Chest Wall Reconstruction

RECONSTRUCTIVE Single-Stage Muscle Flap Reconstruction of the Postpneumonectomy Empyema Space: The Emory Experience Hisham Seify, Kamal Mansour, Joseph Miller, Trent Douglas, Renee Burke, Albert Losken, John Culbertson, Glyn Jones, Foad Nahai, T. Roderick Hester,

M.D. M.D. M.D. M.D. M.D. M.D. M.D. M.D. M.D. M.D.

Atlanta, Ga.

Background: Postsurgical chronic empyema continues to present a complicated treatment scenario for thoracic and reconstructive surgeons. Muscle flaps are an important option in the management of complex thoracic wounds. This study was designed to report the Emory experience with muscle flaps for the management of complex postsurgical empyema. The authors also present their treatment algorithm for managing empyema thoracis. Methods: The authors retrospectively reviewed the charts of 55 patients requiring different treatment modalities, including muscle flap transposition. Patients were divided into four groups according to the initial thoracic procedure: group A, no surgical resection; group B, postpneumonectomy; group C, postlobectomy; and group D, prophylactic postpneumonectomy or postlobectomy. The study included 42 men (76.4 percent) and 13 women with a mean age of 62 years (range, 39 to 77 years). Results: Fifty-one muscle flap procedures were performed in 42 patients (serratus anterior flaps, 16 patients and 23 flaps; latissimus dorsi flaps, 16 patients and 18 flaps; pectoralis major muscle flaps, intercostal muscle flaps, and rectus abdominis flaps, three patients each: omental flap, one patient). The mean number of ribs resected before flap intervention, usually during the open window thoracostomy, was three. The average time from initial thoracic operation to flap intervention was 4 months. Average time from flap intervention to discharge was 12.5 days. Average hospital stay was 26.6 days. The 51 muscle flaps represented an average of 1.2 procedures per patient. Conclusion: Because of the excellent blood supply of extrathoracic muscle flaps and their ability to reach any place in the pleural cavity, they represent an ideal tissue with which to fill the contaminated pleural space. (Plast. Reconstr. Surg. 120: 1886, 2007.)

E

mpyema continues to be an uncommon but potentially lethal complication of resectional pulmonary procedures in which a pyogenic infection of the pleural space develops. Postpneumonectomy empyema occurs in 1 to 11 percent of patients. These patients are difficult to manage and can carry mortality rates as high as 50 percent.1 More than 2000 years ago, Hippocrates recognized that complete evacuation of the pleural From the Joseph Whitehead Department of Surgery, Divisions of Plastic Surgery and Thoracic Surgery, Emory University. Received for publication May 20, 2005; accepted September 12, 2005. Presented at the 71st Annual Meeting of the American Society of Plastic Surgeons, in San Antonio, Texas, October of 2002. Copyright ©2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000256051.99115.fb

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cavity was necessary to effectively treat empyema thoracis. He later described incision and insertion of metal tubes into the pleural space to drain an empyema.2 This principle of dead space obliteration, in combination with the advent of antibiotic therapy in the 1940s, provides the basis of treatment of empyema today. Traditional therapy now begins with thoracentesis and culture-directed antibiotic therapy. This is followed by tube thoracostomy and concludes with either an open drainage procedure such as a rib resection and creation of an open window thoracostomy or by thoracoplasty.3,4 In 1898, J. B. Murphy outlined the surgical management of chronic empyema by thoracoplasty.5 At the Mayo Clinic in 1915, Robinson described transposition of skeletal muscles into the chest to

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Volume 120, Number 7 • Postpneumonectomy Empyema Space treat empyema6 and, in 1920, Kanavel described the treatment of the noncollapsing wound by debridement and obliteration of dead space with vascularized muscle flaps.7 Arnold and Pairolero further popularized this therapy in the 1980s.8 Miller et al. reported single-stage complete muscle flap closure of postpneumonectomy empyema space.9 Others have reported use of the omentum, myocutaneous flaps, and free flaps.10 –13 Muscle flaps have also been an important option in the management of bronchopleural fistula as first described in 1911.14 Often, these complex wounds are infected, have been previously irradiated, and may have an associated bony defect and/or open communication with the lung airway. Extrathoracic muscle flaps using serratus anterior, latissimus dorsi, and pectoralis major muscles have also been described.15 The goal of this study is to report the Emory experience with the use of muscle flaps for the management of complex postsurgical empyema. In addition, we present our treatment algorithm for the management of empyema thoracis.

