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INFECTION OF THE PLOMBAGE SPACE
INFECTION OF THE PLOMBAGE SPACE Its Prevention and Treatment Thomas F. Boyd, M.D.*
and John W. Strieder, M.D.,**
Boston,
Mass.
W
ITH the advent of effective antimicrobial agents and the low morbidity of resectional therapy, the surgical collapse treatment of pulmonary tuberculosis has been much less frequently used. Nevertheless, at the Sanatorium Division of the Boston City Hospital, we believe collapse procedures have a definite sphere of usefulness. During the year July 1, 1960, through June 30, 1961, we performed 12 thoracoplasties, of which one was a classical seven-rib, two-stage thoracoplasty, four were "tailoring" post-resection thoracoplasties, 6 were plombage thoracoplasties, and one was a modified Schede thoracoplasty. We have used and continue to use plombage thoracoplasty 1 ' 2 only for the treatment of certain cases of "open positive" tuberculosis. Classical thoracoplasty is reserved for the treatment of tuberculous empyema with bronchopleural fistula, and the "tailoring" type of thoracoplasty (with the preservation of the first ribs and the transverse processes) is used for the post-resection residual intrapleural air space. In general, our indications at the present time for the use of plombage thoracoplasties in positive cavitary tuberculosis are: (1) older age group, (2) moderate to severe pulmonary insufficiency, (3) bilaterally diffuse extensive disease regionally located, and (4) positive sputum on drugs after prolonged treatment time. If collapse therapy is to be used as the primary surgical treatment of cavitary pulmonary tuberculosis, it is our opinion that plombage thoracoplasty is the best available method for the following reasons: 1. The collapse procedure is completed at the first stage, thereby reducing positive secretions and the possibility of tuberculous spread. 2. There is no paradoxical motion of the thoracic cage; hence, the patient is able to cough effectively and raise secretions efficiently. 3. The pulmonary function loss is less, and the rise to final postoperative function level is more rapid than after standard posterolateral thoracoplasty of identical extent. 3 4. Unlike the results of classical thoracoplasty, the x-ray appearance of the disease or the appearance of the pleura and lung at the time of the extraFrom the Surgical Service, Sanatorium Division, Boston City Hospital, Boston, Mass. Received for publication Sept 24, 1962. •Associate Visiting- Thoracic Surgeon, Boston City Hospital, and Assistant Professor of Surgery, Boston University School of Medicine. **Surgeon-in-Chief for Thoracic Surgery, Boston City Hospital, and Clinical Professor of Surgery, Boston University School of Medicine. 682
Vol. 45 No. 5
I N F E C T I O N O F PLOMBAGE SPACE
683
periosteal exploration do not influence the results from this operation. By this, we mean that the type of disease, size of the cavity, flexibility of the pleura, and the ability of the lung to collapse do not influence the eventual rate of sputum conversion or the percentage of cases considered arrested. 4 Initially, the material used for the plomb consisted of gauze sponges, but, after experimenting with many plastic materials, perforated polyethylene truncated spheres ("doughnuts") were found to be the most satisfactory (Fig. 1). These are sterilized by boiling in distilled water for 30 minutes just before use. We use two sizes, either 1 inch or l1/^ inch in diameter, and place them in a polyethylene bag which has been sterilized by soaking in aqueous Zephiran for at least 18 hours prior to use. The neck of the bag is tied with heavy black silk to prevent escape of the spheres.
Fig. 1.—The polyethylene truncated spheres currently used In the performance of plombage thoracoplasty are shown. The two sixes are 1 inch and 1% inches in diameter. The depicted scale is a centimeter rule.
An early study from this clinic5 revealed that the incidence of tuberculosis organisms surrounding the plombage material was very high (37.5 per cent). In most instances, therefore, we have advised removal of the plombage material and the overlying devitalized ribs at approximately 4 months after the initial collapse procedure. This second stage of the operation has been designated "conversion" thoracoplasty. Throughout the period of this study, all patients were kept in the Sanatorium for at least 6 months after the original collapse procedure. At 4 months after the original operation, two or three cultures of fasting gastric contents were drawn from each patient who had plombage thoracoplasty performed. While awaiting the results of the gastric cultures, the so-called "conversion" thoracoplasty was performed if it were not thought to be contraindicated for specific reasons. If the gastric cultures were reported negative and thus sputum conversion attained, the patient was discharged. If not, laminagrams of the area were taken and further medical and/or surgical therapy outlined. If resectional surgery is thought to be indicated in a patient who still has the plombage material in situ, the surgical therapy should be staged. The first
BOYD AND STRIEDEE
684
stage should consist of "conversion" thoraeoplasty. resection may be attempted.
