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Bronchopleural fistula
J THoRAc CARDIOVASC SURG 1988;96:433-5
Bronchopleural fistula A novel type of window thoracostomy BronchopleuraI fistula usually associated with chronic empyema after lung operations continues to occur in modern surgical practice. Successful treatment depends to a large extent on adequate dependent drainage of the empyema space. Tube thoracostomy, although useful initially, is unacceptable as long-term treatment. Window thoracostomy as currently performed is effective but unnecessarily extensive. We describe a simpler procedure, triangular window thoracostomy, for use as a permanent pleurocutaneous stoma or as an interim measure before definitive surgical treatment.
I. F. Galvin, FRCSI, J. R. P. Gibbons, MBE, FRCS, FCCP, and M. H. Maghout, FRCS, Belfast. Northern Ireland
Apart from hemorrhage, bronchopleural fistula is the most serious technical complication occurring after pulmonary resection. It is caused by dehiscence of a bronchial stump and leads to empyema. Retrograde contamination and infection of the remaining bronchial tree occurs via the fistula. The mainstay of treatment, at least initially, depends on adequate dependent drainageY of the empyema space. In practice this means window thoracostomy, sometimes preceded by tube thoracostomy. Window thoracostomy was first described by Eloesser' in 1935 and has been modified since then. Various types of aperture made in the chest wall tend to stenose because of granulations and chest wall shrinkage. As a consequence, large unslightly fenestrations were often performed in an effort to overcome this problem. More recently, the fashioning of skin-lined thoracostomies 2• 4 has improved the long-term viability of the stoma but still involves unnecessarily extensive and sometimes disfiguring operations. Materials and methods On nine occasions in a 7Y2 year period, January 1980 to June 1987, we have found it necessary to employ window thoracostomy in the management of bronchopleural fistula
From the Department of ThoracicSurgery, Royal Victoria Hospital, Belfast, and ForsterGreen Hospital, Belfast, Northern Ireland. Received for publication Sept. 2, 1987. Accepted for publication Feb. 7, 1988. Address for reprints: I. F. Galvin, Senior Registrar, Department of Cardiothoracic Surgery, The Prince Henry Hospital, Little Bay, Sydney, N.S.w. 2036, Australia.
complicating pulmonary resection. During this time 751 resections, 238 pneumonectomies and 513 lobectomies, were performed. All thoracostomies were skin lined and were considered highly satisfactory with regard to drainage of the empyema space and permanency where required. Believing that skin-lined thoracostomy as currently performed is unnecessarily extensive, we have modified our technique in favor of a novel procedure called triangular window thoracostomy. This procedure optimally functions as a chest wall stoma with the advantage of a cosmetic result, in our opinion, superior to that obtained in current practice. Technique of triangular window thoracostomy. In planning the position of the stoma, one must remember that maximal dependent drainage overlies the lower aspects of an empyema cavity. In most cases, however, the best site for this thoracostomy after pneumonectomy lies in the midaxillary line. A stoma in this area is easy for the patient to care for, is camouflaged by the overhanging arm, and does not have the discomfort of posterior stomas when the patient is lying in bed. The most dependent site is selected by carefully reviewing the chest x-ray films or by a space roentgenogram after a transthoracic injection of a small amount of contrast medium. A triradiate or "Mercedes Benz symbol" incision (Fig. 1) is now made, centered 3 em above the lowest point of the empyema space. The skin and subcutaneous flaps are developed as in Fig. 1. By means of diathermy the muscles of the chest wall are divided down to rib. Two segments of rib are removed, and these should measure approximately 10 cm in length. There is now a good opening to the interior of the empyema cavity. Bulky muscle or periosteum that may still encroach on the stomal entrance is trimmed away. The diaphragm, which is often covered with granulations, will be found to form the floor of the cavity and to slope down and outward. Flap 1 is now turned inward and marsupulized to the diaphragm with heavy absorbable suture and forms a gutter for empyema drainage. Flaps 2 and 3 are similarly turned inward and sutured to the inner aspect of the empyema cavity. The net result is a skin-lined stoma that effectively prevents
433
434 Galvin. Gibbons. Maghout
The Journal of Thoracic and Cardiovascular Surgery
Fig. 1. Operative steps for triangular window thoracostomy. 1, Dependent position midaxillary line. 2, Triradiate or "Mercedes Benz symbol" incision.3, Undermining three flaps of skin and subcutaneous tissue. 4, Muscle and rib resection. 5, Marsupulization of flaps to empyema lining.
granulations from growing, which would otherwise cause stomal stenosis. Any loose debris, granulation tissue, or remaining pus is evacuated from the cavity and a large external soakable dressing is applied. With time, discharge from the space greatly lessens. The operation is easy to perform and can be done with local or general anesthesia. The three triangular flaps must be adequately undermined so that they advance into the cavity easily and without tension. This will occur only if surrounding muscles and obstructing tissue are liberally cut away by diathermy. The excision of lengths of two ribs is mandatory.
