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Postpneumonectomy empyema
Postpneumonectomy empyema Neomycin instillation and definitive closure Edward G. Stafford, M.D., and O. Theron Clagett, M.D., Rochester, Minn.
J_
of this paper is to review and evaluate the further experience of the Mayo Clinic in the late management of postpneumonectomy empyema by the instillation of neomycin solution and the definitive closure of the pleural space. Method and material During the 12 year period from 1958 through 1969, there were 18 patients who had empyema after pneumonectomy and who were treated by the method previously outlined. Twelve patients had undergone operations for primary lung malignancies, 1 for benign adenoma, and 5 for chronic pulmonary infection; their ages ranged from 55 to 65 years. Fourteen patients underwent right pneumonectomy, while the remaining 4 had left pneumonectomy. The 15 patients who were originally operated upon at the Mayo Clinic received antibiotics after the operation, most commonly a combination of penicillin and streptomycin intramuscularly for 5 days. The other 3 patients had their initial surgery at other institutions and were referred to our institution for treatment of the pleural space infection. In 8 patients, the empyema was diagnosed within 1 month of operation. In the remaining 10 patients, the infection developed from 6 weeks to 26 years after lung resection. One patient had empyema secondary to a bronchopleural fistula, and 3 patients had empyema after an esophagopleural fistula had developed. 77 1
The Journal of
772
Stafford and Clagett
Thoracic and Cardiovascular Surgery
New opening - 3 *
*
>
■
-
v<
__-\-Scapula _4Latissimusdorsi m. Trapeziusm,
Intercostal m. Latissimus ~\ dorsi m.
\ Periosteum incised
'Contents of empyema removed with a sucker and irrigated
Fig. 1. Technique for open drainage and definitive closure. A, Anterior end of previous incision opened. B, Section of rib excised. C, Cavity completely evacuated and thoroughly irrigated. D, For later closure, tissues are mobilized and closed with continuous catgut in layers. E, Continuous suture for skin.
In every patient, an open drainage procedure was done at some stage before closure was attempted. Such drainage was usually preceded by diagnostic pleural aspiration and, in some patients, by closed tube drainage of the pleural space. For open drainage, the anterior end of the thoracotomy is opened and a segment of rib in the midaxillary line is excised. The opening must not be made too far anteriorly because then less muscle and fascia are available for wound closure. Because the ipsilateral hemidiaphragm rises after pneumonectomy, the previous incision is usually at a satisfactory level to allow dependent drainage. Occasionally, a separate lower incision is necessary to obtain complete drainage (Fig. 1). The pleural space is then evacuated and thoroughly irrigated. Subcutaneous tissue is sutured to the pleura, thereby creating an open window; no drainage tubes are required. The absence of drain tubes makes it more comfortable for the patient and
simplifies irrigations and wound dressings. If the pleural cavity has been properly cleansed, there is little drainage after the second day. Irrigation of the cavity is continued daily with half-strength Dakins solution until the patient leaves the hospital on the fifth or sixth day; the patient can have regular irrigations at home, with little inconvenience. After 4 to 8 weeks of open drainage, the size of the pleural space decreases, and the space becomes lined by clean granulation tissue. In our series, on three occasions, dilute antibiotic solution was used to irrigate the empyema cavity from one to three times. For definitive closure, light general anesthesia is required. The sinus tract is excised, and skin and deeper muscle layers are mobilized. The cavity is repeatedly irrigated with saline to remove all debris and is filled with 0.25 per cent neomycin in saline solution. Usually 300 to 1,000 ml. of fluid is required to fill the space completely. The
Volume 63 Number 5
Postpneumonectomy
empyema
773
May, 1972
muscle and fascial layers are closed separately with a continuous chromic catgut suture in an attempt to get a water-tight closure. After the skin has been sutured, an elastic-sponge dressing is firmly applied to prevent extravasation of the intrapleural fluid into the subcutaneous tissue of the chest wall. The dressing is not disturbed for 8 days. Results In 11 of the 18 patients in the series, the cavity remained closed after the first closure operation (Table I ) . The follow-up on these 11 patients ranged from 4 months to 6 years, with a mean of 3 years. Four of the 7 patients whose cavities did not remain closed had drainage from the wound within 1 month of closure. One of the 4 patients had drainage of the antibiotic solution within 5 days, but the cavity was not infected and reclosure was successfully performed shortly