Ann Thorac Surg 2004;78:273-276
© 2004 The Society of Thoracic Surgeons
Original article: general thoracic
Thoracoscopic management of postpneumonectomy empyema
Dominique Gossot, MDa*,
Jean-Baptiste Stern, MDa,
Domenico Galetta, MDa,
Denis Debrosse, MDa,
Philippe Girard, MDa,
Raffaele Caliandro, MDa,
Luke Harper, MDa,
Dominique Grunenwald, MDa
a Thoracic Department, Institut Mutualiste Montsouris, Paris, France
Accepted for publication February 6, 2004.
* Address reprint requests to Dr Gossot, Thoracic Department, Institut Mutualiste Montsouris, 42 Bd Jourdan, F-75014 Paris, France
e-mail: dominique.gossot{at}imm.fr
 |
Abstract
|
|---|
BACKGROUND: Even when there is no associated bronchopleural fistula, empyema is a serious complication of pneumonectomy. Aggressive surgical treatments are usually applied. However, a minimally invasive approach might achieve satisfactory results in selected patients.
METHODS: Out of 17 patients presenting with a postpneumonectomy empyema (PPE), 11 had a thoracoscopic approach. There were 9 males and 2 females, (age, 38–74; mean, 59 years). Ten patients had no proven bronchopleural fistula (BPF). One of them had a minor (< 3 mm) BPF. Empyema was confirmed by thoracentesis and bacteriological examination. All patients had immediate chest tube drainage and underwent emergency thoracoscopic debridement of the empyema. No irrigation was used postoperatively.
RESULTS: There was no mortality and no morbidity related to the procedure. The average duration of thoracoscopic debridement was 62 minutes (range: 45–80 minutes). In 8 patients the chest tube was removed between the fifth and thirteenth postoperative day (average, 8.6 days). They were discharged between the 9th and 24th postoperative day. In 3 patients, clinical and/or biological signs of infection persisted and reoperation was decided at day 5, day 10, and day 11. All 3 patients underwent open-window thoracostomy. The average follow-up of the 8 patients who underwent only thoracoscopy was 10 months (range, 2–27 months). None had recurrent empyema. The patient who presented with a minor BPF remained asymptomatic and is doing well after a 27 month follow-up.
CONCLUSIONS: Thoracoscopy might be a valuable approach for patients presenting with PPE with or without minor bronchopleural fistula.
|
Introduction
|
|---|
Empyema of pleural space occurs in 2%–15% of patients after pneumonectomy [1]. It is a major event in the postoperative course with a substantial mortality rate. The prognosis of postpneumonectomy empyema (PPE) mainly depends on the presence or absence of a bronchopleural fistula (BPF). In cases of large BPF, it is usually admitted that urgent thoracotomy is required for closure of the fistula, lavage, and drainage of the pleural space. When BPF is absent or only minor (ie, less than 3 mm) [2], several treatments have been proposed: simple drainage followed by irrigation [3], aggressive management with rethoracotomy [4], or open-window thoracostomy combined with repeated dressings [5]. Recently, we decided—when there was no clinical or bronchoscopic evidence of BPF—to use thoracoscopy as an alternative to either thoracotomy or simple drainage and irrigation. The goal was to improve the efficiency of drainage by removing pus and any false membrane under direct vision control. The aim of this study was to state the outcome of the first 11 patients whose PPE was managed using this approach.
|
Patients and methods
|
|---|
From January 1998 to December 2003, 17 patients were operated on for empyema of the pleural cavity after pneumonectomy. Six patients with a major BPF were reoperated on by thoracotomy for closure of the fistula and reinforcement with an omentoplasty or a muscle flap transposition. Three patients had an open window-thoracostomy. In the remaining 11 patients, there was no fistula (10 patients) or bronchoscopy showed only a minor fistula (<3 mm) (1 patient). These 11 patients underwent a thoracoscopic approach and constituted the basis of this study (patients who underwent thoracoscopy for examination of the postpneumonectomy cavity but who had negative bacteriology [1 patient case of clotting and 1 patient case of chylothorax] were excluded from this study). There were 9 males and 2 females ranging in age from 38–74 (mean: 59 years). Seven patients had undergone a left pneumonectomy and 4 patients had undergone a right pneumonectomy. Time between pneumonectomy and readmission for empyema ranged from 15 days to 11 years. Whereas 9 patients had an early empyema, it occurred late in 2 patients (1 year and 11 years, respectively). Empyema of the pleural cavity was proven by direct thoracentesis and bacteriological examination (Table I).
