- Email: [email protected]
Cerebral Air Embolism During Imaging of a Sentinel Lymphatic Drainage in the Respiratory Tract
Ann Thorac Surg 2006;81:721–3
The authors gratefully acknowledge the assistance of Julia Beeson in the preparation of this article.
References 1. Maiwand MO. Cryotherapy for advanced carcinoma of the trachea and bronchi. BMJ 1986;293:181–2. 2. Maiwand MO, Evans JM, Beeson JE. The application of cryosurgery in the treatment of lung cancer. Cryobiology 2004;1:55– 61. 3. Ruers TJM, Joosten J, Jager GJ, Wobbes T. Long-term results of treating hepatic colorectal metastases with cryosurgery. Br J Surg 2001;88:844 –9. 4. Maiwand MO, Asimakopoulos G. Cryosurgery for lung cancer: clinical results and technical aspects. Technol Cancer Res Treat 2004;3:143–50. © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
UEDA ET AL AIR EMBOLISM
721
5. Maiwand MO, Homasson JP. Cryotherapy for tracheobronchial disorders. Clin Chest Med 1995;16:427– 43. 6. Rubinsky B. Cryosurgery. Ann Rev Biomed Eng 2000;02:157– 87. 7. Hewitt PM, Zhao J, Akhter J, Morris DL. A comparative study of liquid nitrogen and argon gas cryosurgery systems. Cryobiology 1997;35:303– 8. 8. Gage AA, Baust JG. Cryosurgery – a review of recent advances and current issues. CryoLetters 2002;23:69 –78. 9. Wang BY, Boag AH, Idrees M, Young ID, Unger PD. Malignant fibrous histiocytoma: a case report and review of the literature. Arch Pathol Lab Med 2004;128(4):456 – 60. 10. Damron TA, Beauchamp CP, Rougraff BT, Ward WG. Soft tissue lumps and bumps. J Bone Joint Surg Am 2003;6:1142–56.
Cerebral Air Embolism During Imaging of a Sentinel Lymphatic Drainage in the Respiratory Tract Kazuhiro Ueda, MD, Yoshikazu Kaneda, MD, Manabu Sudo, MD, Mitsutaka Jinbo, MD, Kazuyoshi Suga, MD, and Kimikazu Hamono, MD First Department of Surgery and Department of Radiology, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
We report a rare but notable case of cerebral air embolism complicating transthoracic intrapulmonary injection of an imaging agent used to locate sentinel lymph nodes. After a bolus injection of 2 mL of iopamidol into the peritumoral area with a 23-gauge needle, the patient complained of complete paralysis on his left side. Intraaortic gas was detected by computed tomography immediately after the injection. The patient recovered spontaneously without any additional complication. Surgeons should be aware of this rare but possible complication during sentinel lymph node assessment. (Ann Thorac Surg 2006;81:721–3) © 2006 by The Society of Thoracic Surgeons
S
ince Liptay and colleagues showed that sentinel lymph node mapping improves the detection of nodal micrometastasis in patients with nonsmall cell lung cancer [1], many investigators have explored the usefulness of various modalities in identifying the sentinel node [2–5]. However, little is known about the complications of sentinel lymph node assessment in the respiratory tract. Herein, we describe a case of cerebral air embolism complicating transthoracic intrapulmonary injection of an imaging agent used to locate the sentinel lymph node. A 77-year-old man was admitted to our hospital for suspected lung malignancy. The primary tumor was 5 cm in diameter and was located in the left lower lobe (S6). Although no motor paralysis was present at the time of Accepted for publication Nov 12, 2004. Address correspondence to Dr Ueda, Yamaguchi University School of Medicine, 1–1–1 Minami-Kogushi, Ube Yamaguchi 755– 8505, Japan; e-mail: [email protected].