afterward. Two other patients had early drainage due to recurrence of esophagopleural fistula. The fourth patient had early recurrent infection. Three patients had empyema develop late: one 7 months later and two 1 and 6 years after initial closure. The patient who had empyema after 6 years had been receiving cortisone for several years. In these 3 patients, the empyema was due to Staphylococcus aureus infection. Two of the patients with late recurrence refused further operative treatment and were satisfied to manage their persistently draining sinuses with intermittent irrigation and repeated dressings. Both had several operations for closure of esophagopleural fistulas; the fistulas were closed but the pleural infections persisted. One patient has had continuous drainage for 3 years and the other for 9 years. Five patients underwent a second attempt at closure. The procedure was successful in 3, and the cavities have stayed closed for 4, 5, and 9 years. One of the 5 patients had an immediate recurrence and underwent a third closure that was successful; the patient died 15 months later. The other patient with recurrence became reinfected with S. aureus 1 year after the second attempt at closure
Table I. Results of surgical closure of postpneumonectomy empyema cavities Closure First Remained closed Recurred Recurrent fistula Reinfection None Early Late Second Remained closed Recurred Reinfection Early Late Third Remained closed
No. of cases 18 11 7 2 5 1 1 3 5 3 2 2 1 1 2 2
but underwent successful closure at a third operation; follow-up was 7 months. Of the 8 patients with empyemas occurring in the early postoperative period, 6 had cavities that remained closed after the first attempt, whereas only 5 of the 10 patients with late-occurring empyema had successful closure. In our series, there were no deaths related to the operative procedure. Comment The diagnosis of early postoperative empyema is not always obvious because there are several causes of pyrexia more common than empyema and often patients who develop empyema early also have respiratory problems. Several bacterial cultures may be required before a positive growth is obtained because these patients usually have been receiving antibiotics. Late empyema was commonly overlooked in our series; 6 of the 10 patients who had late empyema had empyema necessitatis. In some, symptoms were considered to be due to tumor recurrence. This not only delayed the diagnosis but also sometimes delayed definitive closure because of the possibility of limited prognosis. The infections encountered were often low grade. Unless the infected postpneumonectomy space
The Journal of
774
Stafford and Clagett
Thoracic and Cardiovascular Surgery
is adequately drained surgically, it will either point externally or rupture into the bronchial stump. Rupture may account for some of the sudden deaths after pneumonectomy. Starkey and Ullyot- have commented on the poor prognosis of late-appearing postoperative empyema. As in other reported series,3-* S. aureus was the most common organism cultured in our series and was noted in 9 cases. Pseudomonas and Streptococcus organisms accounted for most of the remainder. It has often been quoted that multiple organisms growing from an empyema cavity should arouse suspicion of an internal fistula. Two or more organisms were cultured in 6 cases of primary empyema, and 2 of these cases were associated with fistulas. Usually, empyema is due to residual infection in the pleural cavity after operation. It is surprising that pleural space infection is so uncommon in light of the inevitable soiling that can occur with an infective lesion. Part of the recent decrease in the incidence of pleural infection after lung resection may be due to the routine use of the bronchial stapler as well as careful attention to surgical technique. The postpneumonectomy space is filled with serous fluid,' which provides an excellent growth medium for bacteria. Hematogenous spread may be responsible for some infections and can occur at any time. In our series, the empyema that occurred the longest after operation was noted 26 years after initial pneumonectomy. In 4 cases in our series, empyema occurred secondary to fistulas. One fistula was a small bronchopleural fistula which closed spontaneously after open drainage was established. There were three esophagopleural fistulas, all occurring on the right side. Formation of esophagopleural fistulas is a rare complication after pneumonectomy. Two such cases have been reported elsewhere.6 Obviously, these fistulas must close spontaneously or be closed surgically before an attempt at repair of the draining empyema sinus may be made. The recurrence of the fistula was responsible for failure of attempted closure of the empyema wound on
