Completion Pneumonectomy and Thoracoplasty for Bronchopleural Fistula and Fungal Empyema Joe R. Utley, MD Division of Cardiac Surgery, Spartanburg Regional Medical Center, Spartanburg, South Carolina

Achieving sterilization of the postpneumonectomy space and bronchial healing may be difficult when active granulomatous infection of the pleural space and lung parenchyma is present at the time of operation. Three patients with chronic bronchopleural fistula, fungal em- pyema, and fungal cavities of the remaining ipsilateral lobe were managed with one-stage completion pneumo- nectomy and modified eight-rib thoracoplasty. Two pa- tients had infection with Aspergillus fumigatis and l patient had Coccidioides immitis. Two patients had re- ceived mediastinal radiation after prior upper lobectomy for carcinoma of the lung. Two patients were having massive hemoptysis at the time of pneumonectomy.

chieving bronchial stump closure and control of A pleural space infection is often difficult when pneu- monectomy is performed in the presence of both pleural space and lung parenchymal granulomatous infection [l]. Experience with completion pneumonectomy for benign conditions has shown that the mortality and morbidity is high. The Mayo Clinic found 27.6% mortality and major complications in 55.2% of patients when completion pneumonectomy was performed for benign disease. The principal causes of death were related to uncontrolled hilar hemorrhage at the time of operation and multiorgan system failure after persistent pleural space infection postoperatively. The Mayo Clinic group postulated that muscle transposition to reinforce the bronchial stump and obliterate the pleural space might contribute to reducing the mortality [2].

We have performed completion pneumonectomy and simultaneous eight-rib thoracoplasty in 3 patients with postlobectomy bronchopleural fistula, fungal empyema, and active fungal infection of the remaining lobe. The purpose of this report is to describe the surgical tech- niques and management of these patients. The surgical techniques included methods for controlling the hilar vessels, reinforcing the bronchial stump, and obliterating the pleural space.

Patients and Methods The characteristics of the 3 patients are shown in Table 1. All patients had persistent fungal infection in the empy- ema cavity and in cavities in the remaining lobe that was

Accepted for publication June 19, 1992.

Address reprint requests to Dr Utley, 100 E Wood St, Suite 300, Spartan- burg, SC 29303.

Eight-rib thoracoplasty with suturing of the intercostal muscles to the bronchial stump was performed on all patients. In 2 patients a mass closure of hilar vessels and bronchus was used because of inability to individually close the vessels and bronchus due to ligneous scamng of the hilum. Antibiotic and antifungal irrigations into the operative area were used postoperatively. Chest tubes were left in place 6 to 8 weeks. All wounds healed primarily. Patients were alive without recurrent local infection or tumor at follow-up 3 to 13 years postopera- tively.

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refractory to antifungal therapy. Two patients had the additional complication of massive hemoptysis from em- pyema, lung cavities, or both. Two patients had received hilar and mediastinal radiation. In every patient no alter- native to pneumonectomy was considered a satisfactory option in managing the infection or hemoptysis.

The extensive fungal infection of the empyema cavity and the remaining lung made sterilization of the post- pneumonectomy space virtually impossible. Tissue cover- age of the bronchial stump was considered desirable to achieve healing of the bronchial closure. Thoracoplasty was performed to obliterate the pleural space and to cover the bronchus with viable muscle.

In 2 patients the effects of radiation and fungal infection had produced such ligneous scamng and induration of the Mum of the lung that individual ligation and closure of pulmonary vessels and bronchus was found to be impossible. The techniques used for closing the vessels and bronchus, performing the modified eight-rib thoraco- plasty, and covering the bronchus with intercostal muscle are shown in Figures 1 through 7. The entire hilum is transfixed with multiple mattress sutures of 3-0 Prolene (Ethicon, Somerville, NJ). As the pulmonary artery and vein are divided they are oversewn with running 3-0 Prolene. The bronchus is oversewn with interrupted 3-0 Prolene. Additional sutures are placed in the tissue sur- rounding the bronchial stump. Decortication of the pari- etal pleura is performed.