0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2004.11.020
FEATURE ARTICLES
ance but was not appropriate for metastatic disease. Malignant fibrous histiocytoma is the most common soft tissue sarcoma of late adult life [9], with the pleomorphic subtype being the commonest. The 5-year survival rate after appropriate treatment for low-grade, large, softtissue sarcomas is 82% to 98%, for intermediate-grade tumors it is 80%, and for high-grade tumors it is 52% to 60% [10]. As a palliative procedure, endobronchial cryosurgery reduces tumor load and helps to maintain airway patency. However, at thoracotomy for planned resection, a significant number of patients have inoperable, obstructing lung carcinoma inaccessible through the tracheobronchial tree. A series of 17 such patients received direct intraoperative cryosurgery using nitrous oxide as the coolant for primary nonsmall cell carcinoma with encouraging results [4]. With this experience and the success of liquid nitrogen cryoablation in other tumors, such as colorectal liver metastases [4], we believe that this case was suitable for direct freezing of the tumors with liquid nitrogen at thoracotomy. In this particular patient, there was a very significant reduction in tumor mass 12 months post-cryosurgery, and the FDG18 positron-emission tomographic scan showed no evidence of active tumor at the site of cryosurgery, nor any evidence of metastatic disease elsewhere in the body. One of the main problems encountered in cryosurgery of organs such as the liver, kidney and prostate is the limiting, potential irreversible destruction of nearby healthy tissues and organs during cooling. With endobronchial and direct lung cryosurgery, air in the alveoli being a very poor thermal conductor provides a natural insulation hence protection of the adjacent healthy lung tissue during freezing. The outcome of this case suggests that direct liquid nitrogen cryosurgery may offer symptomatic benefit and potential curative treatment of metastatic malignant fibrous histiocytoma of the lung, especially when resection and endobronchial ablation is not possible, or both are not possible, and chemoradiotherapy is of limited value. Further research is being conducted to assess the possible contribution of cryosurgery to patients with other metastatic lung disease and unresectable primary lung tumors.
CASE REPORT
722
CASE REPORT AIR EMBOLISM
UEDA ET AL
FEATURE ARTICLES
Fig 1. With the patient in the prone position, the contrast material is injected into the peritumoral area under full inspiration to image the lymphatic drainage system.
admission, the patient’s history included cerebral infarction. On the basis of a clinical diagnosis of T2N0M0 lung cancer, he was considered eligible for indirect computed tomographic lymphography for the purpose of locating a sentinel lymph node [3] to be followed by surgery. With the patient in the prone position, the local anesthesia was achieved with a total of 5 mL of 1% lidocaine hydrochloride at the injection site. An injection of 2 mL of iopamidol (Iopamiron 300 [Nippon Shering, Osaka, Japan]), targeted to the periphery of the tumor, was given through a 23-gauge needle attached to a 2.5 mL syringe (Fig 1). This contrast agent, which is conventionally used as an extracellular contrast agent for angiography and enhanced computed tomography, has an iodine concentration of 300 mg/mL, an osmolarity of 585 mOsm/kg, a viscosity of 4.4 mPa/s, and a pH of 6.5 to 7.5. Indirect lymphography scans at full inspiration with predefined measurements were obtained successively at 30 seconds, and at 1, 3, and 5 minutes after the iopamidol injection. Immediately after the last scan, the patient complained of complete paralysis on his left side. Intra-arterial gas noted on the computed tomographic scan at 1 minute after the injection was strongly suggestive of cerebral air embolism (Fig 2). Fortunately the patient recovered spontaneously and fully during 15 minutes of placing the patient in the Trendelenburg position to keep air out of the cerebral circulation. Magnetic resonance imaging of the brain on the following day showed no abnormality.
Ann Thorac Surg 2006;81:721–3
hook-type marker into the lung parenchyma to locate small or impalpable tumors [7]. The air embolism may be caused primarily by the pulmonary puncture itself, which can open a communication between a bronchiole and contiguous pulmonary vein [6, 7]. Therefore, care should be taken during sentinel lymphatic drainage assessment that requires pulmonary puncture for delivering an imaging agent into the tumor or peritumoral area. We have performed sentinel lymph node assessment in patients with lung cancer since August 2001, with the approval of our institutional review board. Initially, we injected radiolabeled tin colloid into the peritumoral area with computed tomographic guidance for intraoperative detection of radioactive lymph nodes by means of a hand-held ␥-detecting probe [2]. We now use iopamidol as the contrast material to image the lymphatic drainage preoperatively by means of computed tomographic lymphography [3]. We have performed this procedure in 42 cases to date without significant adverse effects, except in 1 patient who required transient chest tube drainage for moderate pneumothorax. Although the patient described herein recovered fully without any treatment, air embolism can occasionally be fatal [7]; five of 12 reported cases developing systemic air embolism were fatal despite intensive treatment. Treatment of systemic air embolism consists of placing the patient in a left lateral decubitus position (to prevent air within the left atrium from embolizing systemically) or in the Trendelenburg position. Ventilatory support with 100% oxygen should be administered to promote resorption of air bubbles. Transfer to a hyperbaric chamber may improve survival after air embolization. Little is known about risk factors for air embolism complicating pulmonary puncture. Positive airway pressure with mechanical ventilation, coughing, puncturing
Comment Air embolism is recognized as a rare but potentially fatal complication of transthoracic lung needle biopsy with a reported incidence of 0.07% [6]. Thoracic surgeons have also experienced this problem during insertion of a
Fig 2. Intra-arterial gas is detected in the descending aorta 1 minute after the injection of contrast material.
