ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Shin-ichi Takeda
Masayoshi Inoue
Noriyoshi Sawabata
Hajime Maeda
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Okumura, Y.
Right arrow Articles by Maeda, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Okumura, Y.
Right arrow Articles by Maeda, H.
Related Collections
Right arrow Pleura

Ann Thorac Surg 2005;79:1857-1861
© 2005 The Society of Thoracic Surgeons

Original article: General thoracic

Surgical Results for Chronic Empyema Using Omental Pedicled Flap: Long-Term Follow-Up Study

Yoshitomo Okumura, MD, Shin-ichi Takeda, MD*, Hiroki Asada, MD, Masayoshi Inoue, MD, Noriyoshi Sawabata, MD, Hiroyuki Shiono, MD, Hajime Maeda, MD

Department of Thoracic Surgery, Toneyama National Hospital, Toyonaka, Osaka, Japan

Accepted for publication January 3, 2005.

* Address reprint requests to Dr Takeda, Toneyama National Hospital, Toneyama 5-1-1, Toyonaka 560-8552, Japan (E-mail: stakeda{at}toneyama.hosp.go.jp).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Successful treatment of chronic empyema remains a challenge for thoracic surgeons. Herein, we report our 17 years of experience with the omental pedicled flap procedure for management of chronic empyema secondary to pulmonary tuberculosis.

METHODS: We retrospectively reviewed the surgical results of 23 patients who underwent surgical treatment for chronic empyema using an omental pedicled flap from 1987 to 2003.

RESULTS: The subjects were 20 men and 3 women (mean age, 58.1 years) with average % vital capacity (VC) and forced expiratory volume in 1 second (FEV1) values of 48.1% and 1.19 L, respectively. Sixteen patients (69.6%) had bronchopleural fistulas and 21 (91.3%) were associated with infection by causative organisms (6 Aspergillus organisms, 4 methicillin-resistant Staphylococcus aureus, 10 others). An open window thoracostomy preceded in 17 patients (72.9%). Eleven patients were treated using an omental pedicled flap with or without a muscle flap, and 12 were treated using an omental pedicled flap with a partial thoracoplasty. There was 1 operation-related death, and clinical success was achieved in 19 patients (82.6%), in whom pulmonary function did not decrease significantly. During long-term follow-up, 5 patients died of respiratory failure, and their mean postoperative %VC and FEV1 values were 30.1% and 0.76 L, respectively.

CONCLUSIONS: We concluded that the use of an omental pedicled flap for chronic empyema was effective even in cases with active infection, and did not compromise pulmonary function. Further, an additional thoracoplasty may completely obliterate the dead space, although indications should be referenced to preoperative pulmonary function.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Successful treatment of chronic empyema remains a concern for thoracic surgeons. The chronic empyema secondary to pulmonary tuberculosis includes a sequel of underlying substrate of tuberculous infection, because of its prolonged and complicated course including marked pleural thickening, and bronchopleural fistula with a mixed infection. Several operative procedures including decortication, thoracoplasty, pleuropneumonectomy [1], muscle flap instillation, and air plombage [2] have been employed, with only limited success, however, in cases with active infection. An additional aspect of the therapeutic difficulties may be a limited pulmonary functional reserve in patents with chronic empyema owing to the nature of the disease.

The omentum is known to play a protective role in abdominal inflammation, such as gastrointestinal perforation [3, 4], and has been used for cardiothoracic problems [4, 5], including lung transplantation [6], tracheal reconstruction [7], and bronchopleural fistula [8], because of its advantages of angiogenesis, healing promotion, and soft-tissue coverage in cases with an existing infection. Since our initial success with a 70-year-old patient who had previously undergone multiple surgical interventions for pleuropulmonary tuberculosis, we have used an omentum pedicled flap (OPF) procedure for the management of chronic empyema in 23 selected patients. In the present study, we retrospectively reviewed our series of patients who underwent an OPF procedure for managing chronic empyema secondary to pulmonary tuberculosis. From our findings, we discuss the usefulness, indications, and limitations of our method, with particular focus on long-term outcome as well as pulmonary function.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
From 1987 to 2003, a total of 131 consecutive patients received a radical operation for chronic empyema at Toneyama National Hospital, of whom 120 had chronic empyema secondary to pulmonary tuberculosis and 11 had postoperative empyema. A one-stage operation was performed in 6 patients, whereas the other 125 were treated with a two-stage operation using an open-window thoracostomy followed by radical procedures. Decortication was performed in 43 (33.4%), decortication with muscle plombage in 21 (16.8%), muscle plombage in 11 (8.8%), a thoracoplasty (excluding 12 with OPF) in 8 (6.4%), a pleuropneumonectomy in 15 (12.0%), and air plombage [2] in 3 patients (2.4%). In particular, omentum use was indicated and performed in 23 patients (18.4%), including 12 who also underwent an additional thoracoplasty during this period.

