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Postpneumonectomy empyema in pulmonary carcinoma patients
Postpneumonectomy empyema in pulmonary carcinoma patients Treatment with antibiotic irrigation and closed-chest drainage Seven patients with postpneumonectomy empyema who had had pulmonary carcinoma were treated with intrapleural antibiotic irrigation and closed-chest drainage. Two tubes were used to irrigate and drain the cavity. Although most patients had a bronchopleural or esophagopleural fistula, the treatment was successful in every case. Three of the 7 patients died of far-advanced carcinoma I to 2 years postoperative!}', but none died of sequela of the empyema. In 3 patients with bronchopleural fistula, empyema recurred during the first postoperative year. However, it responded well to repeated irrigation and drainage. This simple, time-saving, and easily repeatable regimen proved to be both effective and also very comfortable for the patient. It has none of the disadvantages of open thoracic drainage or mutilating thoracoplasty.
Pentti Karkola, M . D . , Matti I. Kairaluoma, M . D . , and T e u v o K. I. Larmi, M . D . , Oulu,
Finland
IT ostpneumonectomy empyema with bronchopleural fistula is an infrequent but serious complication. This is particularly so because most of these operations have been performed on poor-risk patients with carcinoma of the lung, for which the prognosis is unpredictable. These patients are unable to tolerate any more extensive operation, such as thoracoplasty. Open thoracostomy drainage with neomycin irrigation, originally described by Clagett and Geraci,1 has been reported as yielding very good results. However, the patient might find an open thoracostomy with daily dressings uncomfortable, and most of them will later require a second operation, though a minor one, for closure of the open thoracostomy. Since 1971 we have successfully managed postpneumonectomy empyema in 7 patients who had had pulmonary carcinoma. We used two tubes to irrigate and drain the empyema cavity, as described by ProFrom the Department of Surgery, Oulu University Central Hospital, Oulu, Finland. Received for publication Jan. 19, 1976. Accepted for publication May 4, 1976. Address for reprints: Teuvo K.I. Larmi, M.D., Department of Surgery, Oulu University Central Hospital, SF-90220 Oulu 22, Finland.
van,2 with small modifications. This paper reports our experience with these patients. Method We followed the method described by Provan2 in which two tubes were used to irrigate and drain the empyema cavity. Once the diagnosis of bronchopleural fistula or pleural empyema was confirmed, a large silicone rubber tube was inserted under local anesthesia through the most dependent intercostal space and was connected to an underwater-seal drainage bottle. A large Intracath was inserted by needle puncture technique through the second or third intercostal space at the midclavicular line and connected to an intravenous infusion set. The systemic antibiotic and the antibiotic for intrapleural irrigation were selected on the basis of sensitivity tests. If a resistance developed during the treatment, the antibiotic was replaced by another antibiotic to which the organism was still sensitive. The pleural space was permitted free gravity drainage, and intrapleural antibiotic drip was continued, the unaffected side of the chest being supported and the patient held in such a position that the whole cavity, including the apex, was bathed in the antibiotic solution until the bronchopleural fistula was closed spontaneously. The fistula was considered to be closed when air 3 19
The Journal of Thoracic and Cardiovascular Surgery
3 2 0 Kdrkold, Kairaluoma, Larmi
Table I. Clinical data, treatment, and results
Patient
Age
1
J. 0 .
2
Primary operation
Occurrence and identification of fistula
60, M
Right pneumonectomy for squamous carcinoma with mediastinal metastases and a localized empyema pocket in 1971
Two weeks later, at bronchoscopy, a small bronchopleural fistula
1. Gentamicin and chloramphenicol 2. Erythromycin and nystatin 3. Erythromycin and nystatin
L. S.
52, M
No fistula; Empyema occurred 5 mo. later
Cephaloridine
3
O. H.
59, M
Right pneumonectomy for malignant papilloma with no glandular involvement in 1971 Right pneumonectomy for squamous carcinoma with no glandular involvement in 1972
4
A. K.
39, M
Right pneumonectomy for squamous carcinoma with no glandular involvement in 1972
1. Cephaloridine and gentamicin 2. Cephaloridine and gentamicin Cephaloridine
5
F. B.
42, M
Right pneumonectomy for squamous carcinoma with mediastinal involvement in 1972
6
P. M.
72, M
7
P. Y.
63, M
Left pneumonectomy for anaplastic, large-cell carcinoma with no glandular involvement in 1973 Right pneumonectomy for squamous carcinoma with no glandular involvement in 1973
Postop. day 1, a large bronchopleural fistula occurred requiring tracheostomy Postop. day 1, an esophagopleural fistula requiring reoperation 3 days later Postop. day 1, a large bronchopleural fistula at bronchoscopy Three weeks later, empyema without bronchopleural fistula
Case No.