two occasions. In the third case, the empyema occurred 7 months after closure, but the fistula had healed. Neomycin was chosen as the antibiotic because of its broad antimicrobial range and bactericidal properties. Also, when the drug was initially used, there was an apparent lack of side effects from topical applications. It may be possible to use other antibiotics or mixtures of antibiotic solutions with equal effectiveness, depending on the organisms and sensitivity studies. Except on one occasion, we have not used other antibiotics because neomycin has seemed effective. None of our patients had toxic reactions from intrapleural neomycin, although the only patient whose cavity was irrigated with neomycin solution shortly after open drainage developed an itchy rash. The use of neomycin as well as that of the systemic antibiotics was ceased. Because Pseudomonas infection was resistant to neomycin, we decided to instill polymyxin B sulfate at the closure operation, with success. The most serious toxic reaction reported from the use of topical neomycin is perceptive nerve damage/ which is irreversible and may occur as long as 4 weeks after the cessation of treatment.8 This complication has been noted on four occasions*"1" after intrapleural use of neomycin. In all four, nerve damage occurred after neomycin solution was used on an acutely inflamed pleura at a total dose range of 4 to 498 Gm. Open drainage certainly provides more complete drainage than that with a closed tube system and probably involves less chance of antibiotic toxicity because, in our opinion, a clean noninflamed pleura results in slower systemic absorption of neomycin and, therefore, less toxicity and more local effectiveness in dealing with any residual infection. We have been reluctant to aspirate this fluid for study after closure because of the possibility of reinfection. Therefore, we do not know what happens to this space. Radiologically, the hemothorax remains opacified after closure, as it would after an uncomplicated pneumonectomy. The saline and neomycin solution either may remain in the space for
Volume 63 Number 5 May, 1972
awhile or may be replaced by the usual serous effusion that normally fills the space. This method of management has been used successfully by other authors.11- 1J With a different regimen, Dieter and colleagues'" used repeated neomycin irrigation via a closed tube drainage system until three cultures were negative; then they filled the pleural space with the antibiotic. They used this method on 2 postpneumonectomy patients, with successful follow-up of more than 1 year. Conklin1' has described another modification: He carried out early open debridement and primary closure with 0.25 per cent neomycin instillation in 2 patients. The cavities were still closed 7 months and 3 years later. We believe that open drainage is preferable in most of these patients because it allows complete evacuation of the pleural space and provides better drainage. Hospitalization is short, and irrigations can be done at home. After 4 to 8 weeks of open drainage, the pleural space will be lined by clean granulation tissue, which provides an optimal setting for definitive closure. This closure is a relatively minor procedure, and we advocate an aggressive approach to the problem unless there is positive evidence of tumor recurrence. Another alternative is to close the area of chronic infection by a mutilating thoracoplasty, which is a major surgical undertaking. Summary Empyema occurring after pneumonectomy is an uncommon but formidable problem that may present early after the operation or many years later. At the Mayo Clinic, from 1958 through 1969, there were 18 cases of postpneumonectomy empyema. Initial open drainage of the empyema was performed, and several weeks later a definitive closure of the pleural space was obtained after instillation of 0.25 per cent neomycin solution. With this relatively minor procedure, 11 patients had no further problems from the empyema after the initial closure, with a mean follow-up of 5 years. In the remaining 5 who underwent further surgery, closure was successful on
Postpneumonectomy
empyema
77 5
the second or third attempt; 2 patients elected not to undergo further surgery. The factors responsible for early failure were recurrence of an internal fistula and reinfection. Late recurrence of empyema was noted as long as 6 years after the initial closure procedure. REFERENCES 1 Clagett, O. T., and Geraci, J. E.: A Procedure for the Management of Postpneumonectomy Empyema, J. T H O R A C CARDIOVASC. SURG. 45:
141, 1963. 2 Starkey, G. W. B., and Ullyot, D. J.: Pleural Empyema: A Grave Surgical Complication, Surg. Clin. North Am. 48: 507, 1968. 3 Geha, A. S.: Pleura Empyema: Changing Etiologic, Bacteriologic, and Therapeutic Aspects, J. THORAC. CARDIOVASC. SURG. 6 1 : 626,
1971. 4 Snider, G. L., and Saleh, S. S.: Empyema of the Thorax in Adults: Review of 105 Cases, Chest 54: 410, 1968. 5 Suarez, J., Clagett, O. T., and Brown, A. L., Jr.: The Postpneumonectomy Space: Factors Influencing Its Obliteration, J. THORAC. CARDIOVASC SURG. 57: 539, 1969.