Ribs one through eight are removed subperiosteally from the costovertebral junction to just lateral to the articulation with the cartilaginous ribs. The extent of rib resection and the number of ribs resected are determined at the time of operation. Sufficient ribs are removed to allow collapse of the chest wall against the mediastinurn

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UTLEY 673 COMPLETION PNEUMONECTOMY AND THORACOPLASTY

Table 1. Patient Characteristics Patient No.

Variable 1 2 3

Age (Y) Sex Previous interventions

Prior lobectomy Original pathology Radiation

thoracoplasty performed Time since lobectomy (y) Massive hemoptysis Bronchial fistula Empyema organism Previous drainage of empyema Foreign body in empyema cavity Cavities in remaining lobe Cavities in opposite lung

Duration (y) Status

Condition when pneumonectomyl

FOUOW-UP

32 Female

Right upper Carcinoma 100 GP

2 Yes Yes Aspergillus fumigatis No Yesb Yes No

13 Alive, no tumor

56 Female

Right upper Carcinoma 50 Gy

3 No Yes Aspergillus fumigatis Yes No Yes No

3 Alive, no tumor

58 Female

Left lower Coccidioidomycosis None

10 Yes Yes Coccidioides immitis No No Yes No

3 Alive

a Sixty grays external radiation, 40 Gy interstitial radiation after lobectomy. placed at the original lobectomy in preparation for irradiation with iridium 192 after loading needles.

The foreign body was a sheet of silicone rubber material that had been

and elevated diaphragm to completely obliterate the pleu- ral space and have viable muscle in contact with the mediastinum, diaphragm, and hilar structures.

The peribronchial sutures above the bronchus, the interrupted sutures in the bronchus, and the peribron- chial sutures below the bronchus are passed through

three adjacent intercostal bundles. These sutures are tied to attach the intercostal muscles to the bronchial stump.

Chest tubes are placed into the space deep and super- ficial to the intercostal muscles. An irrigation catheter is placed beneath the intercostal muscle layer in the upper portion of the thorax. In my patients the chest tubes were left in place 6 to 8 weeks. Antibiotics and antifungal agents (amphotericin) were continuously infused into the irrigation catheter. The antibiotic and antifungal agents were determined by cultures and sensitivities of the chest

Fig 1 . The hilum of the right lung has been isolated. The empyema has been evacuated and the pleural and mediastinal adhesions divided. No plane of dissection around hilar vessels and bronchus could be identified. The divided azygos vein is shown.

- c

\

I

Fig 2 . Mattress sutures of 3-0 Prolene were placed through the hilum of the lung to include pulmona y vessels and bronchus.

674 UTLEY COMPLETION PNEUMONE~OMY AND THORACOPLASTY

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Fig 3. In the upper left portion of the figure the mut- tress sutures have been tied. The upper right portion shows that us the pulmonary artery and vein are di- vided, the vessels are oversewn with 3-0 Prolene. In the lower center of the figure the oversewing is com- pleted.

tube drainage. All patients received amphoterian solution through the irrigation catheter. The chest tubes were slowly removed after the drainage diminished, the con- sistency cleared, and absence of cavity formation was demonstrated by chest roentgenography and sinograms through the chest tubes. All wounds healed primarily, and no secondary drainage of abscesses or fluid collec- tions was required.

Results Patients were followed up 3 to 13 years. There was no recurrence of tumor in the 2 patients whose original resection was for carcinoma of the lung. There was no recurrence of infectious complications in the hemithorax. There has been no evidence of infection related to the gutter created by retention of the transverse processes of the vertebrae. One patient required bronchoscopic re-

A

Fig 4. The upper portion of the figure shows that the bronchus has been divided. In the lower portion the stump of the bronchus has been closed with interrupted 3-0 Prolene. These sutures are left long so that they m y be used to secure the intercostal muscles to the bronchus after the modified eight-rib thoracoplusty.