PATIENTS AND METHODS In this study, the authors retrospectively reviewed the charts of 55 patients requiring different treatment modalities, including muscle flap transposition, from 1991 to 2002. Data cards were filled out retrospectively for each patient indicating age, sex, diagnosis, procedures performed, period of hospitalization, complications, and outcome. Patients were divided into four groups according to the initial thoracic procedure performed: group A, no surgical resection; group B, postpneumonectomy; group C, postlobectomy; and group D, prophylactic postpneumonectomy or postlobectomy (Table 1). The diagnosis of empyema required one of the following criteria: (1) grossly purulent pleural fluid documented by thoracentesis or at thoracotomy; (2) positive pleural fluid culture or Gram’s stain; or (3) pleural fluid pH ⬍7.0 and lactate dehydrogenase greater than 1000 U/liter. Empyema was defined as multiloculated if two or more

Neoplastic Inflammatory Other Total

15 2 17

RESULTS The study included 42 men (76.4 percent) and 13 women; the mean age of the patients was 62 years (range, 39 to 77 years). The initial thoracic surgery was performed for lung or pleural cancer in 28 patients, following complicated pneumonia and other inflammatory conditions in 24 patients, and following spontaneous esophageal rupture in two patients. Bronchopleural fistula was present in 20 patients, five in group A (no surgical resection), seven in group B (postpneumonectomy), and eight in group C (postlobectomy). The mean number of ribs resected before flap intervention, usually during the open window thoracostomy, was three. Procedures performed included chest tube thoracostomy/decortication in two patients, Eloesser flap in 27 patients, and muscle flap transfer in 42 patients (Table 2). A total of 51 muscle flaps were performed in 42 patients as follows: serratus anterior flaps in 16 patients (23 flaps), latissimus dorsi flaps in 16 patients (18 flaps), pectoralis flaps in three patients, intercostal flaps in three patients, rectus abdominis flaps in three patients, and an omental flap in one patient (Table 3). The average time from initial thoracic surgery to flap intervention was 4 months. The average Table 2. Different Types of Procedures Performed Divided According to the Initial Thoracic Procedure Group A Group B Group C Group D (n ⴝ 17) (n ⴝ 16) (n ⴝ 13) (n ⴝ 9) Chest tube thoracotomy/ decortication Eloesser flap Muscle flaps Total

2 13 3 18

6 21 27

8 18 26

9 9

Table 3. Different Muscle Flaps Performed Divided According to the Initial Thoracic Procedure Group A Group B Group C Group D (n ⴝ 17) (n ⴝ 16) (n ⴝ 13) (n ⴝ 9)

Table 1. Cause of Surgical Empyema Divided According to the Initial Thoracic Procedure Group A (n ⴝ 17)

pleural fluid collections were seen on chest computed tomographic scan. The results were compared between the different patient groups with identification of patient morbidity and mortality.

Group B (n ⴝ 16)

Group C (n ⴝ 13)

Group D (n ⴝ 9)

13 3

7 6

8

16

13

1 9

Intercostal muscle Serratus muscle Latissimus muscle Pectoralis muscle Omentum Rectus abdominal muscle Total

1 1

1 8 9 1

2 7 6 2

7 2

2 21

1 18

9

1 3

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Plastic and Reconstructive Surgery • December 2007 Table 4. Outcome Measurements Divided According to the Initial Thoracic Procedure

Average stay Complications Mortality

Group A (n ⴝ 17)

Group B (n ⴝ 16)

Group C (n ⴝ 13)

Group D (n ⴝ 9)

28 days

34 days 2 (recurrent empyema) 1

14 days 1 (partial flap necrosis)

6 days

time from flap intervention to discharge was 12.5 days. The average hospital stay was 26.6 days. In total, 51 flap procedures were performed, for an average of 1.2 procedures per patient.

died 10 days after surgery as a result of sepsis (Table 4).