6 Benjamin, I., Olsen, A. M., and Ellis, F. H., Jr.: Esophagopleural Fistula: A Rare Postpneumonectomy Complication, Ann. Thorac. Surg. 7: 139, 1969. 7 Lindsay, J. R., Proctor, L. R., and Work, W. P.: Histopathologic Inner Ear Changes in Deafness Due to Neomycin in a Human, Laryngoscope 70: 382, 1960. 8 Leach, W.: Ototoxicity of Neomycin and Other Antibiotics, J. Laryngol. Otol. 76: 774, 1962. 9 Helm, W. H.: Ototoxicity of Neomycin Aerosol (Letter to the Editor), Lancet 1: 1294, 1960. 10 Myerson, M., Knight, H. F., Gambarini, A. J., and Curran, T. L.: Intrapleural Neomycin Causing Ototoxicity, Ann. Thorac. Surg. 9: 483, 1970. 11 McElvein, R. B., Mayo, P., and Long, G. A.: Management of Post-pneumonectomy Empyema: Report of a Case, Chest 53: 663, 1968. 12 Robinson, C. L. N . : Pyogenic Postpneumonectomy Empyema, Can. Med. Assoc. J. 95: 1294, 1966. 13 Dieter, R. A., Jr., Pifarre, R., Neville, W. E., Magno, M., and Jasuja, M.: Empyema Treated With Neomycin Irrigation and Closed-Chest Drainage,
J.
THORAC.
CARDIOVASC
SURG.
59:
496, 1970. 14 Conklin, W. S.: Post-pneumonectomy Empyema: Single-Stage Operative Treatment, J. T H O R A C CARDIOVASC
SURG. 5 5 : 634, 1968.
J_
of this paper is to review and evaluate the further experience of the Mayo Clinic in the late management of postpneumonectomy empyema by the instillation of neomycin solution and the definitive closure of the pleural space. Method and material During the 12 year period from 1958 through 1969, there were 18 patients who had empyema after pneumonectomy and who were treated by the method previously outlined. Twelve patients had undergone operations for primary lung malignancies, 1 for benign adenoma, and 5 for chronic pulmonary infection; their ages ranged from 55 to 65 years. Fourteen patients underwent right pneumonectomy, while the remaining 4 had left pneumonectomy. The 15 patients who were originally operated upon at the Mayo Clinic received antibiotics after the operation, most commonly a combination of penicillin and streptomycin intramuscularly for 5 days. The other 3 patients had their initial surgery at other institutions and were referred to our institution for treatment of the pleural space infection. In 8 patients, the empyema was diagnosed within 1 month of operation. In the remaining 10 patients, the infection developed from 6 weeks to 26 years after lung resection. One patient had empyema secondary to a bronchopleural fistula, and 3 patients had empyema after an esophagopleural fistula had developed. 77 1
The Journal of
772
Stafford and Clagett
Thoracic and Cardiovascular Surgery
New opening - 3 *
*
>
■
-
v<
__-\-Scapula _4Latissimusdorsi m. Trapeziusm,
Intercostal m. Latissimus ~\ dorsi m.
\ Periosteum incised
'Contents of empyema removed with a sucker and irrigated
Fig. 1. Technique for open drainage and definitive closure. A, Anterior end of previous incision opened. B, Section of rib excised. C, Cavity completely evacuated and thoroughly irrigated. D, For later closure, tissues are mobilized and closed with continuous catgut in layers. E, Continuous suture for skin.