J. Thoracic and Cardiovas. Surg.
Three to 6 weeks later,
DATA
Our first plombage thoraeoplasty was performed in February, 1949. Through June, 1959, 135 consecutive "conversion" thoracoplasties have been performed on patients who had previously undergone unilateral plombage. Bacteriologic study of the space was not performed in 38 patients. In the 97 patients in whom bacteriologic study of the space was performed, 27 (28 per cent) had a smear, a culture, or both, positive for tuberculosis. The removal of the plombage material with smear and culture of the material at the time of removal yields valuable prognostic data. At the time of "conversion" thoraeoplasty, there were 27 spaces which were positive for tuberculosis. Of those patients with positive spaces, there were 11 in whom the sputum did not convert, a 41 per cent failure rate. Conversely, of the 70 patients who had negative spaces at the time of "conversion" thoraeoplasty, there were only 8 (11 per cent) in whom the sputum did not convert from positive to negative. The difference between these two groups is statistically very significant (p < 0.005). CLINICAL I N F E C T I O N
In this series of 135 patients, 125 developed no obvious clinical problem with the plombage space. However, 10 patients (7.4 per cent) revealed clinical evidence of infection of the space, so-called " extrapleural empyema." Of these, four were pure tuberculous infections, three were pure pyogenic infections, three were mixed pyogenic-tuberculous infections. This high incidence of clinical infection is a most compelling reason for the removal of the spheres and performance of "conversion" thoraeoplasty. Certain concepts have become part of our routine practice because of this study. If early ' ' conversion'' thoraeoplasty had been performed, 2 months after the original procedure, many of the cases of clinical infection in this series would have been obviated. None of the tuberculous infections, only one of the pyogenic infections, and only one of the mixed infections seems likely to have developed in these patients. M E T H O D OP H A N D L I N G T H E I N F E C T E D PLOMBAGE SPACE
If clinical infection develops immediately postoperatively, we permit the plombage to remain in place for at least 10 days before performing "conversion" thoraeoplasty. This is facilitated by repeated aspirations of the subscapular fluid or by the insertion of a tube attached to under-water seal drainage. Moderate negative pressure may be used. The patient also receives systemic antibiotics to which the pyogenic organisms in the space have been shown to have specific sensitivity. In those cases in which the infection develops more than 10 days postoperatively, immediate "conversion" thoraeoplasty has been performed. At this time, the plombage material and the devitalized ribs, with the exception of the first rib, are removed from the subscapular space. The pyogenic membrane is
Vol. 45, No. 5 May, 1963
I N F E C T I O N OF PLOMBAGE SPACE
685
removed by sharp dissection and curettage. Copious irrigation with normal saline is employed. If the scapula falls into the thoracoplasty area, that is, if it does not impinge on the first unresected rib, partial resection of the scapula is unnecessary. If it does impinge, leaving a subscapular space, partial resection should be carried out. The residual space is drained with several spiral rubber drains (Fig. 2). The parascapular muscles are closed tightly with interrupted sutures of catgut. The skin is closed tightly with interrupted sutures of stainless steel wire. Horizontal mattress sutures of the same material are placed about each drain but not tied. When the drains are removed on the third and fourth day, the mattress sutures are tied tightly. Large amounts of
Fig. 2.—The spiral-cut hard rubber drains used for drainage of the Infected subcostal space are shown. The various sizes are depicted against a centimeter rule.
the appropriate antibiotics are left in the subscapular space prior to closure. Since much of this material undoubtedly drains out within a few minutes after the dressing is applied, its usefulness is only conjectural. Appropriate systemic antibiotics are given in the postoperative period. RESULTS
With this method of therapy, all the pure tuberculous infections healed per primam. Of the mixed infections, two of the three healed per primam, as did two of the three pyogenic infections. The two that did not heal by primary intention required open drainage and packing for long periods of time. However, eight of the ten clinical "extrapleural empyemata" healed by primary union with this method of therapy (Table I ) .
686
J. Thoracic and Cardiovas. Surg.
BOYD AND STRIEDER TABLE I.
TYPE
NO. OF CASES
CLINICAL
l i
EXTRAPLEURAL E M P Y E M A "
L E N G T H OP T I M E BEFORE INFECTION DEVELOPED AFTER ORIGINAL OPERATION
R E S U L T W I T H OUTLINED SURGERY
Tuberculous
4 yr. 3 % yr. 3 % yr. 3 yr.
Healed Healed Healed Healed
per per per per
primam primam primam primam
Pyogenic
5 yr. 2 mo. 5 da.