Group A The nonresectional group included 17 patients who developed empyema from various causes: 15 patients following pneumonia and two patients following spontaneous esophageal rupture. Three patients in this group underwent flap coverage (serratus, latissimus, and omentum).

The optimum treatment strategy for the management of empyema thoracis remains elusive. As stated by Thurer, “The goals of appropriate therapy for empyema are to limit morbidity and mortality, shorten hospital stay, and return pulmonary function to baseline.”16 This is often easier in principle than in practice, and surgical input is often delayed until the failure of “medical management” with the advent of image-directed catheter placement and concomitant use of fibrinolytics. In a recent report by Thourani et al., patients undergoing a decortication procedure had the shortest hospital stay when compared with patients having image-directed catheters or tube thoracostomy. In this series, 45 percent (nine of 20) of image-directed catheters failed, which resulted in this group having the longest hospital stay and the highest hospital charges.17 These data have persuaded Emory University thoracic surgeons to opt for early surgical intervention in the management of thoracic empyema. Treatment strategies for empyema thoracis use a variety of methods. The method is selected on the basis of the stage of the empyema, the general condition of the patient, and response to the initial therapy. Ideally, the patients who had old, thick pleura and did not respond to tube thoracostomy would require early surgical therapies such as decortication. However, these operations often carry an increased risk of perioperative morbidity to the debilitated patient, as described by Kaplan and Light.18,19 Although open drainage, advocated by Eloesser and modified by Clagett and Geraci20 with instillation of antibiotics at the time of closure, is an alternative choice, the time required to sterilize the empyema cavity is long and additional surgery is necessary to close the fenestration. Virkkula et al. reported that the interval between the construction of the fenestration and its closure was on average 6 months (range, 1.5 to 28 months) for postpneumonectomy chronic empyema.21

Group B The postpneumonectomy group included 16 patients: 13 following pneumonectomy for neoplasms and three following pneumonectomy for complicated inflammatory conditions. Eleven patients in this group underwent muscle flap coverage (total, 21 flaps: one intercostal, eight serratus, nine latissimus, one pectoralis, and two rectus abdominis muscle flaps). Group C The postlobectomy group included 13 patients: seven following lobectomy for neoplasms and six following lobectomy for complicated inflammatory conditions. Ten patients in this group underwent muscle flap coverage (total, 18 flaps: two intercostal, seven serratus, six latissimus, two pectoralis, and one rectus abdominis). Group D The prophylactic postpneumonectomy and postlobectomy group included nine patients, and all underwent muscle flap coverage. Complications Two patients developed persistent empyema (8.7 percent). One patient required treatment by means of computed tomography– guided drainage and the other patient was treated with open drainage. One patient developed partial necrosis of a rectus abdominis muscle flap requiring debridement and local flap closure. One patient

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DISCUSSION

Volume 120, Number 7 • Postpneumonectomy Empyema Space Advances in the transposition of vascularized tissue offered another alternative for the management of chronic wounds of the chest. Arnold and Pairolero have described their extensive experience with the intrathoracic transposition of extrathoracic skeletal muscles. Multiple flaps, including the omentum, have been described in the treatment of these patients.22 Michaels et al. recently reviewed the closure of 16 cases of postpneumonectomy empyema cavities with flaps. The average number of flaps per patient was 2.1, and 11 patients required combined thoracoplasty. Two patients in this series had free flaps transferred microsurgically, with the remaining tissues transferred as pedicled flaps.23 Perkins et al. described the successful management of five patients with intrathoracic sepsis by the transfer of free flaps. One transverse rectus abdominis musculocutaneous and four latissimus dorsi flaps were used in the care of these patients.24 Chronic thoracic wounds are prevented from shrinking by secondary intention by the rigidity of the surrounding chest wall and are especially complicated when associated with radiation fibrosis and recurrent infection. Nevertheless, conven-

tional thoracic surgical techniques such as the Clagett procedure are usually successful in resolving these problems. However, further measures must occasionally be instituted, such as flap transposition.13 Ideally, it would be advantageous to close these patients with tissue transposition alone and avoid thoracoplasty. In cases of total pneumonectomy, a significant volume is required to fill the empyema cavity. Multiple flaps are usually required to fill the defect (Figs. 1 and 2). According to our study, the serratus muscle flap and the latissimus muscle flap were the flaps most frequently used for empyema cavity obliteration. The choice of flap was a decision made by the reconstructive surgeon based on the anatomical defect and the availability of various flaps. Previous thoracic incisions could compromise flap choice, especially the latissimus dorsi muscle flap. The omentum is used only when a significant volume is required together with other flaps or as a salvage procedure. In this series, the only flap morbidity was a partial necrosis in a rectus muscle flap that required local flap closure. There was no use of free tissue transfer in this series, and it