Fig 5. Sutures of 3-0 Prolene are pluced in the tissue surrounding the bronchial stump. These sutures will be passed through the intercostal muscles to secure the muscle to the bronchus.

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UTLEY 675 COMPLJTION PNEUMONECTOMY AND THORACOPLASTY

Fig 6. Ribs one through eight are resected subperiosteally from the costovertebral articulation posteriorly to just lateral to the junction with the cartilaginous ribs.

moval of a Prolene mattress suture from the bronchial stump 3 years postoperatively. Figures 8 and 9 show the posteroanterior chest roentgenogram of patient 1 before the operation and 6 months after the operation.

Comment In the Mayo Clinic experience with completion pneumo- nectomy, operative death caused by uncontrollable hem-

Fig 7. The left side of the figure s h m s the bronchial and peribronchial sutures being passed through the intercostal muscles. The sutures are passed through three adjacent intercostal muscle bundles. The right side of the figure shows the position of the intwcostal muscles aftw the bronchial and peribronchial sutures have been tied.

Fig 8. This is the preoperative posteroanterior chest roentgenogram of patient I . There is air in the fungal empyema at the apex of the right pleural space. The remaining Imw lobe contains numerous cavities.

orrhage typically occurred in patients with benign disease who had previous mediastinal radiation and obliteration of the pericardial space [Z]. Others have recommended intrapericardial control of the difficult pulmonary artery at the time of completion pneumonectomy [3, 41. My col- leagues and I chose not to explore the pericardial space because of concern that we might spread the fungal infection to the pericardial cavity. Obliteration of the pericardial space is common in patients having comple-

Fig 9. The chest roentgenogram of patient I 6 months after operation shows complete obliteration of the right pleural space. The left lung has remained free of active infection.

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tion pneumonectomy [2]. The technique of closure of the hilum of the lung with horizontal mattress sutures that we describe has the advantage of being applicable in virtually every situation without opening the pericardium.

Thoracoplasty for the management of postpneumonec- tomy empyema has been recommended by several authors in recent years [5, 61. Some authors have recommended leaving the first rib but resecting the costovertebral artic- ulation and portions of the transverse processes of the thoracic vertebrae [6]. We chose to resect the fust eight ribs including the first rib but to leave the costovertebral articulation undisturbed. Tube drainage of the pleural space after thoracoplasty is recommended for several weeks [6]. The pleural space was completely obliterated in all our patients with the costovertebral junction left intact. It is our impression the complete obliteration of the space is facilitated by prolonged tube drainage along with con- tinuous antibiotic and antifungal irrigation.

We were impressed by the progressive clearing of the drainage from the collapsed pleural space as antibiotic and antifungal solutions were continuously irrigated into the area. Other authors have recommended the local irrigation of antifungal solutions after pulmonary resec- tion for aspergillosis [7]. The radiation effects and scarring of the mediastinal pleura may delay the healing and obliteration of the space and diminish the local concentra- tions of systemic antibiotics and antifungal agents.

Physical deformity and incapacity due to chest wall changes have not been severe in our patients. One of our patients returned to full-time employment and has been capable of fairly strenuous activities including skiing. The degree of function in these patients has been comparable with the functional state we have observed in patients after intrathoracic transposition of extrathoracic muscle for closure of bronchial fistulas. The blood loss associated with these operations was not excessive. Use of the electrocautery has greatly diminished the blood loss asso- ciated with thoracoplasty in my experience. Recent experi-

ence with intrathoracic muscle transposition after pneumo- nedomy shows that patients require multiple procedures (1 to 19; median, 5). Failure to achieve chest wall healing and bronchial closure was common (16% and 14.3% respectively) after intrathoracic muscle transposition [8]. In my opinion, the thoracoplasty closure technique herein described is a more certain method of obliterating infected thoracic spaces and achieving chest wall healing and bronchial closure than is transposition of muscle. Pro- longed tube drainage with instillation of antimicrobials into the infected space is important in achieving these results.

This work was supported by the Cardiothoraac Research and Education Foundation.

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