We retrospectively evaluated the 23 patients who underwent an OPF procedure. They included 20 men and 3 women (Table 1), ranging in age from 21 to 72 years old (mean 58.1). Radical surgery for chronic empyema is employed at our institution by first employing decortication in cases without a bronchopleural fistula, and then adding muscle plombage when dead space remains. In cases with a bronchopleural fistula, we use a muscle flap to close the fistula with or without decortication.


View this table:
[in this window]
[in a new window]
  		Table 1. Clinical Profile of 23 Patients
 
Patients were selected for undergoing OPF procedure if they met one of the following criteria: (1) recurrent bronchopleural fistula after radical surgery for empyema; (2) failure to control infection due to multiresistant tuberculosis, Aspergillus, or methicillin-resistant Staphylococcus aureus (MRSA); (3) prevention of thoracic deformity in patients with poor pulmonary functional reserve; and (4) failure to eliminate empyema dead space due to malnutrition or previous surgery. Namely, an OPF procedure was applied for patients with intractable empyema that was difficult to treat with other procedures.

Sixteen patients (69.6%) had a bronchopleural fistula, and 21 (91.3%) were associated with infection by causative organisms. For the current series of patients, we adopted a two-stage operation in principle, with an open-window thoracostomy preceding in 17 (72.9%). The two-stage operations were performed as follows. An open-window thoracostomy followed by daily gauze dressing was done, and then a radical operation was performed 2 to 12 months after the initial surgery. Briefly, adequate curettage or decortication was performed in the empyema space, regardless of the extent of lesions through the posterolateral thoracotomy. To prepare the omentum pedicle flap, a short median laparotomy was performed, and the greater omentum was freed from the greater curvature of the stomach, while preserving the right gastroepiploic artery. A hole was created in the diaphragm below the sternum, and the omentum flap was drawn into the thoracic cavity without difficulty. After the abdomen was closed, the omental flap was fixed to the target fistula with or without additional muscle plombage in terms of the thoracic cavity. Twelve of the 23 patients required an additional partial thoracoplasty to obliterate the considerable empyema dead space, and 8 of those received a partial thoracoplasty with preservation of the ribs and intercostal muscles as reported by Wilms [9].

Complete records were available for all of the patients, including preoperative and postoperative pulmonary function, and were reviewed for patient demographic data, clinical presentation, causative organisms, patient treatment, and outcome. Pulmonary function tests were performed preoperatively and 6 months postoperatively. Clinical success was defined as an empyema space that was cured without dead space or infection 6 months postoperatively. Results are given as the mean ± SD. Comparisons before and after the OPF procedure were made using a paired t test. Comparisons among the groups were made by analysis of variance (ANOVA) and the Newman-Keuls test. A probability level of less than 0.05 was regarded as statistically significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Patient profiles are summarized in Table 1. All had a history of pulmonary tuberculosis. Attempts to identify the causative organism in the thoracic fluid or open-window space revealed that 21 patients (91.3%) had causative organisms, including Aspergillus in 6 cases, MRSA in 3, atypical Mycobacterium species in 2, Mycobacterium tuberculosis in 1, and other bacteria in 9 (Table 1).

Postoperatively, there was 1 operation-related death, which was due to a muscle flap infection followed by sepsis; 3 patients were complicated by ileus; and 1 had gastrointestinal bleeding (Table 1). Another 6 patients suffered from minor abdominal complaints such as abdominal distension, diarrhea and anorexia. According to the criteria of success for empyema at 6 months after surgery, 2 patients had empyema due to residual dead space and 1 died within 30 days. Overall clinical success was obtained for 19 patients (82.6%); however, 5 patients (2 without a thoracoplasty and 3 with an additional thoracoplasty) died of respiratory failure in the remote period (Table 1). Regarding pulmonary function, % vital capacity (VC) and FEV1 were not changed significantly at 6 months after surgery in the 22 patients who underwent the OPF procedure (Table 2).