Fig. 1. Different pedicled flaps used in the obliteration of the empyema space. Reprinted with permission from Miller, J. I., Mansour, K. A., Nahai, F., et al. Single stage complete muscle flap closure of the postpneumonectomy space: A new method and possible solution to a disturbing complication. Ann. Thorac. Surg. 38: 227, 1984.

Fig. 2. Total obliteration of the empyema space with multiple flaps (PM, pectoralis major; LD, latissimus dorsi; REC, rectus abdominis; SA, serratus anterior). Reprinted with permission from Miller, J. I., Mansour, K. A., Nahai, F., et al. Single stage complete muscle flap closure of the postpneumonectomy space: A new method and possible solution to a disturbing complication. Ann. Thorac. Surg. 38: 227, 1984.

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Plastic and Reconstructive Surgery • December 2007 would be indicated in cases where no regional muscle flap option is available. In this series, muscle flap closure was used in conjunction with other modalities. It is to be noted that the number of complicated empyema cases has declined over the years as a result of early surgical management and culture-directed antibiotic management. The Emory algorithm, as outlined by Miller et al., consists of prompt pleural drainage by closed tube thoracostomy once the diagnosis of postpneumonectomy empyema, with or without bronchopleural fistula, has been established. Chest tube drainage is continued until the mediastinum becomes stabilized, generally after approximately 2 weeks. Thereafter, open drainage or another therapy for the empyema space can be undertaken safely without the mediastinum shifting. Once the patient is medically stable and has entered into the chronic phase at 3 to 4 weeks, a modified Clagett’s procedure is performed if no bronchopleural fistula is present. This is performed by placement of a second small chest tube

inserted into the second intercostal space with a continuous inflow-outflow irrigation system established through the pleural cavity. The irrigant is based on antibiotic sensitivities to the pleural drainage. If this method is successful and the return is culture-negative on three consecutive days after 2 weeks of irrigation, the chest tubes can be removed and the pleural fluid is allowed to reaccumulate to fill the remaining space. If the modified Clagett’s technique fails, a complete muscle flap closure of the pneumonectomy space can be performed. If a patient with postpneumonectomy empyema has a bronchopleural fistula, it is likewise treated during the acute phase with closed chest tube thoracostomy, with conversion to open drainage at the appropriate time when mediastinal stabilization has occurred. If the fistula closes, one can attempt the modified Clagett’s procedure. If the fistula persists, the space is managed by surgical closure of the fistula and muscle flap transposition9 (Fig. 3).

Fig. 3. Algorithm for the management of postpneumonectomy empyema.

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Volume 120, Number 7 • Postpneumonectomy Empyema Space CONCLUSIONS The management of postpneumonectomy empyema remains a challenge in the fields of thoracic and reconstructive surgery. It is an uncommon but disturbing complication. Several methods have been described historically, ranging from rib resection to complete thoracoplasty and tissue transfer. Because of the excellent blood supply of extrathoracic muscle flaps and their ability to reach any place in the pleural cavity, they represent an ideal tissue with which to fill a contaminated space. Hisham Seify, M.D. Joseph Whitehead Department of Surgery Divisions of Plastic Surgery and Thoracic Surgery Emory University 92 Via Candelaria Coto de Caza 92679, Calif. [email protected] [email protected]

