10 YEARS EXPERIENCE WITH OPEN-WINDOW THORACOSTOMY OR ELOESSER FLAP

ERCİYES UNİVERSİTY THORACİC SURGERY DEPARTMENT

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 PARAPNEUMONİC EFFUSİONS.

Other less common causes of ET include .Thoracic surgical procedures .Trauma

.Malignant pleural effusion .Esophageal perforation .Foreign body .Chest wall infections .Tuberculosis and .Subdiaphragmatic abscesses

Optimal effective treatment for ET requires control of the infection with antibiotics, evacuation of the pus and reexpansion of the lung.

İnitially, most patients are treated by nonsurgical modalities including ;

.Repeat aspiration thoracentesis .İmage- 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

In those debilitated patients with chronic empyema thoracis, extensive thoracoplasty and sophisticated muscle transfer techniques may be poorly tolerated.

For those patients who may be too ill to tolerate a major thoracotomy, we advocate open surgical drainage with the Modified Eloesser Flap (MEF).

Patients and Methods A retrospective review was performed on the

available charts of 18 consecutive patients who underwent the MEF procedure at Gevher Nesibe Hospital of Erciyes University from 1998 to 2008.

Mean age was 58 ± 14 years (range 41 to 71 years old); 16 (89%) were men and 2 (11%) were women.

Before surgical intervention, empyema thoracis was confirmed in all patients by one of the following criteria:

1- Aspiration of grossly purulent pleural fluid during .Thoracentesis

.İmage- directed catheters, .Thoracostomy

2- Biochemical evidence of plural fluid defined as pH less than 7.20, lactate dehydrogenase level greater than 1000IU/L, glucose level less than 40 mg /dL and white blood cell count (WBC) greater than 500/ml or

3- Positive pleural fluid microbiology culture or gram stain revealing organism.

Preoperatively, all patients underwent conventional chest roentgenography, computed tomography and standard laboratory evaluation.

Fiberoptic bronchoscopy scanning were performed most of the patients.

All patients in this series received various therapeutic interventions before the modified Eloesser Flap (MEF).

Common therapeutic modalities that were used included .İmage-directed catheter .Thoracente sis .Tube thoracostomy . VATS .Decortication

All patients underwent the modified Eloesser procedure as described by Symbas and associates ın 1971 for the treatment of nontuberculous pleural empyema in adults.

The modification consisted of making an inverted “U” base incision rather than the original “U” base incision as proposed by Dr.Eloesser in 1935. The inverted “U” incision is based at the most inferior portion of the thoracic empyema space.

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

The base of the flap is 3 to 4 cm wide, and lies over the most dependent part of the cavity; its length is 3 to 4 cm or equal to the width of one to two ribs and their intercostal spaces

Portions of one or two 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

The soft tissue portion of the chest wall overlying the abscessed cavity is then resected completing the unroofing of the empyema cavity. The U- shaped skin flap is reflected onto the most dependent portion of the abscessed cavity and sutured to the cavity’s floor

The edges of the skin are marsupialized onto the surrounding soft tissue, and a sterile dressing is applied

Table 1. Surgical İndication for the Modified Eloesser Flap

Cause Number of patients (%)

Parapneumonic 12 (% 66) Malignant pleural effusion 4 (% 22)

Postresectional 1 (% 5 )

Tuberculosis related 1 (% 5)

The most common organisms from

preoperative pleural fluid or intraoperative empyema tissue cultures were gram-negative organisms (mainly Pseudomonas and E.coli ) and gram- positive organisms (mainly Staphylococcus and streptococcus )

Using the MEF, adequate drainage was successful in all patients and there were no intraoperative deaths or complications.

In all of these patients ,the MEF was viable and granulating well or healed.

We followed –up these patients at least 3 months.

We have confirmed that in a selected patient population the MEF is a safe , effective surgical technique for the treatment of advanced ET.

Thank you so much