balls in the superficial parietal layers.

View larger version (135K): [in this window] [in a new window]   Fig 6. . Mediastinal migration of a Lucite ball creating compression of the airways at the carinal level.

View larger version (140K): [in this window] [in a new window]   Fig 7. . A normal angiogram does not rule out vascular erosion. This patient underwent repair of an aortic tear under cardiopulmonary bypass with total circulatory arrest.

View larger version (120K): [in this window] [in a new window]   Fig 8. . Substraction angiogram reveals multiple intercostal arterial erosions, which have resulted in an intraoperative blood loss of 11,000 mL.

The treatment in the standard case is well established [1–3]. The surgical approach is made through the previous thoracoplasty incision, which may be extended anteriorly when more exposure is required. All plombage material has to be removed. On occasion, one or more balls may be imbedded in the floor of the collapse space and covered by calcified tissues. Therefore, even when the initial operative report is available and the number of Lucite spheres is indicated, we recommend routine intraoperative fluoroscopy to ascertain that there is no material left in place. The devitalized ribs are excised, including the first rib in our practice [1]. Leaving the first rib in place might lower the deformity of the shoulder girdle but maintains an apical extrapleural cavity, which may secondarily become infected. In fact, an extrapleural abcess actually developed in the only patient from this series in whom the first rib was left behind, requiring reoperation. Calcification of the floor of the collapse space usually determines a peripheral rim, which has to be trimmed away to prevent any residual space disease. The operative wound is closed in layers over a double drainage put to suction. In case of infection, lavages are made during at least 7 to 10 days. When erosion of the aorta or major vessels is anticipated, angiograms are mandatory. Suggestive findings include hemoptysis, hemorragic effusion, and closeness of balls to mediastinal structures on computed tomographic scan. Intraoperatively, femorofemoral bypass should be available in these cases. It is usually impossible to dissect out the aorta and to clamp it adequately, and hence repair has to be made under hypothermic cardiocirculatory arrest. We routinely perform bronchoscopy and esophagography to ascertain the integrity of these structures.

Although the surgical indication is obvious when complications are present, we recommend routine ablation of the material in any patient without major operative risk. Respiratory tolerance of the operation is generally excellent, because lung and pleura remain untouched; postoperative outcome merely depends on the patient's general health status. A minimal operation under local anesthesia should be restricted to poor-risk patients.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Massard, Department of Thoracic Surgery, University Hospital of Strasbourg, F-67091, Strasbourg, France.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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This Article Abstract 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): Gilbert Massard Pascal Thomas Pierre Riera Roger Giudicelli Eugène Reboud Georges Morand Pierre A. Fuentes Jean-Marie Wihlm Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Massard, G. Articles by Wihlm, J.-M. Search for Related Content PubMed PubMed Citation Articles by Massard, G. Articles by Wihlm, J.-M. Related Collections Related Articles