In every patient, an open drainage procedure was done at some stage before closure was attempted. Such drainage was usually preceded by diagnostic pleural aspiration and, in some patients, by closed tube drainage of the pleural space. For open drainage, the anterior end of the thoracotomy is opened and a segment of rib in the midaxillary line is excised. The opening must not be made too far anteriorly because then less muscle and fascia are available for wound closure. Because the ipsilateral hemidiaphragm rises after pneumonectomy, the previous incision is usually at a satisfactory level to allow dependent drainage. Occasionally, a separate lower incision is necessary to obtain complete drainage (Fig. 1). The pleural space is then evacuated and thoroughly irrigated. Subcutaneous tissue is sutured to the pleura, thereby creating an open window; no drainage tubes are required. The absence of drain tubes makes it more comfortable for the patient and
simplifies irrigations and wound dressings. If the pleural cavity has been properly cleansed, there is little drainage after the second day. Irrigation of the cavity is continued daily with half-strength Dakins solution until the patient leaves the hospital on the fifth or sixth day; the patient can have regular irrigations at home, with little inconvenience. After 4 to 8 weeks of open drainage, the size of the pleural space decreases, and the space becomes lined by clean granulation tissue. In our series, on three occasions, dilute antibiotic solution was used to irrigate the empyema cavity from one to three times. For definitive closure, light general anesthesia is required. The sinus tract is excised, and skin and deeper muscle layers are mobilized. The cavity is repeatedly irrigated with saline to remove all debris and is filled with 0.25 per cent neomycin in saline solution. Usually 300 to 1,000 ml. of fluid is required to fill the space completely. The
Volume 63 Number 5
Postpneumonectomy
empyema
773
May, 1972
muscle and fascial layers are closed separately with a continuous chromic catgut suture in an attempt to get a water-tight closure. After the skin has been sutured, an elastic-sponge dressing is firmly applied to prevent extravasation of the intrapleural fluid into the subcutaneous tissue of the chest wall. The dressing is not disturbed for 8 days. Results In 11 of the 18 patients in the series, the cavity remained closed after the first closure operation (Table I ) . The follow-up on these 11 patients ranged from 4 months to 6 years, with a mean of 3 years. Four of the 7 patients whose cavities did not remain closed had drainage from the wound within 1 month of closure. One of the 4 patients had drainage of the antibiotic solution within 5 days, but the cavity was not infected and reclosure was successfully performed shortly afterward. Two other patients had early drainage due to recurrence of esophagopleural fistula. The fourth patient had early recurrent infection. Three patients had empyema develop late: one 7 months later and two 1 and 6 years after initial closure. The patient who had empyema after 6 years had been receiving cortisone for several years. In these 3 patients, the empyema was due to Staphylococcus aureus infection. Two of the patients with late recurrence refused further operative treatment and were satisfied to manage their persistently draining sinuses with intermittent irrigation and repeated dressings. Both had several operations for closure of esophagopleural fistulas; the fistulas were closed but the pleural infections persisted. One patient has had continuous drainage for 3 years and the other for 9 years. Five patients underwent a second attempt at closure. The procedure was successful in 3, and the cavities have stayed closed for 4, 5, and 9 years. One of the 5 patients had an immediate recurrence and underwent a third closure that was successful; the patient died 15 months later. The other patient with recurrence became reinfected with S. aureus 1 year after the second attempt at closure
Table I. Results of surgical closure of postpneumonectomy empyema cavities Closure First Remained closed Recurred Recurrent fistula Reinfection None Early Late Second Remained closed Recurred Reinfection Early Late Third Remained closed
No. of cases 18 11 7 2 5 1 1 3 5 3 2 2 1 1 2 2