Once confirmed, urgent treatment consisted of immediate chest tube drainage and the patient was operated within 24 hours of diagnosis.
Technique
The goal of thoracoscopy was to retrieve as much infected tissue as possible, to check that there was no fistula, and to wash and drain the cavity. It was performed with the patient in a lateral position. Two ports were used: one for the telescope and one for the working instruments. Both ports were inserted relatively low (usually at the seventh intercostal space) to obtain a general view of the whole cavity. In addition to the usual thoracoscopic instruments, the following devices were used: 5 and 10 mm suckers, endoscopic straight and curved curettes, and 10-mm curved spoon forceps. This instrument was used for retrieval of large debris and as a swab-carrier for achieving pleural cleaning. Pus was aspirated and all false membranes were debrided with the scrapers and then retrieved with the spoon forceps. In some instances, debris and false membranes were left in place when they were too adherent to the chest. The cavity was washed with an iodine solution and then with normal saline serum to verify the absence of fistula. A 30F chest tube was left in place. In the postoperative course, no irrigation was used. Antibiotics adapted to the bacteriological examination were administered for 4 weeks. In the case of persistent infectious symptoms, thoracoscopy was not repeated and an open-window thoracostomy was performed.
|
Results
|
|---|
Thoracoscopy was possible in all patients. There was no mortality and no morbidity related to the procedure. The average time of thoracoscopic debridement was 62 minutes (range: 45–80 minutes). The procedure was technically easy except in the 2 patients with late PPE, because the narrow postpneumonectomy cavity made insertion of trocars and maneuvering of instruments difficult. In 8 patients the chest tube was removed between the 5th and 13th postoperative day (mean: 9 days). Criteria for chest tube removal were the regression of clinical signs of infection, considerable decrease C-reactive protein (CRP), and two sterile successive cultures of the pleural fluid. Out of the 8 patients who had successful thoracoscopic treatment, the mean preoperative CRP level decreased from 241 (range: 152–350) to 35 (range: 3–80) at hospital discharge (Fig 1).
Patients were discharged between the 9th and 24th postoperative day after control of CRP and white blood cell count (WBC) every other day. The average follow-up of these 8 patients was 11 months (range: 2–27 months). None had recurrence of infection. One patient died 26 months later from progression of his malignant disease. The patient who presented with a minor BPF remained asymptomatic and is doing well after 27 months of follow-up.
View larger version (16K):
[in this window]
[in a new window]
|
Fig 1. Evolution of C-reactive protein (CRP) level at admission (on the left) and hospital discharge (on the right). Each symbol corresponds to one patient. (CRP was not available in the first patients of the series).
|
|
In 3 patients, clinical and/or biological signs of infection persisted and reoperation was decided at day 5, day 10, and day 11. All 3 patients underwent open-window thoracostomy. Postoperative course was uneventful and they left the hospital between the 25th and 37th day after admission. They died at 1 month, 2 months, and 26 months from progression of their disease. None of them had infection.
|
Comment
|
|---|
Empyema of the pleural cavity is a serious complication of pneumonectomy. Its incidence ranges from 2%–15% [1] and its mortality is superior to 10% [6]. When no BPF is present, or even when a minor BPF is discovered, the management of empyema is controversial. All authors admit treatment must be done urgently. However, many different techniques have been described. Some surgeons use a relatively low invasive approach, such as simple drainage followed by cyclical irrigation [3, 7] or rethoracotomy followed by daily dressings [4], whereas most favor a more aggressive treatment (ie, open-window thoracostomy sometimes combined with muscle flap closure of the pleural space) [1, 8].
In the absence of BPF, aggressive surgery is a questionable option because of its high morbidity and because it does not totally prevent recurrences. The mortality of open-window thoracostomy has been reported to be up to 29% [9] with a recurrence rate of infection up to 38% [10]. It remains the standard management in many teams—and is still used in our institution—but entails a long-lasting postoperative course. In many patient cases, the thoracostomy cannot be closed because of the poor general condition of most patients or of the bad prognosis of their malignant disease. Besides, closure may require muscle flap transposition or even thoracoplasty.
