OBJECTIVE: A retrospective study to evaluate effectiveness of transpleural
approach to postpneumonectomy empyema
with bronchopleural fistula.
METHODS: 227 patients (55 females
and 172 males, aged from 19 to 63 years) underwent surgery for chronic postpneumonectomy empyema caused
by bronchopleural fistula between April 1975 and
February 2005. Indications for previous pneumonectomy
were: pulmonary tuberculosis - in 104 cases, COPD - in
76, lung cancer - in 39, traumatic injury - in 5, and pulmonary aspergillosis - in 3. Right pneumonectomy
was performed in 131 (57.7%) cases, left pneumonectomy
- in 96 (42.3%). Duration of empyemas ranged from 2
month to 18 years. Bronchopleural fistulae were
present in all the patients, esophago-pleural
fistulae - in 14, pleuro-cutaneous fistulae - in 86. 40 patients previously underwent Clagett
procedure with resection of 2-4 ribs and had large open-window thoracostomies. In 45 patients there was a history of
previous unsuccessful attempts of surgery: resuturing
of bronchial stumps plus thoracomyoplasty with
resection of 8 to10 ribs (39 cases), or Abruzzini procedure - transsternal
transpericardial occlusion of the main bronchus (6
cases).
In all 227 cases, transpleural reamputation
of bronchial stumps and debridement of empyema cavity was performed. In
14 patients esophago-pleural
fistulae were closed simultaneously. In all cases
bronchial suture line was reinforced using adjacent tissues, diaphragmatic or
pericardial flaps. In 40 cases chest wall defects
caused by open-window thoracostomy were closed as
well. Postoperatively intensive lavage of pleural
cavity was performed in all cases.
RESULTS: Intraoperative
morbidity made up 12.3% (28 complications - mostly bleeding), intraoperative mortality - 0.4% (1 case).
Postoperative morbidity made up 17.7%, postoperative mortality - 10.2%, overall
mortality - 10.6%.
Duration of follow-up period ranged from 3 month to 20 years. Excellent results
(no bronchial fistula, no empyema, no chest wall
defect) were achieved in 200 patients (88.1% overall, or 98.5% of those who
survived surgery). Bronchopleural fistulae and/or empyema recurred in 3 cases (1.3%
overall, or 1.5% survivors).
CONCLUSION: Transpleural
bronchial stump reamputation with debridement
of empyema cavity is a fast and highly effective
method of treatment for chronic postpneumonectomy empyema caused by bronchopleural
fistulae, with acceptable mortality and morbidity rates.