Discussion Eloesser' is usually credited as the first to popularize window thoracostomy. His much quoted paper, "An Operation for Tuberculous Empyema," written in 1935, described a V-shaped skin flap to the empyema space combined with a single rib resection. Although ingenious in concept, in practice many surgeons were unable to get good results with the procedure and the Eloesser flap became widely known as the "Eloesser flop."! This is probably more a reflection of the then untreatability and poor prognosis of pulmonary tuberculosis than a condemnation of the Eloesser technique. Thoracostomy in
the treatment of tuberculosis" became less important as antituberculous drugs made their impact. However, the Eloesser flap was revived with the advent of surgical resection for carcinoma of the lung, which, particularly in its early days, was not uncommonly complicated by bronchopleural fistula and empyema. In its new application the flap idea, modified by some, was popularized during the 1960s by Clagett and Geraci.' Window thoracostomy as performed today exists in a number of forms. 1-3.5. 7 Although some continue to use Eloesser's original technique, many now opt for the more permanent fish-mouth flap with a double skin flap or the alternative true skin-lined thoracostomy involving a sizable hole in the thorax with four skin flaps. This latter procedure, nicely described by Hurvitz and Tucker,' can be used as a permanent skin-lined stoma or be taken down at a later date if one wishes to do a definitive surgical procedure for the bronchopleural fistula.Soil. Our method of triangular window thoracostomy achieves the same end but with a much better cosmetic result. A triradiate incision with three resulting skin flaps, turned into and sutured to the empyema cavity,
Volume 96 Number 3 September 1988
Triangular window thoracostomy
435
involving four rib resections 15 to 20 em in length, is avoided. We are impressed enough with this technique so far to recommend it as our choice for a window thoracostomy. REFERENCES
/ Fig. 2. Triangular window thoracostomy (4 months postoperatively) produces permanent neat skin-lined thoracostomy.
makes maximum geometric use of the least amount of skin required to fashion a chest wall stoma. The result is a neat hole in the side of the thorax that can function as a permanent skin-lined stoma (Fig. 2). The positioning and cosmetic appearance are very acceptable to the patient. Chest wall disfigurement, which invariably follows procedures like those advocated by Weissberg-
1. Hurvitz RJ, Tucker BL. The Eloesser flap: past and present. J THORAC CARDIOVASC SURG 1986;92:958-61. 2. Weissberg D. Empyema and bronchopleural fistula: experience with open window thoracostomy. Chest 1982; 82:447-50. 3. Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935;60:I096-7. 4. Goldstraw P. Treatment of postpneumonic empyema: the case for fenestration. Thorax 1979;34:740-5. 5. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J THORAC CARDIOVASC SURG 1963;45:141-50. 6. Hankins JR, Miller JE, Attar S, et al. Satterfield J, McLaughlin JS. Bronchopleural fistula: thirteen-year experience with 77 cases. J THORAC CARDIOVASC SURG 1978;76:755-62. 7. Shamji FM, Ginsberg RJ, Cooper JD, et al. Open window thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula. J THORAC CARDIOVASC SURG 1983;86:818-22. 8. Sturridge MF. Bronchopleural fistula after pneumonectomy and lobectomy. In: Rob & Smith's operative surgery. 4th ed. Thoracic surgery. London: Butterworths, 1983: 204-9. 9. Hankins JR, Miller JE, McLaughlin JS. The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients. Ann Thorac Surg 1978;25:491-9. 10. Iioka S, Sawamura K, Mori T, et al. Surgical treatment of chronic empyema: a new one-stage operation. J THORAC CARDIOVASC SURG 1985;90:179-85. 11. Hopkins RA, Underleider RM, Staub EW, Young WG Jr. The modern use of thoracoplasty. Ann Thorac Surg 1985;40:181-7.
