Introduction

Thoracoplasty was originally described by Eastlander and Schede₁. The procedure has undergone various modifications by different surgeons. Andrew's thoracoplasty was initially used for treating unresponsive tuberculous chronic empyemas with persistent bronchopleural fistulas. Principles of Andrew's staged method of thoracomediastinal plication (thoracoplasty) can be currently used and are combined with muscle flaps to achieve obliteration of the space and preserve functionality. Briefly, the ribs overlying the empyema cavity are resected, the cavity is curetted, the bronchial fistula, if present, is closed, and the parietal plane is sutured to the mediastinal plane.₂ Because of the availability of effective antituberculous medications, this operation is infrequently done in contemporary surgical practice. It remains a valuable adjunct in dealing with difficult problem of persistent postpneumonectomy empyema space. We present a case where modified single stage Andrew's thoracoplasty and muscle flaps were used together to successfully obliterate a persistent postpneumonectomy empyema space.

Case Presentation

A 46-year-old African-American male smoker underwent a right pneumonectomy in September 1999 for squamous cell carcinoma of the lung, stage IIB (T2N1M0). Postoperatively, he received chemotherapy and radiotherapy. A follow up in September 2004 showed opacification of right hemithorax and an area of positive activity in pneumonectomy area by a positron emission tomography (PET scan). A diagnostic radiological needle aspiration was performed to evaluate for recurrence of malignancy and was negative. Two weeks later, this acutely sick patient was referred to thoracic surgery when he presented with right side chest pain, fever and right pleural effusion with air fluid level on chest roentgenogram (Figure 1 A, B).

Figure 1

Figure 1: Chest roentgenograms A at admission showing massive right pleural effusion; B during chest tube drainage; C complete obliteration of right thoracic cavity one and half year later.

Thoracentesis revealed frank empyema. There was no evidence of associated bronchopleural fistula. The patient was treated initially with chest tube insertion in the operating room, daily irrigation of the empyema cavity and systemic antibiotics. The empyema cavity and fluid drainage persisted and an Eloesser flap was constructed. On January 2005, he underwent a right-sided standard limited thoracoplasty and muscle flaps to obliterate the empyema space as a definitive procedure.

Technique of thoracoplasty: The procedure was done under general anesthesia in lateral position. Prior posterolateral thoracotomy incision was opened. Second, 3^rd, 4^th and 5^th ribs were resected subperiosteally such that increasing lengths of anterior ribs were preserved and back ends of the ribs were removed. First rib, costovertebral joint and the transverse process of the vertebra were preserved. The exposed intercostals muscles and the parietal pleura were linearly divided in mid-axillary line and thoracomediastinal plication was performed with both the anterior and posterior flaps. The apex of the right parietal pleura and the adjacent soft tissues were retracted downwards (Semb's apicolysis). Tube drains were inserted and wound was closed.

One year postoperative follow up reveals a normal range of motion of the right shoulder and excellent cosmetic result (Figure 2). Chest roentgenogram, one year postoperatively, shows completely obliterated postpneumonectomy space (Figure 1C) with no distortion of the spine.

Figure 2

Figure 2: Picture of the patient showing excellent cosmetic results one year after surgery.

Discussion

Postpneumonectomy empyema is a life-threatening complication. The optimal treatment of empyema complicating pulmonary resection should take into account the infectious state, the characteristics of the pleural space, and the presence of bronchopleural fistula. The objectives of the treatment include: effective drainage of the empyema cavity and appropriate antibiotic therapy. Adequate drainage is the first step. Our protocol is to initially control the sepsis and delay the definitive procedure. Presence or absence of the bronchoplueral fistula needs to be carefully assessed. Patients with bronchopleural fistula will require closure of the fistula prior to space obliteration.

The various methods that can be used to obliterate the persistent postpneumonectomy space include use of pedicled muscle flaps, thoracoplasty or a combination of these maneuvers. Schede₂ and Eastlander₃ described the technique of rib resection for collapse of the chest wall in order to obliterate the empyema cavity. However, their technique was quiet mutilating and disfiguring. Subsequently, preservation of first rib and use of muscle flaps were described and provided a less mutilating procedure. We modify the procedure for optimal functional result.

Latissimus dorsi was the preferred muscle flap because of its size. But prior thoracotomy in out patient precluded the use of the previously divided latissimus dorsi muscle and hence we utilized pectoralis major muscle flap for reduction of the empyema space. Thus complete obliteration of the space was achieved by combination of muscle flaps and thoracoplasty. Preservation of the first rib, costovertebral joint and the transverse vertebral process preserved the structural integrity of the neck, shoulder girdle and thoracic spine. The final result was preservation of functionality and a desirable cosmesis.

Conclusion

Limited thoracoplasty, a time-honored surgical procedure has a place in the management of persistent pleural space in selected patients. The management of persistent postpneumonectomy space demands judicious decision making and execution of multidisciplinary plan, often involving thoracic surgery, pulmonary medicine and physical therapy. The combination of limited thoracoplasty and muscle flap transposition will be useful to achieve cosmetic result and functionality. Apicolysis ensures adequate collapse of the cupola of the lung and mediastinum. If drainage of the cavity remains inadequate in spite of chest tubes, Eloesser flap is used and space is irrigated with antibiotic solution as described by Clagett. Addition of limited thoracoplasty, apicolysis and muscle flaps will optimize the space obliteration in carefully selected cases.

Correspondence to

Gilda Diaz-Fuentes, MD, FCCP Address: Pulmonary Division, 1650 Grand Concourse, Bronx, NY 10457 Phone: (718) 960-2003 Fax: (718) 960-1333 E-mail: gdf.gdfuentes210@verizon.ne