Closure of bronchopleural fistula after pneumonectomy with a pedicled intercostal muscle flap

208

182

A review of the recent literature on treatment modalities of adult thoracic empyema was conducted in order to expose the controversies and verify where consensus exists. Critical reading filtered through clinical experience was the method followed. The roles of surgical drainage, lavage techniques, debridement via VATS, decortication, thoracoplasty and open window thoracostomy were considered using the Oxford Center of Evidence Based Medicine criteria. The roles of the different therapeutical modalities were interpreted in the light of the triphasic nature of empyema thoracis. The randomised controlled trials came up with conflicting results. With two exceptions all of the papers reviewed provide level (2b) or below evidences. The lack of a single ideal treatment modality or policy reflects the complexity of the diagnosis and staging of this heterogeneous disease. Basic elements of intervention--drainage, different evacuation techniques, decortication, thoracoplasty and open window thoracostomy--are well-established technical modalities; however, neither a universally acceptable primary modality nor the gold standard of their sequence is available. Drainage remains to be the initial treatment modality in Phase I disease. Debridement via VATS is a safe, reliable and efficient method in the fibrinopurulent phase. Organised pleural callus requires formal decortication. Open window thoracostomy is a simple and safe procedure for high-risk patients and results in quick detoxication. Thoracoplasty kept its final role in pleural space management. Acute postoperative bronchial stump insufficiency requires immediate surgery. Evacuation of toxic material is mandatory. No single-stage procedure offers a solution. An optimised agressivity treatment modality should be tailored to the condition of the patient and to the potential of the persisting cavity. Decision-making involves a triad consisting of the aetiology of empyema (i.e. primary vs secondary), general condition of the patient and stage of disease, while considering the triphasic nature of development of thoracic empyema. The current attitudes show that the present concepts are based mainly on expert opinion. Flexibility and patience on behalf of the surgeon and nursing staff, the patient and the hospital management, as well as a good understanding of the complexity of this condition are the cornerstones of the treatment. No exclusive sequence of procedures leading to a uniformly predictable successful outcome is available. Individualised approaches can be recommended based on institutional practice and local protocols. Thoracic empyema in general seems to remain resilient to fit completely into the categories of evidence-based medical approach.

Section: Open Window Thoracostomy (Owt)/fenestration/ Empyema Marsupimentioning

confidence: 99%

“…Clagett's procedure [69,70,72,73] is the best-evidenced (3b) method for historical reasons. The complex procedure consists of open pleural drainage, serial operative debridement and eventual chest closure after filling the pleural cavity with antibiotic solution [70].…”

Section: Open Window Thoracostomy (Owt)/fenestration/ Empyema Marsupimentioning

confidence: 99%

Current surgical treatment of thoracic empyema in adults

Molnár¹

2007

208

182

“…The effective use of an intercostal muscle flap to close bronchopleural fistula after pneumonectomy or pancreaticopleural fistula with pedicled intercostals muscle flap has been reported [18]. Our technique for the intercostal flap maintains the blood flow and the vascular bundle attached to the bronchus stump.…”

Section: Discussionmentioning

confidence: 91%

Bronchial stump reinforcement with the intercostal muscle flap without adverse effects

Maniwa

Saito

Kaneda

et al. 2006

“…_ 2 ) T D $ F I G ] resuture and reinforcement is necessary [7][8][9]. The success rate of surgical closure of BPF has been reported between 80% and 95% [10][11][12], but is associated with the risk of open thoracotomy, although reported surgical mortality has been as low as 0% [10][11][12]. Surgical closure includes chronic open drainage, direct stump closure with intercostal muscle reinforcement, omental flap, trans-sternal bronchial closure and thoracoplasty with or without extrathoracic chest-wall muscle transposition [6].…”

Section: Discussionmentioning

confidence: 99%

The integrated place of tracheobronchial stents in the multidisciplinary management of large post-pneumonectomy fistulas: our experience using a novel customised conical self-expandable metallic stent

Dutau¹,

Breen²,

Gomez³

et al. 2011