View this table:
[in this window]
[in a new window]
  		Table 2. Changes in Pulmonary Function of Patients with OPF: OPF Without Thoracoplasty, OPF With Thoracoplasty, and OPF Who Died of Respiratory Failure
 
Preoperative and postoperative pulmonary function results are listed in Table 2, including the 9 patients who survived without a thoracoplasty, the 8 who survived with a thoracoplasty, and the 5 patients who died later of respiratory failure. Compared with the OPF patients with or without thoracoplasty, the 5 patients who died showed significantly lower pulmonary function both preoperatively and postoperatively, as the preoperative mean %VC and FEV1 were 37.1% and 0.94 L, respectively, and the postoperative values were 30.1% and 0.76 L, respectively. Postoperatively, %VC decreased significantly (p = 0.023) in 8 surviving OPF patients after receiving an additional thoracoplasty (Table 2).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
A variety of options are available for managing chronic empyema, with an OPF procedure indicated for patients with chronic empyema that is otherwise intractable. In addition, patients with associated mixed MRSA infection, which is difficult to completely eliminate with a muscle flap alone, have been proposed as good candidates for an OPF procedure. However, the impact and late outcome after use of such a procedure for managing chronic empyema with intractable infection have not been fully evaluated.

In the setting of chronic empyema, two-stage procedures are usually performed for severely ill patients [10–14], and we believe that a radical curative operation should be attempted after reduction of bacteria of the empyema cavity and recovery of the general condition of the patient. In addition, the therapeutic effects of the OPF procedure for chronic empyema have been limited compared with those for postoperative empyema [11, 12, 15–17]. According to the criteria of surgical success in the intermediate stage, the present overall results are acceptable (success rate, 82.6%), although we do not have data from another alternative for direct comparison.

We consider the limitations of an OPF procedure to be as follows. First, the omentum volume may not be sufficient to eliminate the empyema space for patients, particularly with malnourished chronic empyema. Second, the OPF procedure is not applicable for patients who have undergone previous abdominal surgery or who have abdominal morbidity.

Yokomise and associates [13, 15] reviewed unsuccessful OPF procedure cases, and concluded that the procedure should be applied after the empyema space had been near sterilized, because in cases with insufficient sterilization, muscle filling and thoracoplasty were required to completely obliterate the dead space. To improve the operative results, Laisaar and colleagues [16] also emphasized that an OPF procedure together with a partial thoracoplasty [9] was safe and effective for patients with chronic empyema.

As for drawbacks of an OPF procedure, 4 of 23 patients showed omentum-related abdominal complications in our series, although they eventually recovered, and the operative results were not affected. Considering the risk, however, meticulous care should be taken during omentum harvest and placement to minimize any technical problems.

In contrast to patients with postoperative empyema [10, 18, 19], our empyema patients had a poor pulmonary function reserve, as the mean %VC value of 48.1% for all 23 patients was lower than those in previous reports of empyema surgery. Patients with poor lung function required home oxygen therapy in the later period and died of respiratory failure. In particular, patients with a poor pulmonary functional reserve have a risk of remote respiratory failure, as shown in Table 2. Failures were seen in patients with preoperative %VC values of less than 40% or FEV1 values of less than 1.0 L, regardless of an additional thoracoplasty being performed. In patients with severely compromised pulmonary function, an open-window thoracostomy may be also an alternative.

Because of the deleterious effects on pulmonary function caused by the standard thoracoplasty procedure [18–20], we used a partial thoracoplasty (Wilms method) [9], to preserve pulmonary function by preserving the bony chest wall, and found that pulmonary function was mildly decreased. However, the superiority of the Wilms method as compared with a standard thoracoplasty has not been not elucidated. Nevertheless, in light of the high long-term mortality rate in the present patients with poor lung function, such a radical approach should not outweigh the loss of functional reserve. Even if a partial relapse develops, the patient can survive with an improved quality of life without respiratory failure developing.