Ann Thorac Surg 2006;81:723–5
References 1. Liptay MJ, Grondin SC, Fry WA, et al. Intraoperative sentinel lymph node mapping in non-small cell lung cancer improves detection of micrometastases. J Clin Oncol 2002;20:1984 – 8. 2. Ueda K, Suga K, Kaneda Y, et al. Radioisotope lymph node mapping in nonsmall cell lung cancer: can it be applicable for sentinel node biopsy? Ann Thorac Surg 2004;77:426 –30. 3. Ueda K, Suga K, Kaneda Y, Li TS, Ueda K, Hamano K. Preoperative imaging of the lung sentinel lymphatic basin with computed tomographic lymphography: a preliminary study. Ann Thorac Surg 2004;77:1033–7. 4. Sugi K, Kaneda Y, Sudoh M, Sakano H, Hamano K. Effect of radioisotope sentinel node mapping in patients with cT1 N0 M0 lung cancer. J Thorac Cardiovasc Surg 2003;126:568 –73. 5. Nakagawa T, Minamiya Y, Katayose Y, et al. A novel method for sentinel lymph node mapping using magnetite in patients with non-small cell lung cancer. J Thorac Cardiovasc Surg 2003;126:563–7. 6. Sinner WN. Complications of percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diagn (Stockh) 1976;17: 813–28. 7. Sakiyama S, Kondo K, Matsuoka H, et al. Fatal air embolism during computed tomography-guided pulmonary marking with a hook-type marker. J Thorac Cardiovasc Surg 2003;126:1207–9.
Management of Empyema Cavity With the Vacuum-Assisted Closure Device Kimberly A. Varker, MD, and Thomas Ng, MD, FACS Surgical Oncology, Roger Williams Medical Center, Department of Surgery, Brown University Medical School, Providence, Rhode Island © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
723
Management of empyema after pulmonary resection remains a challenging problem. Along with mandatory drainage of the thoracic cavity and investigations to rule out bronchopleural fistula, a reliable method of thoracic cavity closure is needed. The open thoracic window and Eloesser flap techniques rarely represent definitive therapy. Muscle flap and thoracoplasty procedures may provide well-vascularized tissue to close bronchopleural fistula and obliterate the empyema cavity, but they are quite complex and involve significant patient morbidity. We report a case of empyema without bronchopleural fistula after lobectomy in which the vacuum-assisted closure device was used to achieve complete wound healing after open drainage. (Ann Thorac Surg 2006;81:723–5) © 2006 by The Society of Thoracic Surgeons
A
fter preexisting pulmonary infections, postsurgical procedure is the second most common cause of empyema [1]. The incidence of empyema after lobectomy is 1% to 3%, and after pneumonectomy as high as 12% [1]. Although postpneumonectomy empyema is associated with bronchopleural fistula in 75% to 80% of cases, postlobectomy empyema is usually due to prolonged parenchymal air leak with persistent pleural space [2]. Initial management of postlobectomy empyema includes tube thoracostomy drainage and systemic antibiotic therapy [1, 2]. Thoracoscopic adhesiolysis or installation of fibrinolytic agents may be useful in the early stages of empyema [3]. Failure of conservative management should prompt open drainage of the empyema space to promote control of sepsis and patient stabilization [2]. Options for management of the empyema space after open drainage have traditionally included muscle flap closure, thoracoplasty procedures, or delayed thoracic closure after sterilization (the Clagett procedure) [4, 5]. We believe that this is the first report of complete healing and closure of postlobectomy empyema space using the vacuum-assisted closure (VAC) device. A 72-year-old man who had undergone a three-incision esophagectomy for T2N0 squamous cell carcinoma 13 months previously was found to have a new right lower lobe lung nodule on computed tomographic scan. Computed tomographic-guided biopsy revealed squamous cell carcinoma. Metastatic work-up, including computed tomography of the head and bone scan was negative. The patient was taken to the operating room. Flexible bronchoscopic examination was normal, and cervical mediastinoscopy revealed no malignant involvement of mediastinal nodes. At thoracotomy, the lesion involved the chest wall, necessitating right lower lobectomy with chest wall resection, including portions of the sixth and seventh ribs. Reconstruction of the resulting 6 ⫻ 6 cm
Accepted for publication Oct 8, 2004. Address correspondence to Dr Varker, 424 Comprehensive Cancer Center, 410 West 12th Avenue, Columbus, OH 43210; e-mail: varker-1@ medctr.osu.edu.