but underwent successful closure at a third operation; follow-up was 7 months. Of the 8 patients with empyemas occurring in the early postoperative period, 6 had cavities that remained closed after the first attempt, whereas only 5 of the 10 patients with late-occurring empyema had successful closure. In our series, there were no deaths related to the operative procedure. Comment The diagnosis of early postoperative empyema is not always obvious because there are several causes of pyrexia more common than empyema and often patients who develop empyema early also have respiratory problems. Several bacterial cultures may be required before a positive growth is obtained because these patients usually have been receiving antibiotics. Late empyema was commonly overlooked in our series; 6 of the 10 patients who had late empyema had empyema necessitatis. In some, symptoms were considered to be due to tumor recurrence. This not only delayed the diagnosis but also sometimes delayed definitive closure because of the possibility of limited prognosis. The infections encountered were often low grade. Unless the infected postpneumonectomy space
The Journal of
774
Stafford and Clagett
Thoracic and Cardiovascular Surgery
is adequately drained surgically, it will either point externally or rupture into the bronchial stump. Rupture may account for some of the sudden deaths after pneumonectomy. Starkey and Ullyot- have commented on the poor prognosis of late-appearing postoperative empyema. As in other reported series,3-* S. aureus was the most common organism cultured in our series and was noted in 9 cases. Pseudomonas and Streptococcus organisms accounted for most of the remainder. It has often been quoted that multiple organisms growing from an empyema cavity should arouse suspicion of an internal fistula. Two or more organisms were cultured in 6 cases of primary empyema, and 2 of these cases were associated with fistulas. Usually, empyema is due to residual infection in the pleural cavity after operation. It is surprising that pleural space infection is so uncommon in light of the inevitable soiling that can occur with an infective lesion. Part of the recent decrease in the incidence of pleural infection after lung resection may be due to the routine use of the bronchial stapler as well as careful attention to surgical technique. The postpneumonectomy space is filled with serous fluid,' which provides an excellent growth medium for bacteria. Hematogenous spread may be responsible for some infections and can occur at any time. In our series, the empyema that occurred the longest after operation was noted 26 years after initial pneumonectomy. In 4 cases in our series, empyema occurred secondary to fistulas. One fistula was a small bronchopleural fistula which closed spontaneously after open drainage was established. There were three esophagopleural fistulas, all occurring on the right side. Formation of esophagopleural fistulas is a rare complication after pneumonectomy. Two such cases have been reported elsewhere.6 Obviously, these fistulas must close spontaneously or be closed surgically before an attempt at repair of the draining empyema sinus may be made. The recurrence of the fistula was responsible for failure of attempted closure of the empyema wound on
two occasions. In the third case, the empyema occurred 7 months after closure, but the fistula had healed. Neomycin was chosen as the antibiotic because of its broad antimicrobial range and bactericidal properties. Also, when the drug was initially used, there was an apparent lack of side effects from topical applications. It may be possible to use other antibiotics or mixtures of antibiotic solutions with equal effectiveness, depending on the organisms and sensitivity studies. Except on one occasion, we have not used other antibiotics because neomycin has seemed effective. None of our patients had toxic reactions from intrapleural neomycin, although the only patient whose cavity was irrigated with neomycin solution shortly after open drainage developed an itchy rash. The use of neomycin as well as that of the systemic antibiotics was ceased. Because Pseudomonas infection was resistant to neomycin, we decided to instill polymyxin B sulfate at the closure operation, with success. The most serious toxic reaction reported from the use of topical neomycin is perceptive nerve damage/ which is irreversible and may occur as long as 4 weeks after the cessation of treatment.8 This complication has been noted on four occasions*"1" after intrapleural use of neomycin. In all four, nerve damage occurred after neomycin solution was used on an acutely inflamed pleura at a total dose range of 4 to 498 Gm. Open drainage certainly provides more complete drainage than that with a closed tube system and probably involves less chance of antibiotic toxicity because, in our opinion, a clean noninflamed pleura results in slower systemic absorption of neomycin and, therefore, less toxicity and more local effectiveness in dealing with any residual infection. We have been reluctant to aspirate this fluid for study after closure because of the possibility of reinfection. Therefore, we do not know what happens to this space. Radiologically, the hemothorax remains opacified after closure, as it would after an uncomplicated pneumonectomy. The saline and neomycin solution either may remain in the space for
