FLAP CLOSURE OF POSTPNEUMONECTOMY EMPYEMA

Empyema continues to be an uncommon, frustrating, and potentially leth al complication of pneumonectomy. Between 1990 and 1994 we treated 16 cases of recalcitrant postpneumonectomy (partial or total) empyema wit h combinations of pulse lavage, sharp debridement, muscle flaps, myode rmal flaps, and thoracoplasty. We performed 11 pectoralis muscle flaps , 6 serratus anterior muscle flaps, 9 latissimus dorsi muscle flaps, 6 rectus abdominis muscle flaps, and 1 trapezius muscle flap for an ave rage of 2.1 muscle flaps per patient. There was 1 omental flap. Of the se flaps, 2 were free and the rest pedicled. Ten of the muscle flaps c arried deepithelialized cutaneous paddles, and 6 were larger than 150 cm(3). Thoracoplasty was done in 11 patients to decrease the volume of the postpneumonectomy empyema cavity. Of 16 patients, 4 failed initia lly because of persistent bronchopleural fistula or infection but reso lved after one additional procedure. There was 1 perioperative death, 3 reoperations for bleeding, 1 patient with upper extremity deep vein thromboses, 1 seroma, and 1 patient with significant postoperative pai n syndrome. In order to determine the efficacy of different operative approaches, patients were retrospectively divided into two groups acco rding to the number of operations using flaps needed to resolve their postpneumonectomy empyema. Group A required only one operation using f laps to eliminate the postpneumonectomy empyema. Group B required two operations using flaps to remedy the post-pneumonectomy empyema. Group B operations were further classified into B-1, for the first operatio n, and B-2, for the second operation. No patient needed more than two operations using flaps. Three significant variables were identified, t he number of muscle flaps, the number of ribs in any thoracoplasty, an d the preoperative serum albumin level. The A and B-2 groups had signi ficantly more muscle flaps transposed (p = 0.006) and ribs resected (p = 0.0002) than the B-1 group. These findings suggest that filling the postpneumonectomy empyema space with muscle and collapsing any remain ing space by thoracoplasty were the most successful strategy. The B-2 group's average albumin level was significantly higher (p = 0.03) than that in either the A or the B-1 group, suggesting that improved nutri tion may have played a role in the lack of recurrence. Our goals of si ngle-stage closure and decontamination of empyema cavities were best a chieved by following these principles: removal of infected and necroti c tissue using sharp debridement and pulsed lavage, repair of bronchop leural fistulas with muscle flaps, and minimization of the dead space with combinations of muscle flaps and thoracoplasty.