These findings have led some surgeons to consider a less invasive management. In 1981, Rosenfeld and associates demonstrated that conventional open management had no advantage over simple irrigation of the pleural cavity [3]. They reported successful results of irrigation in 5 out of 6 patients, although one of them had a BPF. Some authors who initially pled for immediate open-window thoracostomy [5] found that similar results may eventually be obtained with irrigation [10]. As mentioned by Hakim and Milstein, irrigation, if it fails, does not preclude the use of other procedures [7].
However, even though tube thoracostomy and irrigation is successful in most patients, there is something illogical about leaving false membranes and large debris in the pleural cavity. These debris may harbor germs that can cause late recurrences. Although one may assume that antibiotics and pleural irrigation will finally get over it, retrieving what can be easily debrided seems wise.
A similar reasoning has recently been held for empyema thoracis leading some surgeons to prefer a thoracoscopic approach [11–13]. Indeed, thoracoscopy makes it possible to remove most of the false membranes and debris and to wash the cavity under direct visual control. In a randomized trial comparing chest tube pleural drainage plus streptokinase and video-assisted thoracic surgery (VATS), Wait and associates demonstrated that there were considerably less recurrences in the VATS group and that chest drainage and hospital stay were also substantially shorter [14]. Although more and more authors now consider thoracoscopy as a major tool in the management of empyema thoracis—either as primary treatment or in case of failure of medical therapy—it has rarely been proposed in the management of PPE without BPF. One of the reasons may be the fear of using VATS for a serious and potentially lethal complication and of overlooking infected tissues in the regions that are difficult to reach with the thoracoscope (ie, the costodiaphragmatic recess) [2]. However, there is no evidence that success relies on complete debridement of all infected tissues. As mentioned by Wait and associates, if VATS does not accomplish as thorough a pleural cleaning as does thoracotomy, it is often successful because the bacterial load and inflammatory exudates are reduced below a critical level allowing the pleural space to recover [14].
Three publications have reported the use of VATS for PPE [2, 15, 16]. The largest series comprises 9 patients [2]. Thoracoscopic debridement was combined with postoperative irrigation. The authors had no failure with an average follow-up of 21 months.
In our series, we had 8 patient success and 3 patient failures. We may retrospectively wonder whether these 3 patients could not have been reoperated on by thoracoscopy for repeated cleaning as proposed by Ernst and Nies [16]. In their 3 patients, the authors performed 3–7 thoracoscopies without evident drawback. Because of the lack of experience with this approach, we preferred a more radical solution (ie, open-window thoracostomy). Another option in patients with persistent signs of infection could be to apply irrigation with antibiotics, as proposed by Hollaus and associates, who used this method in all 9 of their patients [2]. They did not observe any problem (such as mediastinal shifting) during irrigation.
In case of minor and asymptomatic BPF (1 patient case in our series), we made the choice to neglect it and perform thoracoscopic debridement. Postoperative course was uneventful and the patient is well with a follow-up of 27 months. This attitude is possible only if the patient does not require irrigation of the pleural space. Hollaus and associates, who systematically irrigate the cavity after thoracoscopy, prefer sealing the bronchial stump defect with fibrin glue after chest tube drainage and before thoracoscopy [2]. In a patient with PPE combined with a minor BPF (<2 mm), Urschell and associates have successfully used sclerotherapy for bronchial closure followed by VATS [17]. These options deserve evaluation and may enlarge indications of VATS for PPE with minor fistulas.
|
Conclusion
|
|---|
Although this series is too short to draw definite conclusions, it confirms the conclusion of other reports [2, 15, 16]: some patients presenting with PPE with or without minor asymptomatic BPF can be cured by thoracoscopic management. However, the method seems difficult to apply for patients with late PPE. Whether failure of this approach must lead to rethoracoscopy [16] or to a more aggressive treatment is still not clear. However, a thoracoscopic approach has three advantages: (i) it can cure most patients, (ii) chest drainage duration and hospital stay are dramatically reduced, and (iii) it does not preclude more aggressive surgical management in case of failure or relapse.