0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2004.10.040
FEATURE ARTICLES
through disease lung (with air trapping), puncturing with a large needle (19 gauge or larger), and deep puncturing are all considered risk factors because they are thought to promote air aspiration by airway-venous communication, as well as increase the opportunity for such communication. This hypothesis is based in part on the fact that puncturing of a collapsed lung during one-lung ventilation has never caused air embolism. The patient reported herein, as well as some of our other patients, had a fit of coughing that continued about 10 to 20 seconds as a natural reflex after injection of the imaging agent. The large tumor in the present case might contribute to development of air trapping at the periphery of the tumor. In addition, the tumor in the present case was situated away from the visceral pleura and required deep injection (albeit, a 23-gauge needle was used). It is also possible that cerebral ischemic disease exacerbated the symptoms of cerebral air embolism. The lung is a unique organ with respect to sentinel lymph node mapping because of the possibility that tracer injection will cause an air embolism. Because air embolism is a serious and sometimes fatal complication, a large tumor and a centrally located tumor should not be considered for sentinel lymph node assessment in this manner.
CASE REPORT VARKER AND NG VAC OF EMPYEMA CAVITY
The authors gratefully acknowledge the assistance of Julia Beeson in the preparation of this article.
References 1. Maiwand MO. Cryotherapy for advanced carcinoma of the trachea and bronchi. BMJ 1986;293:181–2. 2. Maiwand MO, Evans JM, Beeson JE. The application of cryosurgery in the treatment of lung cancer. Cryobiology 2004;1:55– 61. 3. Ruers TJM, Joosten J, Jager GJ, Wobbes T. Long-term results of treating hepatic colorectal metastases with cryosurgery. Br J Surg 2001;88:844 –9. 4. Maiwand MO, Asimakopoulos G. Cryosurgery for lung cancer: clinical results and technical aspects. Technol Cancer Res Treat 2004;3:143–50. © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
UEDA ET AL AIR EMBOLISM
721
5. Maiwand MO, Homasson JP. Cryotherapy for tracheobronchial disorders. Clin Chest Med 1995;16:427– 43. 6. Rubinsky B. Cryosurgery. Ann Rev Biomed Eng 2000;02:157– 87. 7. Hewitt PM, Zhao J, Akhter J, Morris DL. A comparative study of liquid nitrogen and argon gas cryosurgery systems. Cryobiology 1997;35:303– 8. 8. Gage AA, Baust JG. Cryosurgery – a review of recent advances and current issues. CryoLetters 2002;23:69 –78. 9. Wang BY, Boag AH, Idrees M, Young ID, Unger PD. Malignant fibrous histiocytoma: a case report and review of the literature. Arch Pathol Lab Med 2004;128(4):456 – 60. 10. Damron TA, Beauchamp CP, Rougraff BT, Ward WG. Soft tissue lumps and bumps. J Bone Joint Surg Am 2003;6:1142–56.