We conclude that the present OPF procedure was an effective radical method, even if residual infection was present, and it did not cause a decrease in pulmonary function for chronic empyema patients. However, preoperative reduction of bacterial infection is recommended to obtain the advantage of the method. Further, an additional thoracoplasty may completely obliterate the dead space, although indications should be referenced to preoperative pulmonary function.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
The authors wish to thank Dr Morihisa Kitano, former Chief of the Department of Thoracic Surgery, Tenri Hospital, Tenri, Japan, for critical review of the manuscript.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Emerson JD, Boruchow IB, Daicoff GR, Bartley TD, Wheat MW. Empyema J Thorac Cardiovasc Surg 1971;62:967-972.[Medline]
  2. Iioka S, Sawamura K, Mori T, et al. Surgical treatment of chronic empyema. A new one-stage operation J Thorac Cardiovasc Surg 1985;90:179-185.[Abstract]
  3. Jurkiewicz MJ, Arnold PG. The omentum. An account of its use in the reconstruction of the chest wall Ann Surg 1977;185:548-554.[Medline]
  4. Mathisen DJ, Grillo HC, Vlahakes GJ, Daggett WM. The omentum in the management of complicated cardiothoracic problem J Thorac Cardiovasc Surg 1988:677-684.
  5. Shrager JB, Wain JC, Wright CD, et al. Omentum is highly effective in the management of complex cardiothoracic surgical problems J Thorac Cardiovasc Surg 2003;125:526-532.[Abstract/Free Full Text]
  6. Lima O, Goldberg M, Peters WJ, et al. Bronchial omentopexy in canine lung transplantation J Thorac Cardiovasc Surg 1982;83:418-421.[Medline]
  7. Fujiwara K, Nakahara K, Fujii Y, Takeda S, Minami M, Matsuda H. Effect of omentopexy on wound healing of the extensively detached and anastomosed canine trachea Surgery 1994;115:227-232.[Medline]
  8. Iverson LIG, Young JN, Ecker RR, et al. Closure of bronchopleural fistulas by an omental pedicle flap Am J Surg 1986;152:40-42.[Medline]
  9. Wilms M. Die Pfeilerresektion der Rippen zur Verengerung de Thorax be Lungentuberculose Therap Gegenw 1913;54:17-24.
  10. Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Yamagishi H, Satake S. Surgical treatment for chronic empyema Surg Today 2000;30:506-510.[Medline]
  11. Shirakusa T, Ueda H, Takata S, et al. Use of pedicled omental flap in treatment of empyema Ann Thorac Surg 1990;50:420-424.[Abstract]
  12. Shimizu J, Oda M, Hayashi S, et al. Evaluation of surgical treatment of pyothorax with special reference to the usefulness of the omental pedicle flap method Eur J Cardiothorac Surg 1993;7:543-547.[Abstract]
  13. Yokomise H, Takahashi Y, Inui K, et al. Omentopexy for postpneumonectomy bronchopleural fistulas Eur J Cardiothorac Surg 1994;8:122-124.[Abstract]
  14. Shamji FM, Ginsberg RJ, Cooper JD, et al. Open window thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula J Thorac Cardiovasc Surg 1983;86:818-822.[Abstract]
  15. Yokomise H, Fukuse T, Ike O, et al. Unsuccessful omentopexy in thoracic surgery Thorac Cardiovasc Surg 1997;45:145-148.[Medline]
  16. Laisaar T, Ilves A. Omentoplasty together with partial thoracoplastya one-stage operation for postpneumonectomy pleural empyema. Ann Chirurg Gynaecolog 1997;86:319-324.
  17. Levashev YN, Akopov AL, Mosin IV. The possibilities of greater omentum usage in thoracic surgery Eur J Cardiothorac Surg 1999;15:465-468.[Abstract/Free Full Text]
  18. Nakaoka K, Nakahara K, Iioka S, Mori T, Sawamura K, Kawashima Y. Postoperative preservation of pulmonary function in patients with chronic empyema thoracisa one-stage operation. Ann Thorac Surg 1989;47:848-852.[Abstract]
  19. Huang CT, Lyons HA. Cardiorespiratory failure in patients with pneumonectomy for tuberculosis. Long-term effects of thoracoplasty J Thorac Cardiovasc Surg 1977;74:409-417.[Medline]
  20. Hopkins RA, Ungerleider RM, Staub EW, Young Jr WG. The modern use of thoracoplasty Ann Thorac Surg 1985;40:181-187.[Abstract]



This article has been cited by other articles:


Home page
 Eur. J. Cardiothorac. Surg.Home page
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]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Shin-ichi Takeda
Masayoshi Inoue
Noriyoshi Sawabata
Hajime Maeda
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Okumura, Y.
Right arrow Articles by Maeda, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Okumura, Y.
Right arrow Articles by Maeda, H.
Related Collections
Right arrow Pleura

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS