Ann Thorac Surg 2003;76:401-406
© 2003 The Society of Thoracic Surgeons
Original article: general thoracic
Twenty-six years of experience with the modified eloesser flap
Vinod H. Thourani, MDa,
R. Todd Lancaster, BSa,
Kamal A. Mansour, MDa,
Joseph I. Miller, Jr, MDa*
a The Joseph B. Whitehead Department of Surgery, Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
* Address reprint requests to Dr Miller, Division of Cardiothoracic Surgery, Crawford Long Hospital, Medical Office Tower, 6th Floor, 550 Peachtree St, Atlanta, GA 30365 USA.
Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.
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Abstract
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BACKGROUND: Empyema thoracis is a common thoracic problem with a multitude of therapeutic options. The modified Eloesser flap (MEF) is one means of dealing with this problem in selected complicated patients. The purpose of this study is to report our 26-year experience with the MEF.
METHODS: A review of 78 patients who had a MEF from 1975 to 2001 was performed.
RESULTS: There were 52 males (67%) and 26 females (33%). Mean age was 59 ± 14 years. The overall length of stay was 26 ± 27 days, while mean postoperative length of stay was 16 ± 17 days. Microbiology of the empyema cavity revealed a predominance of gram-positive organisms. Before a modified Eloesser flap, all patients failed initial conservative interventions and 23 patients (29%) failed surgical interventions. Operative indications were as follows: parapneumonic effusions, 35 patients (45%); postresectional, 23 patients (29%); tuberculosis related, 7 patients (9%); malignant effusion, 4 patients (5%); esophageal fistulas, 4 patients (5%); abdominal sepsis, 3 patients (4%); and hemothorax secondary to trauma, 2 patients (3%). The inverted-U incision was performed in all patients. Average rib resection was 3 ± 1 ribs. There were no intraoperative complications and adequate drainage was achieved in all patients. Thirty-day morbidity/mortality was 4 patients (5%): 3 died of sepsis and 1 died of metabolic encephalopathy; although long-term follow-up (mean: 109 ± 141 months) revealed no additional morbidity related to the MEF.
CONCLUSIONS: We demonstrate that MEF can be performed as a safe, definitive surgical procedure for the treatment of chronic empyema thoracis. The MEF remains an important option in the surgical treatment of chronic, complicated empyema thoracis.
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Introduction
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Despite the recent advances in medical technology, empyema thoracis (ET) remains a debilitating disease process with considerable morbidity and mortality. The most common cause of ET is parapneumonic effusions; other less common causes of ET include thoracic surgical procedures, trauma, esophageal perforation, cystic fibrosis, foreign body, chest wall infections, tuberculosis, and subdiaphragmatic abscesses [1, 2]. Optimal effective treatment for ET requires control of the infection with antibiotics, evacuation of the pus, and reexpansion of the lung [3].
Initially, most patients are treated by nonsurgical modalities, including repeat aspiration thoracentesis, image-directed catheters, and tube thoracostomy. In the case of failed nonsurgical modalities or chronic, multiloculated ET, traditional surgical approaches including decortication, video-assisted thoracoscopic surgery, rib resection, and open drainage with or without a musculoskeletal flap reconstruction have been used [4, 5].
In those debilitated patients with chronic empyema thoracis, extensive thoracoplasty and sophisticated muscle transfer techniques may be poorly tolerated. Among this patient population, the surgical technique first introduced by Leo Eloesser in 1935 [6] and later modified by Symbas and colleagues in 1971 [7] provides an alternative procedure for the evacuation of the empyema thoracis. In the present series, we describe our 26-year experience at one institution with the modified Eloesser flap (MEF) in patients with chronic empyema thoracis.
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Patients and methods
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A retrospective review was performed on the available charts of 78 consecutive patients who underwent the MEF procedure at Crawford Long Hospital and Emory University Hospital of Emory University from 1975 to 2001. The distribution of patients in 5-year intervals was: 1957 to 1979, 8 patients; 1980 to 1984, 9 patients; 1985 to 1989, 10 patients; 1990 to 1994, 23 patients; 1995 to 1999, 19 patients; and 2000 to 2001, 9 patients. Mean age was 59 ± 14 years (range 23 to 82 years old); 52 (67%) were men and 26 (33%) were women.
Before surgical intervention, ET was confirmed in all patients by one of the following three criteria: (1) aspiration of grossly purulent pleural fluid during thoracentesis, image-directed catheters, tube thoracostomy, or thoracotomy; (2) biochemical evidence of pleural fluid defined as pH less than 7.10, lactate dehydrogenase level greater than 1000 IU/L, glucose level less than 40 mg/dL, protein level greater than 2.5 g, and white blood cell count (WBC) greater than 500/mL; or (3) positive pleural fluid microbiology culture or Gram stain revealing organisms. All patients in this series had chronic empyema thoracis.
Preoperatively, all patients underwent conventional chest roentgenography and standard laboratory evaluation. As deemed by the surgeon, pulmonary function testing, chest computed tomography, and fiberoptic bronchoscopy scanning were performed in the most all of patients. All patients in this series received various therapeutic interventions before the modified Eloesser procedure. Common therapeutic modalities that were used included image-directed catheter, thrombolytics, tube thoracostomy, empyema tube, and decortication.
Patient’s charts were retrospectively reviewed for age, sex, presenting symptoms, past medical history, past thoracic surgical history, history of ethanol or tobacco use, empyema etiology, preoperative chest roentgenogram findings, white blood cell count (admission and discharge), operative indications, and operative technique. Inhospital outcomes included length of stay, days on the ventilator, and morbidity and mortality. Long-term follow-up was attained on 65 patients (88%) with a mean follow-up time of 109 ± 141 months.
All patients underwent the modified Eloesser procedure as described by Symbas and associates [7]. In brief, the patient is turned in a lateral decubitus position, with the involved chest up. The empyema cavity is located (Fig 1),
either by a previously placed drainage tube, or through an intraoperative posterolateral minicotomy incision after needle localization. An incision is made so as to create an inverted U-shaped flap of skin and subcutaneous tissue over the empyema cavity (Fig 2).
The base of the flap is 2 to 4 inches wide, and lies over the most dependent part of the cavity; its length is 2 to 3 inches or equal to the width of two to three ribs and their intercostal spaces (Fig 3).
Portions of two or three of the ribs (dependent upon the size of the empyema cavity and the obesity of the patient) just beneath the U-shaped incision are dissected subperiosteally and removed (Fig 4).
The soft tissue portion of the chest wall overlying the abscessed cavity is then resected completing the unroofing of the empyema cavity. After achieving hemostasis and obtaining optimal air seal of the surrounding lung tissue, the U-shaped skin flap is reflected onto the most dependent portion of the abscessed cavity and sutured to the cavity’s floor (Fig 5). The edges of the skin are marsupialized onto the surrounding soft tissue, and a sterile dressing is applied (Fig 6).
In the current series, the inverted "U" incision was utilized in all patients. Postoperative care of the cavity included once-a-day packing with wet-to-dry gauze for approximately 3 months. Thereafter, the cavity can generally be irrigated once daily unless a bronchopleural fistula is present. In which case, continued packing with wet-to-dry gauze is performed secondary to the continued drainage.
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Fig 2. Proposed incision for modified Eloesser flap is illustrated. The proposed inverted "U" incision is in the left chest.
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Fig 6. Cross-sectional view of the drained empyema cavity and the completed modified Eloesser flap with tongue flap sewn to the base of the empyema cavity.
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Results
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The most common presenting symptoms of the patients undergoing the MEF include dyspnea (44 patients, 56%), chronic fever (39 patients, 50%), weight loss (38 patients, 49%), and lethargy (38 patients, 49%); results are illustrated in Table 1.
The most common etiologies for the empyema requiring the modified Eloesser are parapneumonic effusions (35 patients, 45%) and postthoracotomy resectional empyemas (23 patients, 29%), illustrated in Table 2.
The majority of the postthoracotomy resectional empyemas in the current series were patients transferred to the Emory Healthcare Hospitals after undergoing surgical procedures elsewhere. The presenting white blood cell count for all patients was 14 ± 7 (x1000/µL), whereas the discharge white blood cell count was 10 ± 4 (x1000/µL). The most common organisms from preoperative pleural fluid or intraoperative empyema tissue cultures were gram-positive organisms (mainly Staphylococcus and Streptococcus) and gram-negative (mainly Pseudomonas and Haemophilus) organisms (Table 3).
The most common preoperative interventions were antibiotic therapy (69 patients, 88%), image-directed catheters (11 patients, 14%), tube thoracostomy (60 patients, 77%), and surgical interventions (decortication or VATS; 23 patients, 29%). Intraoperative and inhospital outcomes are presented in Table 4.
Adequate drainage was successful in all patients and there were no intraoperative deaths or complications. Short-term follow-up (within 1 month postoperative) revealed 4 deaths: 3 from sepsis and 1 from metabolic encephalopathy. Of the remaining 74 patients, long-term follow-up (mean: 109 ± 141 months; median: 34 months) was available on 65 patients (88%), which revealed ten additional deaths ranging from 2 months to 2 years from surgery. In all of these patients, the MEF was viable and granulating well or healed.
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Comment
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In 1935, while at San Francisco, Leo Eloesser reported an operation for tuberculous empyema and drainage of the infected pleural space [6]. He described a technique for the creation of the flap, in which he constructed a one-way valve allowing air and purulent material to exit and preventing the entry of air into the pleural space. As originally performed, a "U" base flap over the most dependent portion of the wound of the infected cavity was created after the empyema cavity had been appropriately drained. After the underlying segments of two to three ribs were excised, the skin flap was sutured to the underlying thoracic cage. In a follow-up article nearly 35 years after his original publication, Dr. Eloesser [8] notes that antibiotics and antituberculous drugs have modified the usefulness of the Eloesser flap, but that the basic assumptions that prompted the operation remain valid, including the tenets that the pleura resents a foreign intruder and reacts with infection and that successful function of the flap is due to its valve action. Air escapes from the valve opening more readily than it enters, that this valve mechanism maintains negative pressure in the pleural cavity in spite of the partially open drainage, and that this negative pressure, in turn, causes the underlying lung to expand until, reaching the chest wall, it seals the inner opening of the flap drainage and obliterates the emypema [8].
In 1971, Panagiotis Symbas from Emory University [7], reported a MEF in the treatment of nontuberculous pleural empyema in adults. Over a 5-year period, Symbas and colleagues reported on 34 patients who underwent the modified Eloesser procedure with good functional results in 30 patients. The modification consisted of making an inverted "U" base incision rather than the original "U" base incision as proposed by Dr. Eloesser. The inverted "U" incision is based at the most inferior portion of the thoracic empyema space. Once the cavity is totally drained and the underlying ribs resected, the tongue flap is then tacked to the inferior-most aspect of the drained space. In the current series, we have adopted the MEF in all patients utilizing the inverted "U" based incision. Using the MEF, we have obtained complete drainage of the empyema space in all patients.
Nonsurgical treatment modalities including antibiotics, repeat thoracentesis, or tube thoracostomy are adequate for most patients in whom ET has not organized (exudative stage). However, closed-chest drainage with antibiotics is ineffective once the empyema organizes into the fibrinopurulent stage. In that patient population, more invasive surgical procedures (eg, decortication) may be necessary for evacuation of the infectious process and to release the entrapped lung. Moreover, there are patients with empyema thoracis, particularly with bronchopleural fistulas, who commonly require a chest wall collapse type of procedure for control of infection and closure of the fistula. 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 [9].
For those patients who may be too ill to tolerate a major thoracotomy or with advanced multiloculated empyemas, we advocate open surgical drainage with the MEF [10]. In those patients where the closure of the fistula could not be accomplished with this technique, the modified Eloesser procedure is still of benefit because the infection is controlled and the bronchopleural fistula is converted to a bronchocutaneous one [7]. If deemed appropriate, the patient may undergo thoracomyoplasty following the modified Eloesser procedure once control of the empyema cavity has been performed and the patient is more tolerable of a major operation [11].
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. If the patient is medically unstable, closed chest tube thoracostomy can be converted to an open modified Eloesser’s flap [10].
The Claggett window is used as part of the second stage of the planned three-staged Claggett procedure as practiced at the Mayo Clinic [10], in which the final stage is when the chest if filled with antibiotic solution and the flap closed. In approximately 33% of the patients, the flap is never closed. The Eloesser procedure is intended as a permanent, one-stage procedure and is specifically for those debilitated patients thought not to be a candidate for a muscle flap.
In the current large cohort of empyema patients, we have confirmed that in a select patient population the MEF is a safe, effective surgical technique for the treatment of advanced empyema thoracis. The modified Eloesser procedure remains as an important option in the armamentarium for thoracic surgeons participating in the surgical treatment of chronic, complicated ET.
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Discussion
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DR PETER PAIROLERO (Rochester, MN): Doctor Mavroudis, thank you very much for the invitation to represent the American Board of Thoracic Surgery at the 2002 Annual Meeting of the Southern Thoracic Surgical Association. I also want to thank Dr Thourani and his associates for an excellent presentation and for bringing to our attention the problems of empyema. As we all know, empyema still remains the scourge of thoracic surgery, and despite all the advances in therapy over the years, recalcitrant empyema problems persist. For some patients, an open pleural window is the only way to manage this problem. And for these patients this, indeed, is an excellent choice.
Although the authors reported a 5% operative mortality in their study, the cause of death was not as much related to the procedure as it was to delay in management and the underlying disease process. That being said, their results are excellent. The issue now, however, is that their patients have a large hole in the chest wall leading to the pleural cavity, both of which must be cleaned at leased daily. I think it is logical to ask what is the next step?
In my opinion, the cavity can be obliterated and the chest wall closed in nearly every patient. Usually this can be accomplished with a combination of procedures including filling the pleural space with an antiobiotic solution, intrathoracic muscle transposition, decortication and even thoracoplasty. I would like to ask the authors what was the long-term follow-up in their patients? How many of your patients still have an open window? And what are your plans for closing the window?
And, finally, a historical note! While this procedure is named after Leo Eloesser who reported this procedure in 1935, Dr Eloesser was not the first surgeon to describe this operation. Samuel Robinson first reported open pleural drainage in 1916 in a patient with non-tuberculous empyema (Surg Gynecol Obstet 1916;22:557–71). Even more amazing is that Dr Robinson closed and obliterated the pleural cavity with intrathoracic transposition of the latissimus dorsi muscle.
Again, I would like to thank the Association for the privilege of discussing this paper.
DR THOURANI: Doctor Pairolero, thank you for those eloquent comments and also for the great insight. Most of these patients did remain with an open drainage site, which granulated quite nicely over time. On rare occasions, a patient would develop a small bronchocutaneous fistula, which was easily controlled. In the occasion that the patient’s debilitated conditions were greatly improved and a large cavity remains, methods of muscle or omentum transposition was utilized to fill in that area. In our series, this was performed rarely.
DR CLINTON E. BAISDEN (Temple, TX): I want to thank you for doing this study. I can tell you that as I look around the room, I am one of the residents that participated with some of these patients, and I think there are a whole lot of other people that were either trained or influenced by Dr Miller, Dr Symbas, and Dr Mansour.
A question, I have always wondered, when I went through my training in ’80 to ’83, it seems like there were quite a few patients that we had that we did the modified Eloesser procedure on, and I often wondered what happened to them long term. So I appreciate you doing this study.
A question I would have, though, I was wondering if the incidence of this procedure has declined with time? It seems like in my practice at least it has, and I wonder if the reason might be related to intrapleural fibrinolytics that we use early now sometimes and maybe we don’t have as many patients that get to the point that they have a complicated empyema that needs this type of treatment?