|
References
|
|---|
- Deschamps C., Pairolero P., Allen M., Trastek V. Management of postpneumonectomy empyema and bronchopleural fistula. Chest Surg Clin N Am 1996;6:519-527.[Medline]
- Hollaus P., Lax F., Wurnig P., Janakiev D., Pridun N. Videothoracoscopic debridement of the postpneumonectomy space in empyema. Eur J Cardiothoracic Surg 1999;16:283-286.[Abstract/Free Full Text]
- Rosenfeldt F., McGibney D., Braimbridge M., Watson D. Comparison between irrigation and conventional treatment for empyema and pneumonectomy space infection. Thorax 1981;36:272-277.[Abstract/Free Full Text]
- Schneiter D., Cassina P., Korom S., et al. Accelerated treatment for early and late postpneumonectomy empyema. Ann Thorac Surg 2001;72:1668-1672.[Abstract/Free Full Text]
- Goldstraw P. Treatment of postpneumonectomy empyema: the case for fenestration. Thorax 1979;34:740-745.[Abstract/Free Full Text]
- Gharragozloo F., Trachiotis G., Wolfe A., DuBree K., Cox J. Pleural space irrigation and modified Clagett procedure for the treatment of early postpneumonectomy empyema. J Thorac Cardiovasc Surg 1998;116:943-948.[Abstract/Free Full Text]
- Hakim M., Milstein B. Empyema thoracis and infected pneumonectomy space: case for cyclical irrigation. Ann Thorac Surg 1986;41:85-87.[Abstract]
- Pairolero P., Phillip G., Trastek V., Meland N., Kay P. Postpneumonectomy empyema. The role of intrathoracic muscle transposition. J Thorac Cardiovasc Surg 1990;99:958-968.[Abstract]
- Weber J., Eckersberger F., Moritz E., et al. Treatment of postpneumonectomy empyema. Thorac Cardiovasc Surg 1990;38:352-354.[Medline]
- Wong P., Goldstraw P. Post-pneumonectomy empyema. Eur J Cardiothoracic Surg 1994;8:345-350.[Abstract]
- Lackner R., Hughes R., Anderson L., Sammut P., Thompson A. Video-assisted evacuation of empyema is the preferred procedure for management of pleural space infections. Am J Surg 2000;179:27-30.[Medline]
- Cunniffe M., Maguire D., McAnema O., Johnston S., Gilmartin J. Video-assisted thoracoscopic surgery in the management of loculated empyema. Surg Endosc 2000;14:175-178.[Medline]
- Waller D., Rengarajan A. Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema. Ann Thorac Surg 2001;71:1813-1816.[Abstract/Free Full Text]
- Wait M., Sharma S., Hohn J., DalNogare A. A randomized trial of empyema therapy. Chest 1997;111:1548-1551.[Abstract/Free Full Text]
- Podbielski F., Halldorsson A., Vigneswaran W. Video-assisted thoracoscopic management of post-pneumonectomy empyema. JSLS 1997;1:255-258.[Medline]
- Ernst M., Nies C. Die thoracoskopische therapie des pleuraempyems nach pneumonektomie. Chirurg 1999;70:1480-1483.[Medline]
- Urschell J.D., Barnwell J.M., Lipman B.J. Bronchoscopic sclerotherapy combined with thoracoscopic drainage for postpneumonectomy bronchial fistula and empyema. Surg Endosc 1999;13:932-934.[Medline]
This article has been cited by other articles:
|
|
|
|
 
D. Schneiter, T. Grodzki, D. Lardinois, P. B. Kestenholz, J. Wojcik, B. Kubisa, J. Pierog, and W. Weder
Accelerated treatment of postpneumonectomy empyema: A binational long-term study
J. Thorac. Cardiovasc. Surg.,
July 1, 2008;
136(1):
179 - 185.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. F. Molnar
Current surgical treatment of thoracic empyema in adults
Eur. J. Cardiothorac. Surg.,
September 1, 2007;
32(3):
422 - 430.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Bagan, F. Boissier, P. Berna, A. Badia, F. L. Pimpec-Barthes, R. Souilamas, and M. Riquet
Postpneumonectomy empyema treated with a combination of antibiotic irrigation followed by videothoracoscopic debridement.
J. Thorac. Cardiovasc. Surg.,
September 1, 2006;
132(3):
708 - 710.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Zaheer, M. S. Allen, S. D. Cassivi, F. C. Nichols III, C. H. Johnson, C. Deschamps, and P. C. Pairolero
Postpneumonectomy empyema: results after the Clagett procedure.
Ann. Thorac. Surg.,
July 1, 2006;
82(1):
279 - 286.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