Volume 63 Number 5 May, 1972
awhile or may be replaced by the usual serous effusion that normally fills the space. This method of management has been used successfully by other authors.11- 1J With a different regimen, Dieter and colleagues'" used repeated neomycin irrigation via a closed tube drainage system until three cultures were negative; then they filled the pleural space with the antibiotic. They used this method on 2 postpneumonectomy patients, with successful follow-up of more than 1 year. Conklin1' has described another modification: He carried out early open debridement and primary closure with 0.25 per cent neomycin instillation in 2 patients. The cavities were still closed 7 months and 3 years later. We believe that open drainage is preferable in most of these patients because it allows complete evacuation of the pleural space and provides better drainage. Hospitalization is short, and irrigations can be done at home. After 4 to 8 weeks of open drainage, the pleural space will be lined by clean granulation tissue, which provides an optimal setting for definitive closure. This closure is a relatively minor procedure, and we advocate an aggressive approach to the problem unless there is positive evidence of tumor recurrence. Another alternative is to close the area of chronic infection by a mutilating thoracoplasty, which is a major surgical undertaking. Summary Empyema occurring after pneumonectomy is an uncommon but formidable problem that may present early after the operation or many years later. At the Mayo Clinic, from 1958 through 1969, there were 18 cases of postpneumonectomy empyema. Initial open drainage of the empyema was performed, and several weeks later a definitive closure of the pleural space was obtained after instillation of 0.25 per cent neomycin solution. With this relatively minor procedure, 11 patients had no further problems from the empyema after the initial closure, with a mean follow-up of 5 years. In the remaining 5 who underwent further surgery, closure was successful on
Postpneumonectomy
empyema
77 5
the second or third attempt; 2 patients elected not to undergo further surgery. The factors responsible for early failure were recurrence of an internal fistula and reinfection. Late recurrence of empyema was noted as long as 6 years after the initial closure procedure. REFERENCES 1 Clagett, O. T., and Geraci, J. E.: A Procedure for the Management of Postpneumonectomy Empyema, J. T H O R A C CARDIOVASC. SURG. 45:
141, 1963. 2 Starkey, G. W. B., and Ullyot, D. J.: Pleural Empyema: A Grave Surgical Complication, Surg. Clin. North Am. 48: 507, 1968. 3 Geha, A. S.: Pleura Empyema: Changing Etiologic, Bacteriologic, and Therapeutic Aspects, J. THORAC. CARDIOVASC. SURG. 6 1 : 626,
1971. 4 Snider, G. L., and Saleh, S. S.: Empyema of the Thorax in Adults: Review of 105 Cases, Chest 54: 410, 1968. 5 Suarez, J., Clagett, O. T., and Brown, A. L., Jr.: The Postpneumonectomy Space: Factors Influencing Its Obliteration, J. THORAC. CARDIOVASC SURG. 57: 539, 1969.
6 Benjamin, I., Olsen, A. M., and Ellis, F. H., Jr.: Esophagopleural Fistula: A Rare Postpneumonectomy Complication, Ann. Thorac. Surg. 7: 139, 1969. 7 Lindsay, J. R., Proctor, L. R., and Work, W. P.: Histopathologic Inner Ear Changes in Deafness Due to Neomycin in a Human, Laryngoscope 70: 382, 1960. 8 Leach, W.: Ototoxicity of Neomycin and Other Antibiotics, J. Laryngol. Otol. 76: 774, 1962. 9 Helm, W. H.: Ototoxicity of Neomycin Aerosol (Letter to the Editor), Lancet 1: 1294, 1960. 10 Myerson, M., Knight, H. F., Gambarini, A. J., and Curran, T. L.: Intrapleural Neomycin Causing Ototoxicity, Ann. Thorac. Surg. 9: 483, 1970. 11 McElvein, R. B., Mayo, P., and Long, G. A.: Management of Post-pneumonectomy Empyema: Report of a Case, Chest 53: 663, 1968. 12 Robinson, C. L. N . : Pyogenic Postpneumonectomy Empyema, Can. Med. Assoc. J. 95: 1294, 1966. 13 Dieter, R. A., Jr., Pifarre, R., Neville, W. E., Magno, M., and Jasuja, M.: Empyema Treated With Neomycin Irrigation and Closed-Chest Drainage,
J.
THORAC.
CARDIOVASC
SURG.
59:
496, 1970. 14 Conklin, W. S.: Post-pneumonectomy Empyema: Single-Stage Operative Treatment, J. T H O R A C CARDIOVASC
SURG. 5 5 : 634, 1968.