Healed per primam Healed per primam Healed only after 3 years of packing
Mixed
3 yr. 2 yr. 6 wk.
Healed per primam Healed per primam Never healed
SUMMARY
1. A series of 135 consecutive unilateral "conversion" thoracoplasties is presented. 2. In these cases, there were bacteriologic data available for 97. 3. In the 97 spaces bacteriologically evaluated, in 27 (28 per cent) there was either a positive smear, a positive culture, or both. 4. Prognostic value of the bacteriologic data is great. If the space was bacteriologically negative, sputum conversion occurred in 89 per cent of patients. If the space was positive, there was sputum conversion in only 59 per cent of the patients. This difference is statistically very significant. 5. In this series of 135 patients, ten clinically evident "extrapleural empyemata" developed. Of these infections, four were pure tuberculous, three were mixed, and three were pyogenic. Of these, seven may have been avoided by early "conversion" thoracoplasty. 6. The treatment of clinical infection of the subscapular space by immediate thoracoplasty and tight closure of the wound about drains allowed eight of ten such infections to heal by primary intention. 7. In all of the 125 consecutive patients who were operated upon without evidence of clinical infection, there were no major complications. There were no deaths, no wound infections or disruptions, and no spreads of the tuberculous process. There was no loss of pulmonary function. REFERENCES 1. Lucas, B . G. B., and Cleland, W. P . : Thoracoplasty With Plombage: A Review of the Early Results in 25 Cases, Thorax 5: 248-256, 1950. 2. Woods, F . M., Walker, J . H., and Schmidt, I . : Extraperiosteal Temporary Plombage in Thoracoplasty: A Preliminary Report, Dis. Chest 18: 401-412, 1950. 3. Watson, T. R., and Gaensler, E. A . : Immediate and Late Respiratory Impairment Due to Selective Staged Thoracoplasty, Extraperiosteal Plombage and Extrapleural Conversion Thoracoplasty, Tr. N a t . Tuber. A. 48: 1-17, 1952. 4. Boyd, T. F . , Laforet, E. G., and Strieder, J . W . : Data to be published. 5. Desforges, G., Gibbons, G., and Strieder, J . W . : Tuberculous Infections Complicating Subcostal Plombage With Lucite Spheres for the Collapse Therapy of Pulmonary Tuberculosis, J . THORACIC SURG. 28: 636-637, 1954.
and John W. Strieder, M.D.,**
Boston,
Mass.
W
ITH the advent of effective antimicrobial agents and the low morbidity of resectional therapy, the surgical collapse treatment of pulmonary tuberculosis has been much less frequently used. Nevertheless, at the Sanatorium Division of the Boston City Hospital, we believe collapse procedures have a definite sphere of usefulness. During the year July 1, 1960, through June 30, 1961, we performed 12 thoracoplasties, of which one was a classical seven-rib, two-stage thoracoplasty, four were "tailoring" post-resection thoracoplasties, 6 were plombage thoracoplasties, and one was a modified Schede thoracoplasty. We have used and continue to use plombage thoracoplasty 1 ' 2 only for the treatment of certain cases of "open positive" tuberculosis. Classical thoracoplasty is reserved for the treatment of tuberculous empyema with bronchopleural fistula, and the "tailoring" type of thoracoplasty (with the preservation of the first ribs and the transverse processes) is used for the post-resection residual intrapleural air space. In general, our indications at the present time for the use of plombage thoracoplasties in positive cavitary tuberculosis are: (1) older age group, (2) moderate to severe pulmonary insufficiency, (3) bilaterally diffuse extensive disease regionally located, and (4) positive sputum on drugs after prolonged treatment time. If collapse therapy is to be used as the primary surgical treatment of cavitary pulmonary tuberculosis, it is our opinion that plombage thoracoplasty is the best available method for the following reasons: 1. The collapse procedure is completed at the first stage, thereby reducing positive secretions and the possibility of tuberculous spread. 2. There is no paradoxical motion of the thoracic cage; hence, the patient is able to cough effectively and raise secretions efficiently. 3. The pulmonary function loss is less, and the rise to final postoperative function level is more rapid than after standard posterolateral thoracoplasty of identical extent. 3 4. Unlike the results of classical thoracoplasty, the x-ray appearance of the disease or the appearance of the pleura and lung at the time of the extraFrom the Surgical Service, Sanatorium Division, Boston City Hospital, Boston, Mass. Received for publication Sept 24, 1962. •Associate Visiting- Thoracic Surgeon, Boston City Hospital, and Assistant Professor of Surgery, Boston University School of Medicine. **Surgeon-in-Chief for Thoracic Surgery, Boston City Hospital, and Clinical Professor of Surgery, Boston University School of Medicine. 682
Vol. 45 No. 5
I N F E C T I O N O F PLOMBAGE SPACE
683
periosteal exploration do not influence the results from this operation. By this, we mean that the type of disease, size of the cavity, flexibility of the pleura, and the ability of the lung to collapse do not influence the eventual rate of sputum conversion or the percentage of cases considered arrested. 4 Initially, the material used for the plomb consisted of gauze sponges, but, after experimenting with many plastic materials, perforated polyethylene truncated spheres ("doughnuts") were found to be the most satisfactory (Fig. 1). These are sterilized by boiling in distilled water for 30 minutes just before use. We use two sizes, either 1 inch or l1/^ inch in diameter, and place them in a polyethylene bag which has been sterilized by soaking in aqueous Zephiran for at least 18 hours prior to use. The neck of the bag is tied with heavy black silk to prevent escape of the spheres.