Cerebral Air Embolism During Imaging of a Sentinel Lymphatic Drainage in the Respiratory Tract Kazuhiro Ueda, MD, Yoshikazu Kaneda, MD, Manabu Sudo, MD, Mitsutaka Jinbo, MD, Kazuyoshi Suga, MD, and Kimikazu Hamono, MD First Department of Surgery and Department of Radiology, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
We report a rare but notable case of cerebral air embolism complicating transthoracic intrapulmonary injection of an imaging agent used to locate sentinel lymph nodes. After a bolus injection of 2 mL of iopamidol into the peritumoral area with a 23-gauge needle, the patient complained of complete paralysis on his left side. Intraaortic gas was detected by computed tomography immediately after the injection. The patient recovered spontaneously without any additional complication. Surgeons should be aware of this rare but possible complication during sentinel lymph node assessment. (Ann Thorac Surg 2006;81:721–3) © 2006 by The Society of Thoracic Surgeons
S
ince Liptay and colleagues showed that sentinel lymph node mapping improves the detection of nodal micrometastasis in patients with nonsmall cell lung cancer [1], many investigators have explored the usefulness of various modalities in identifying the sentinel node [2–5]. However, little is known about the complications of sentinel lymph node assessment in the respiratory tract. Herein, we describe a case of cerebral air embolism complicating transthoracic intrapulmonary injection of an imaging agent used to locate the sentinel lymph node. A 77-year-old man was admitted to our hospital for suspected lung malignancy. The primary tumor was 5 cm in diameter and was located in the left lower lobe (S6). Although no motor paralysis was present at the time of Accepted for publication Nov 12, 2004. Address correspondence to Dr Ueda, Yamaguchi University School of Medicine, 1–1–1 Minami-Kogushi, Ube Yamaguchi 755– 8505, Japan; e-mail: [email protected].
0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2004.11.020
FEATURE ARTICLES
ance but was not appropriate for metastatic disease. Malignant fibrous histiocytoma is the most common soft tissue sarcoma of late adult life [9], with the pleomorphic subtype being the commonest. The 5-year survival rate after appropriate treatment for low-grade, large, softtissue sarcomas is 82% to 98%, for intermediate-grade tumors it is 80%, and for high-grade tumors it is 52% to 60% [10]. As a palliative procedure, endobronchial cryosurgery reduces tumor load and helps to maintain airway patency. However, at thoracotomy for planned resection, a significant number of patients have inoperable, obstructing lung carcinoma inaccessible through the tracheobronchial tree. A series of 17 such patients received direct intraoperative cryosurgery using nitrous oxide as the coolant for primary nonsmall cell carcinoma with encouraging results [4]. With this experience and the success of liquid nitrogen cryoablation in other tumors, such as colorectal liver metastases [4], we believe that this case was suitable for direct freezing of the tumors with liquid nitrogen at thoracotomy. In this particular patient, there was a very significant reduction in tumor mass 12 months post-cryosurgery, and the FDG18 positron-emission tomographic scan showed no evidence of active tumor at the site of cryosurgery, nor any evidence of metastatic disease elsewhere in the body. One of the main problems encountered in cryosurgery of organs such as the liver, kidney and prostate is the limiting, potential irreversible destruction of nearby healthy tissues and organs during cooling. With endobronchial and direct lung cryosurgery, air in the alveoli being a very poor thermal conductor provides a natural insulation hence protection of the adjacent healthy lung tissue during freezing. The outcome of this case suggests that direct liquid nitrogen cryosurgery may offer symptomatic benefit and potential curative treatment of metastatic malignant fibrous histiocytoma of the lung, especially when resection and endobronchial ablation is not possible, or both are not possible, and chemoradiotherapy is of limited value. Further research is being conducted to assess the possible contribution of cryosurgery to patients with other metastatic lung disease and unresectable primary lung tumors.
CASE REPORT
722
CASE REPORT AIR EMBOLISM
UEDA ET AL
FEATURE ARTICLES
Fig 1. With the patient in the prone position, the contrast material is injected into the peritumoral area under full inspiration to image the lymphatic drainage system.