DISCLOSURE

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. REFERENCES 1. Ashbaugh, D. G. Empyema thoracis: Factors influencing morbidity and mortality. Chest 99: 1162, 1991. 2. Hippocrates. Writings. In R. M. Hutchins (Ed.), Great Books of the Western World. Chicago: Encyclopedia Britannica, 1952. 29: 142. 3. Mandal, A. K., and Thadepalli, H. Treatment of spontaneous bacterial empyema thoracis. J. Thorac. Cardiovasc. Surg. 94: 414, 1987. 4. Weber, J., Grabner, D., Al-Zand, K., and Beyer, D. Empyema after pneumonectomy: Empyema window or thoracoplasty. Thorac. Cardiovasc. Surg. 38: 355, 1990. 5. Milloy, F. The contributions of John B. Murphy to thoracic surgery. Surg. Gynecol. Obstet. 171: 421, 1990. 6. Robinson, S. The treatment of chronic non-tuberculous empyema. Surg. Gynecol. Obstet. 22: 557, 1916. 7. Kanavel, A. B. Plastic procedures for obliteration of cavities with non-collapsible walls. Chicago Surgical Society Meeting, April of 1920. 8. Arnold, P. G., and Pairolero, P. C. Chest wall reconstruction: Experience with 100 consecutive patients. Ann. Surg. 199: 725, 1984.

9. Miller, J. I., Mansour, K. A., Nahai, F., et al. Single stage complete muscle flap closure of the postpneumonectomy space: A new method and possible solution to a disturbing complication. Ann. Thorac. Surg. 38: 227, 1984. 10. Jurkiewicz, M. J., and Arnold, P. G. The omentum: An account of its use in the reconstruction of the chest wall. Ann. Surg. 185: 548, 1977. 11. Iverson, L. I. G., Young, J. N., Ecker, R. R., et al. Closure of bronchopleural fistulas by an omental pedicle flap. Am. J. Surg. 152: 40, 1986. 12. Hallock, G. G. Intrathoracic application of the transverse rectus abdominis musculocutaneous flap. Ann. Plast. Surg. 29: 357, 1992. 13. Mathes, S. J., Alpert, B. S., and Chang, N. Use of muscle flap in chronic osteomyelitis: Experimental and clinical correlation. Plast. Reconstr. Surg. 69: 815, 1982. 14. Abrashanoff, H. Plastische Methode der Schliessung von Fistelgangen, welche von inneren Organen kommen. Zentralbl. Chir. 38: 186, 1911. 15. Chen, H., Tang, Y., Noordhoff, M. S., and Chang, C. Microvascular free muscle flaps for chronic empyema with bronchopleural fistula when the major local muscles have been divided: One stage operations with primary wound closure. Ann. Plast. Surg. 24: 510, 1990. 16. Thurer, R. J. Decortication in thoracic empyema: Indications and surgical technique. Chest Surg. Clin. North Am. 6: 461, 1996. 17. Thourani, V. H., Brady, K. M., Mansour, K. A., et al. Evaluation of treatment modalities for thoracic empyema: A costeffectiveness analysis. Ann. Thorac. Surg. 66: 1121, 1998. 18. Kaplan, D. K. Treatment of empyema thoracis. Thorax 49: 845, 1994. 19. Light, R. W. Pleural Diseases, 3rd Ed. Baltimore, Md.: Williams & Wilkins, 1995. Pp. 129 –153. 20. Clagett, O., and Geraci, J. E. A procedure for the management of postpneumonectomy empyema. J. Thorac. Cardiovasc. Surg. 45: 141, 1963. 21. Virkkula, L., Eerola, S., and Varstela, E. Surgical approach to the chronic empyema: Space sterilization. In J. Deslauriers and L. K. Lacquet (Eds.), Thoracic Surgery: Surgical Management of Pleural Diseases; International Trends in General Thoracic Surgery, Vol. 6. St. Louis, Mo.: Mosby, 1990. Pp. 263–268. 22. Arnold, P. G., and Pairolero, P. C. Intrathoracic muscle flaps: A 10-year experience in the management of life-threatening infections. Plast. Reconstr. Surg. 84: 92, 1989. 23. Michaels, B. M., Orgill, D. P., Decamp, M. M., et al. Flap closure of postpneumonectomy empyema. Plast. Reconstr. Surg. 99: 437, 1997. 24. Perkins, D. J., Lee, K. K., Pennington, D. G., et al. Free flaps in the management of intrathoracic sepsis. Br. J. Plast. Surg. 48: 546, 1995.

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