Fig. 1.—The polyethylene truncated spheres currently used In the performance of plombage thoracoplasty are shown. The two sixes are 1 inch and 1% inches in diameter. The depicted scale is a centimeter rule.
An early study from this clinic5 revealed that the incidence of tuberculosis organisms surrounding the plombage material was very high (37.5 per cent). In most instances, therefore, we have advised removal of the plombage material and the overlying devitalized ribs at approximately 4 months after the initial collapse procedure. This second stage of the operation has been designated "conversion" thoracoplasty. Throughout the period of this study, all patients were kept in the Sanatorium for at least 6 months after the original collapse procedure. At 4 months after the original operation, two or three cultures of fasting gastric contents were drawn from each patient who had plombage thoracoplasty performed. While awaiting the results of the gastric cultures, the so-called "conversion" thoracoplasty was performed if it were not thought to be contraindicated for specific reasons. If the gastric cultures were reported negative and thus sputum conversion attained, the patient was discharged. If not, laminagrams of the area were taken and further medical and/or surgical therapy outlined. If resectional surgery is thought to be indicated in a patient who still has the plombage material in situ, the surgical therapy should be staged. The first
BOYD AND STRIEDEE
684
stage should consist of "conversion" thoraeoplasty. resection may be attempted.
J. Thoracic and Cardiovas. Surg.
Three to 6 weeks later,
DATA
Our first plombage thoraeoplasty was performed in February, 1949. Through June, 1959, 135 consecutive "conversion" thoracoplasties have been performed on patients who had previously undergone unilateral plombage. Bacteriologic study of the space was not performed in 38 patients. In the 97 patients in whom bacteriologic study of the space was performed, 27 (28 per cent) had a smear, a culture, or both, positive for tuberculosis. The removal of the plombage material with smear and culture of the material at the time of removal yields valuable prognostic data. At the time of "conversion" thoraeoplasty, there were 27 spaces which were positive for tuberculosis. Of those patients with positive spaces, there were 11 in whom the sputum did not convert, a 41 per cent failure rate. Conversely, of the 70 patients who had negative spaces at the time of "conversion" thoraeoplasty, there were only 8 (11 per cent) in whom the sputum did not convert from positive to negative. The difference between these two groups is statistically very significant (p < 0.005). CLINICAL I N F E C T I O N
In this series of 135 patients, 125 developed no obvious clinical problem with the plombage space. However, 10 patients (7.4 per cent) revealed clinical evidence of infection of the space, so-called " extrapleural empyema." Of these, four were pure tuberculous infections, three were pure pyogenic infections, three were mixed pyogenic-tuberculous infections. This high incidence of clinical infection is a most compelling reason for the removal of the spheres and performance of "conversion" thoraeoplasty. Certain concepts have become part of our routine practice because of this study. If early ' ' conversion'' thoraeoplasty had been performed, 2 months after the original procedure, many of the cases of clinical infection in this series would have been obviated. None of the tuberculous infections, only one of the pyogenic infections, and only one of the mixed infections seems likely to have developed in these patients. M E T H O D OP H A N D L I N G T H E I N F E C T E D PLOMBAGE SPACE
If clinical infection develops immediately postoperatively, we permit the plombage to remain in place for at least 10 days before performing "conversion" thoraeoplasty. This is facilitated by repeated aspirations of the subscapular fluid or by the insertion of a tube attached to under-water seal drainage. Moderate negative pressure may be used. The patient also receives systemic antibiotics to which the pyogenic organisms in the space have been shown to have specific sensitivity. In those cases in which the infection develops more than 10 days postoperatively, immediate "conversion" thoraeoplasty has been performed. At this time, the plombage material and the devitalized ribs, with the exception of the first rib, are removed from the subscapular space. The pyogenic membrane is
Vol. 45, No. 5 May, 1963
I N F E C T I O N OF PLOMBAGE SPACE
685
removed by sharp dissection and curettage. Copious irrigation with normal saline is employed. If the scapula falls into the thoracoplasty area, that is, if it does not impinge on the first unresected rib, partial resection of the scapula is unnecessary. If it does impinge, leaving a subscapular space, partial resection should be carried out. The residual space is drained with several spiral rubber drains (Fig. 2). The parascapular muscles are closed tightly with interrupted sutures of catgut. The skin is closed tightly with interrupted sutures of stainless steel wire. Horizontal mattress sutures of the same material are placed about each drain but not tied. When the drains are removed on the third and fourth day, the mattress sutures are tied tightly. Large amounts of
Fig. 2.—The spiral-cut hard rubber drains used for drainage of the Infected subcostal space are shown. The various sizes are depicted against a centimeter rule.