admission, the patient’s history included cerebral infarction. On the basis of a clinical diagnosis of T2N0M0 lung cancer, he was considered eligible for indirect computed tomographic lymphography for the purpose of locating a sentinel lymph node [3] to be followed by surgery. With the patient in the prone position, the local anesthesia was achieved with a total of 5 mL of 1% lidocaine hydrochloride at the injection site. An injection of 2 mL of iopamidol (Iopamiron 300 [Nippon Shering, Osaka, Japan]), targeted to the periphery of the tumor, was given through a 23-gauge needle attached to a 2.5 mL syringe (Fig 1). This contrast agent, which is conventionally used as an extracellular contrast agent for angiography and enhanced computed tomography, has an iodine concentration of 300 mg/mL, an osmolarity of 585 mOsm/kg, a viscosity of 4.4 mPa/s, and a pH of 6.5 to 7.5. Indirect lymphography scans at full inspiration with predefined measurements were obtained successively at 30 seconds, and at 1, 3, and 5 minutes after the iopamidol injection. Immediately after the last scan, the patient complained of complete paralysis on his left side. Intra-arterial gas noted on the computed tomographic scan at 1 minute after the injection was strongly suggestive of cerebral air embolism (Fig 2). Fortunately the patient recovered spontaneously and fully during 15 minutes of placing the patient in the Trendelenburg position to keep air out of the cerebral circulation. Magnetic resonance imaging of the brain on the following day showed no abnormality.
Ann Thorac Surg 2006;81:721–3
hook-type marker into the lung parenchyma to locate small or impalpable tumors [7]. The air embolism may be caused primarily by the pulmonary puncture itself, which can open a communication between a bronchiole and contiguous pulmonary vein [6, 7]. Therefore, care should be taken during sentinel lymphatic drainage assessment that requires pulmonary puncture for delivering an imaging agent into the tumor or peritumoral area. We have performed sentinel lymph node assessment in patients with lung cancer since August 2001, with the approval of our institutional review board. Initially, we injected radiolabeled tin colloid into the peritumoral area with computed tomographic guidance for intraoperative detection of radioactive lymph nodes by means of a hand-held ␥-detecting probe [2]. We now use iopamidol as the contrast material to image the lymphatic drainage preoperatively by means of computed tomographic lymphography [3]. We have performed this procedure in 42 cases to date without significant adverse effects, except in 1 patient who required transient chest tube drainage for moderate pneumothorax. Although the patient described herein recovered fully without any treatment, air embolism can occasionally be fatal [7]; five of 12 reported cases developing systemic air embolism were fatal despite intensive treatment. Treatment of systemic air embolism consists of placing the patient in a left lateral decubitus position (to prevent air within the left atrium from embolizing systemically) or in the Trendelenburg position. Ventilatory support with 100% oxygen should be administered to promote resorption of air bubbles. Transfer to a hyperbaric chamber may improve survival after air embolization. Little is known about risk factors for air embolism complicating pulmonary puncture. Positive airway pressure with mechanical ventilation, coughing, puncturing
Comment Air embolism is recognized as a rare but potentially fatal complication of transthoracic lung needle biopsy with a reported incidence of 0.07% [6]. Thoracic surgeons have also experienced this problem during insertion of a
Fig 2. Intra-arterial gas is detected in the descending aorta 1 minute after the injection of contrast material.
Ann Thorac Surg 2006;81:723–5
References 1. Liptay MJ, Grondin SC, Fry WA, et al. Intraoperative sentinel lymph node mapping in non-small cell lung cancer improves detection of micrometastases. J Clin Oncol 2002;20:1984 – 8. 2. Ueda K, Suga K, Kaneda Y, et al. Radioisotope lymph node mapping in nonsmall cell lung cancer: can it be applicable for sentinel node biopsy? Ann Thorac Surg 2004;77:426 –30. 3. Ueda K, Suga K, Kaneda Y, Li TS, Ueda K, Hamano K. Preoperative imaging of the lung sentinel lymphatic basin with computed tomographic lymphography: a preliminary study. Ann Thorac Surg 2004;77:1033–7. 4. Sugi K, Kaneda Y, Sudoh M, Sakano H, Hamano K. Effect of radioisotope sentinel node mapping in patients with cT1 N0 M0 lung cancer. J Thorac Cardiovasc Surg 2003;126:568 –73. 5. Nakagawa T, Minamiya Y, Katayose Y, et al. A novel method for sentinel lymph node mapping using magnetite in patients with non-small cell lung cancer. J Thorac Cardiovasc Surg 2003;126:563–7. 6. Sinner WN. Complications of percutaneous transthoracic needle aspiration biopsy. Acta Radiol Diagn (Stockh) 1976;17: 813–28. 7. Sakiyama S, Kondo K, Matsuoka H, et al. Fatal air embolism during computed tomography-guided pulmonary marking with a hook-type marker. J Thorac Cardiovasc Surg 2003;126:1207–9.