Bronchopleural fistula A novel type of window thoracostomy BronchopleuraI fistula usually associated with chronic empyema after lung operations continues to occur in modern surgical practice. Successful treatment depends to a large extent on adequate dependent drainage of the empyema space. Tube thoracostomy, although useful initially, is unacceptable as long-term treatment. Window thoracostomy as currently performed is effective but unnecessarily extensive. We describe a simpler procedure, triangular window thoracostomy, for use as a permanent pleurocutaneous stoma or as an interim measure before definitive surgical treatment.
I. F. Galvin, FRCSI, J. R. P. Gibbons, MBE, FRCS, FCCP, and M. H. Maghout, FRCS, Belfast. Northern Ireland
Apart from hemorrhage, bronchopleural fistula is the most serious technical complication occurring after pulmonary resection. It is caused by dehiscence of a bronchial stump and leads to empyema. Retrograde contamination and infection of the remaining bronchial tree occurs via the fistula. The mainstay of treatment, at least initially, depends on adequate dependent drainageY of the empyema space. In practice this means window thoracostomy, sometimes preceded by tube thoracostomy. Window thoracostomy was first described by Eloesser' in 1935 and has been modified since then. Various types of aperture made in the chest wall tend to stenose because of granulations and chest wall shrinkage. As a consequence, large unslightly fenestrations were often performed in an effort to overcome this problem. More recently, the fashioning of skin-lined thoracostomies 2• 4 has improved the long-term viability of the stoma but still involves unnecessarily extensive and sometimes disfiguring operations. Materials and methods On nine occasions in a 7Y2 year period, January 1980 to June 1987, we have found it necessary to employ window thoracostomy in the management of bronchopleural fistula
From the Department of ThoracicSurgery, Royal Victoria Hospital, Belfast, and ForsterGreen Hospital, Belfast, Northern Ireland. Received for publication Sept. 2, 1987. Accepted for publication Feb. 7, 1988. Address for reprints: I. F. Galvin, Senior Registrar, Department of Cardiothoracic Surgery, The Prince Henry Hospital, Little Bay, Sydney, N.S.w. 2036, Australia.
complicating pulmonary resection. During this time 751 resections, 238 pneumonectomies and 513 lobectomies, were performed. All thoracostomies were skin lined and were considered highly satisfactory with regard to drainage of the empyema space and permanency where required. Believing that skin-lined thoracostomy as currently performed is unnecessarily extensive, we have modified our technique in favor of a novel procedure called triangular window thoracostomy. This procedure optimally functions as a chest wall stoma with the advantage of a cosmetic result, in our opinion, superior to that obtained in current practice. Technique of triangular window thoracostomy. In planning the position of the stoma, one must remember that maximal dependent drainage overlies the lower aspects of an empyema cavity. In most cases, however, the best site for this thoracostomy after pneumonectomy lies in the midaxillary line. A stoma in this area is easy for the patient to care for, is camouflaged by the overhanging arm, and does not have the discomfort of posterior stomas when the patient is lying in bed. The most dependent site is selected by carefully reviewing the chest x-ray films or by a space roentgenogram after a transthoracic injection of a small amount of contrast medium. A triradiate or "Mercedes Benz symbol" incision (Fig. 1) is now made, centered 3 em above the lowest point of the empyema space. The skin and subcutaneous flaps are developed as in Fig. 1. By means of diathermy the muscles of the chest wall are divided down to rib. Two segments of rib are removed, and these should measure approximately 10 cm in length. There is now a good opening to the interior of the empyema cavity. Bulky muscle or periosteum that may still encroach on the stomal entrance is trimmed away. The diaphragm, which is often covered with granulations, will be found to form the floor of the cavity and to slope down and outward. Flap 1 is now turned inward and marsupulized to the diaphragm with heavy absorbable suture and forms a gutter for empyema drainage. Flaps 2 and 3 are similarly turned inward and sutured to the inner aspect of the empyema cavity. The net result is a skin-lined stoma that effectively prevents
433
434 Galvin. Gibbons. Maghout
The Journal of Thoracic and Cardiovascular Surgery
Fig. 1. Operative steps for triangular window thoracostomy. 1, Dependent position midaxillary line. 2, Triradiate or "Mercedes Benz symbol" incision.3, Undermining three flaps of skin and subcutaneous tissue. 4, Muscle and rib resection. 5, Marsupulization of flaps to empyema lining.
granulations from growing, which would otherwise cause stomal stenosis. Any loose debris, granulation tissue, or remaining pus is evacuated from the cavity and a large external soakable dressing is applied. With time, discharge from the space greatly lessens. The operation is easy to perform and can be done with local or general anesthesia. The three triangular flaps must be adequately undermined so that they advance into the cavity easily and without tension. This will occur only if surrounding muscles and obstructing tissue are liberally cut away by diathermy. The excision of lengths of two ribs is mandatory.