the appropriate antibiotics are left in the subscapular space prior to closure. Since much of this material undoubtedly drains out within a few minutes after the dressing is applied, its usefulness is only conjectural. Appropriate systemic antibiotics are given in the postoperative period. RESULTS
With this method of therapy, all the pure tuberculous infections healed per primam. Of the mixed infections, two of the three healed per primam, as did two of the three pyogenic infections. The two that did not heal by primary intention required open drainage and packing for long periods of time. However, eight of the ten clinical "extrapleural empyemata" healed by primary union with this method of therapy (Table I ) .
686
J. Thoracic and Cardiovas. Surg.
BOYD AND STRIEDER TABLE I.
TYPE
NO. OF CASES
CLINICAL
l i
EXTRAPLEURAL E M P Y E M A "
L E N G T H OP T I M E BEFORE INFECTION DEVELOPED AFTER ORIGINAL OPERATION
R E S U L T W I T H OUTLINED SURGERY
Tuberculous
4 yr. 3 % yr. 3 % yr. 3 yr.
Healed Healed Healed Healed
per per per per
primam primam primam primam
Pyogenic
5 yr. 2 mo. 5 da.
Healed per primam Healed per primam Healed only after 3 years of packing
Mixed
3 yr. 2 yr. 6 wk.
Healed per primam Healed per primam Never healed
SUMMARY
1. A series of 135 consecutive unilateral "conversion" thoracoplasties is presented. 2. In these cases, there were bacteriologic data available for 97. 3. In the 97 spaces bacteriologically evaluated, in 27 (28 per cent) there was either a positive smear, a positive culture, or both. 4. Prognostic value of the bacteriologic data is great. If the space was bacteriologically negative, sputum conversion occurred in 89 per cent of patients. If the space was positive, there was sputum conversion in only 59 per cent of the patients. This difference is statistically very significant. 5. In this series of 135 patients, ten clinically evident "extrapleural empyemata" developed. Of these infections, four were pure tuberculous, three were mixed, and three were pyogenic. Of these, seven may have been avoided by early "conversion" thoracoplasty. 6. The treatment of clinical infection of the subscapular space by immediate thoracoplasty and tight closure of the wound about drains allowed eight of ten such infections to heal by primary intention. 7. In all of the 125 consecutive patients who were operated upon without evidence of clinical infection, there were no major complications. There were no deaths, no wound infections or disruptions, and no spreads of the tuberculous process. There was no loss of pulmonary function. REFERENCES 1. Lucas, B . G. B., and Cleland, W. P . : Thoracoplasty With Plombage: A Review of the Early Results in 25 Cases, Thorax 5: 248-256, 1950. 2. Woods, F . M., Walker, J . H., and Schmidt, I . : Extraperiosteal Temporary Plombage in Thoracoplasty: A Preliminary Report, Dis. Chest 18: 401-412, 1950. 3. Watson, T. R., and Gaensler, E. A . : Immediate and Late Respiratory Impairment Due to Selective Staged Thoracoplasty, Extraperiosteal Plombage and Extrapleural Conversion Thoracoplasty, Tr. N a t . Tuber. A. 48: 1-17, 1952. 4. Boyd, T. F . , Laforet, E. G., and Strieder, J . W . : Data to be published. 5. Desforges, G., Gibbons, G., and Strieder, J . W . : Tuberculous Infections Complicating Subcostal Plombage With Lucite Spheres for the Collapse Therapy of Pulmonary Tuberculosis, J . THORACIC SURG. 28: 636-637, 1954.