Management of Empyema Cavity With the Vacuum-Assisted Closure Device Kimberly A. Varker, MD, and Thomas Ng, MD, FACS Surgical Oncology, Roger Williams Medical Center, Department of Surgery, Brown University Medical School, Providence, Rhode Island © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
723
Management of empyema after pulmonary resection remains a challenging problem. Along with mandatory drainage of the thoracic cavity and investigations to rule out bronchopleural fistula, a reliable method of thoracic cavity closure is needed. The open thoracic window and Eloesser flap techniques rarely represent definitive therapy. Muscle flap and thoracoplasty procedures may provide well-vascularized tissue to close bronchopleural fistula and obliterate the empyema cavity, but they are quite complex and involve significant patient morbidity. We report a case of empyema without bronchopleural fistula after lobectomy in which the vacuum-assisted closure device was used to achieve complete wound healing after open drainage. (Ann Thorac Surg 2006;81:723–5) © 2006 by The Society of Thoracic Surgeons
A
fter preexisting pulmonary infections, postsurgical procedure is the second most common cause of empyema [1]. The incidence of empyema after lobectomy is 1% to 3%, and after pneumonectomy as high as 12% [1]. Although postpneumonectomy empyema is associated with bronchopleural fistula in 75% to 80% of cases, postlobectomy empyema is usually due to prolonged parenchymal air leak with persistent pleural space [2]. Initial management of postlobectomy empyema includes tube thoracostomy drainage and systemic antibiotic therapy [1, 2]. Thoracoscopic adhesiolysis or installation of fibrinolytic agents may be useful in the early stages of empyema [3]. Failure of conservative management should prompt open drainage of the empyema space to promote control of sepsis and patient stabilization [2]. Options for management of the empyema space after open drainage have traditionally included muscle flap closure, thoracoplasty procedures, or delayed thoracic closure after sterilization (the Clagett procedure) [4, 5]. We believe that this is the first report of complete healing and closure of postlobectomy empyema space using the vacuum-assisted closure (VAC) device. A 72-year-old man who had undergone a three-incision esophagectomy for T2N0 squamous cell carcinoma 13 months previously was found to have a new right lower lobe lung nodule on computed tomographic scan. Computed tomographic-guided biopsy revealed squamous cell carcinoma. Metastatic work-up, including computed tomography of the head and bone scan was negative. The patient was taken to the operating room. Flexible bronchoscopic examination was normal, and cervical mediastinoscopy revealed no malignant involvement of mediastinal nodes. At thoracotomy, the lesion involved the chest wall, necessitating right lower lobectomy with chest wall resection, including portions of the sixth and seventh ribs. Reconstruction of the resulting 6 ⫻ 6 cm
Accepted for publication Oct 8, 2004. Address correspondence to Dr Varker, 424 Comprehensive Cancer Center, 410 West 12th Avenue, Columbus, OH 43210; e-mail: varker-1@ medctr.osu.edu.
0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2004.10.040
FEATURE ARTICLES
through disease lung (with air trapping), puncturing with a large needle (19 gauge or larger), and deep puncturing are all considered risk factors because they are thought to promote air aspiration by airway-venous communication, as well as increase the opportunity for such communication. This hypothesis is based in part on the fact that puncturing of a collapsed lung during one-lung ventilation has never caused air embolism. The patient reported herein, as well as some of our other patients, had a fit of coughing that continued about 10 to 20 seconds as a natural reflex after injection of the imaging agent. The large tumor in the present case might contribute to development of air trapping at the periphery of the tumor. In addition, the tumor in the present case was situated away from the visceral pleura and required deep injection (albeit, a 23-gauge needle was used). It is also possible that cerebral ischemic disease exacerbated the symptoms of cerebral air embolism. The lung is a unique organ with respect to sentinel lymph node mapping because of the possibility that tracer injection will cause an air embolism. Because air embolism is a serious and sometimes fatal complication, a large tumor and a centrally located tumor should not be considered for sentinel lymph node assessment in this manner.
CASE REPORT VARKER AND NG VAC OF EMPYEMA CAVITY