Discussion Eloesser' is usually credited as the first to popularize window thoracostomy. His much quoted paper, "An Operation for Tuberculous Empyema," written in 1935, described a V-shaped skin flap to the empyema space combined with a single rib resection. Although ingenious in concept, in practice many surgeons were unable to get good results with the procedure and the Eloesser flap became widely known as the "Eloesser flop."! This is probably more a reflection of the then untreatability and poor prognosis of pulmonary tuberculosis than a condemnation of the Eloesser technique. Thoracostomy in
the treatment of tuberculosis" became less important as antituberculous drugs made their impact. However, the Eloesser flap was revived with the advent of surgical resection for carcinoma of the lung, which, particularly in its early days, was not uncommonly complicated by bronchopleural fistula and empyema. In its new application the flap idea, modified by some, was popularized during the 1960s by Clagett and Geraci.' Window thoracostomy as performed today exists in a number of forms. 1-3.5. 7 Although some continue to use Eloesser's original technique, many now opt for the more permanent fish-mouth flap with a double skin flap or the alternative true skin-lined thoracostomy involving a sizable hole in the thorax with four skin flaps. This latter procedure, nicely described by Hurvitz and Tucker,' can be used as a permanent skin-lined stoma or be taken down at a later date if one wishes to do a definitive surgical procedure for the bronchopleural fistula.Soil. Our method of triangular window thoracostomy achieves the same end but with a much better cosmetic result. A triradiate incision with three resulting skin flaps, turned into and sutured to the empyema cavity,
Volume 96 Number 3 September 1988
Triangular window thoracostomy
435
involving four rib resections 15 to 20 em in length, is avoided. We are impressed enough with this technique so far to recommend it as our choice for a window thoracostomy. REFERENCES
/ Fig. 2. Triangular window thoracostomy (4 months postoperatively) produces permanent neat skin-lined thoracostomy.
makes maximum geometric use of the least amount of skin required to fashion a chest wall stoma. The result is a neat hole in the side of the thorax that can function as a permanent skin-lined stoma (Fig. 2). The positioning and cosmetic appearance are very acceptable to the patient. Chest wall disfigurement, which invariably follows procedures like those advocated by Weissberg-
1. Hurvitz RJ, Tucker BL. The Eloesser flap: past and present. J THORAC CARDIOVASC SURG 1986;92:958-61. 2. Weissberg D. Empyema and bronchopleural fistula: experience with open window thoracostomy. Chest 1982; 82:447-50. 3. Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935;60:I096-7. 4. Goldstraw P. Treatment of postpneumonic empyema: the case for fenestration. Thorax 1979;34:740-5. 5. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J THORAC CARDIOVASC SURG 1963;45:141-50. 6. Hankins JR, Miller JE, Attar S, et al. Satterfield J, McLaughlin JS. Bronchopleural fistula: thirteen-year experience with 77 cases. J THORAC CARDIOVASC SURG 1978;76:755-62. 7. Shamji FM, Ginsberg RJ, Cooper JD, et al. Open window thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula. J THORAC CARDIOVASC SURG 1983;86:818-22. 8. Sturridge MF. Bronchopleural fistula after pneumonectomy and lobectomy. In: Rob & Smith's operative surgery. 4th ed. Thoracic surgery. London: Butterworths, 1983: 204-9. 9. Hankins JR, Miller JE, McLaughlin JS. The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients. Ann Thorac Surg 1978;25:491-9. 10. Iioka S, Sawamura K, Mori T, et al. Surgical treatment of chronic empyema: a new one-stage operation. J THORAC CARDIOVASC SURG 1985;90:179-85. 11. Hopkins RA, Underleider RM, Staub EW, Young WG Jr. The modern use of thoracoplasty. Ann Thorac Surg 1985;40:181-7.