Thank you for your paper. It was very nice.
DR THOURANI: Thank you also for those kind comments, Dr. Baisden. It has been generally 2 to 3 patients a year. As was evident by this presentation, over 26 years we have accrued 78 patients. It has been relatively standard across the years. As TB is becoming probably a little more prevalent, it is a possibility that we will have more Eloesser procedures to do if the TB is not appropriately treated with medication or earlier surgical intervention.
DR BRYAN F. MEYERS (St. Louis, MO): I enjoyed your presentation, too. Regarding your indications slide, the indications for doing this procedure seem to overlap with the indications for a decortication, and I didn’t catch in your presentation how Emory would discriminate between the two operations. I imagine there are 10 or 20 decortications for every instance this procedure is used, and with the exception of the post-pneumonectomy patients, it is unclear to me how you selected the patients for the Eloesser flap.
DR THOURANI: Thank you for those questions Dr Meyers. It is really truly different indications. In those cases where decortication could be performed to relieve the entrapped lung, we would obviously choose that option. An Eloesser flap was performed in those chronic empyema patients where entrapped lung was not an issue, if they were debilitated and would not tolerate a full thoracotomy, or had a posterior empyema cavitiy in which a posterior-placed chest tube would not be feasible.
DR CONSTANTINE MAVROUDIS (Chicago, IL): With your permission I am going to ask Dr. Pairolero to come to the podium again, and I would like to ask him, what is his method of closing these flaps, what kind of muscle flaps do you use, and what is your experience?
DR PAIROLERO (Rochester, MN): I like to fill the space with something, and basically it depends upon where the empyema is. In the lower spaces it is very hard to put muscle into that area there because very few muscles reach that area, but the muscles that can be used are all of the chest wall muscles, the pectoralis major, the serratus anterior, and the omentum works very well for filling in cavities in the lower space. The other thing you can do is it is a combination. Sometimes you can sort of use local thoracoplasties, filling with antibiotics and just covering the space by itself, and a good number of these patients will do well if there is no destructive lung disease in it. It is a dealer’s choice.
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References
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- Deschamps C., Allen M.S., Trastek V.F., Pairolero P.C. Empyema following pulmonary resection. Chest Surg Clin N Am 1994;4:583-592.[Medline]
- Magovern C.J., Rusch V.W. Parapneumonic and post-traumatic pleural space infections. Chest Surg Clin N Am 1994;4:561-582.[Medline]
- LeMense G.P., Strange C., Sahn S.A. Empyema thoracis: therapeutic management and outcome. Chest 1995;107:1532-1537.[Abstract/Free Full Text]
- Thourani V.H., Brady K.M., Mansour K.A., Miller J.I., Jr, Lee R.B. Evaluation of treatment modalities for thoracic empyema: a cost-effective analysis. Ann Thorac Surg 1998;66:1121-1127.[Abstract/Free Full Text]
- Miller J.I., Jr The history of surgery of empyema, thoracoplasty, Eloesser flap, and muscle flap transposition. Chest Surg Clin N Am 2000;10:45-53.[Medline]
- Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935;60:1096-1097.
- Symbas P.N., Nugent J.T., Abbott O.A., Logan W.D., Hatcher C.R., Jr Nontuberculous pleural empyema in adults. Ann Thorac Surg 1971;12:69-78.[Medline]
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- Miller J.I., Mansour K.A., Nahai F., Jurkiewicz M.J., Hatcher C.R., Jr Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984;38:227-231.[Abstract]
- Miller J.I., Jr Postsurgical empyema. In: Shields T.W., LoCicero J., III, Ponn R.B., eds. General Thoracic Surgery, 5th edition Philadelphia, PA: Lippincott Williams & Wilkins, 2000:709-716.
- García-Yuste M., Ramos G., Duque J.L., et al. Open-window thoracostomy, and thoracomyoplasty to manage chronic pleural emypema. Ann Thorac Surg 1998;65:818-822.[Abstract/Free Full Text]
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Abstract
Introduction