leakage stopped. Closure was also confirmed at bronchoscopy. If no fistula was initially present we proceeded rapidly within a few days to the next step. About 100 to 200 ml. of antibiotic solution was then instilled through the Intracath, and the chest drainage tube was clamped. The antibiotic solution was permitted to remain within the chest for 12 hours, and then the tube was reopened. This procedure was carried out twice a day until the initial purulent drainage converted to a serous drainage and the culture was negative for the first time. The program was then modified in that the chest tube was kept clamped for 24 hours. When three consecutive cultures were reported as negative, the thoracic cavity was filled with antibiotic solution and both chest tubes were removed. Thereafter the instillation of antibiotic by thorecentesis was continued once a day for about a week. If there was no rise in temperature during the following 2 or 3 days, the patient was permitted to leave the hospital.
One week later, at bronchoscopy, a bronchopleural fistula
Antibiotics for irrigation
Cephaloridine and gentamicin Gemtamicin
I. Bacitracin and neomycin 2. Bacitracin and neomycin
Patients and results Clinical data and treatment of the 7 patients are given in Table I. Initially, culture grew Staphylococcus aureus in every patient. Three patients died during the follow-up period of far-advanced carcinoma, but none of empyema. The remainder are now doing well, showing no sign of recurrent empyema or pulmonary malignancy. The empyema recurred once in 3 patients. Their average treatment time was shorter than for patients without such recurrence. The recurrent empyema usually required retreatment for a period of one month. In one patient whose empyema recurred twice, the subsequent cultures also grew Candida in addition to Staphylococcus aureus. Discussion Earlier, postpneumonectomy empyema usually occurred following resections for tuberculosis. Today it is most often seen in patients with pulmonary carcinoma. In the series of Le Roux,3 empyema complicated
Volume 72 Number 2 August, 1976
Treatment time
Postpneumonectomy empyema
Recurrence after discontinuation of treatment
2 wk.
I wk.
1 mo.
3 mo.
Follow-up time
10 mo.
1 mo. 1 mo.
-
2 wk.
4 mo.
1 mo.
Results
4 yr.
Died of far-advanced carcinoma Doing well
3'/2 yr.
Doing well
3yr.
Died of far-advanced carcinoma
1 yr.
Died of far-advanced carcinoma
2yr.
Doing well
2 yr.
Doing well
3 wk.
2 mo.
1 mo. 1 mo. 2 wk.
7 mo. -
pneumonectomies in about 2 per cent of all cases. During the 10 year period from 1965 to 1974, 175 patients underwent pneumonectomy for pulmonary carcinoma at the Oulu University Central Hospital, and in 7 of these patients, i.e., about 4 per cent, postpneumonectomy empyema occurred. Many different methods have been used in the treatment of postpneumonectomy empyema. Initially, Eloesser,4 in 1935, used open thoracostomy in tuberculous postpneumonectomy empyema. In 1963 Clagett and Geraci1 adopted open-window thoracostomy and neomycin irrigation. They closed the thoracostomy wound after 6 to 8 weeks with instillation of neomycin solution to the pleural cavity. In 1970 Dieter and colleagues6 and the following year Provan2 reported their results with antibiotic irrigation and closed-chest drainage. Quite recently, Miller and colleagues7 have recommended balanced drainage of the contaminated pneumonectomy space. Finally, if all the aforementioned methods fail, thoracoplasty can still be used for obliteration of the residual cavity. None of these
321
methods however, has proved to be completely satisfactory or applicable in all cases. Owing to the lack of a uniform method of treatment, the number of papers directly dealing with this difficult subject is relatively small. Many authors1, s- 8~10 have reported very promising results with open-window thoracostomy drainage using neomycin irrigation. However, the series have been small, often consisting of a few cases, with the exception of the series of Virkkula and Eerola,9 which comprises 40 patients. This method requires rather long hospitalization, and the patient might find the open thoracostomy wound and daily dressings unpleasant. If the coexistent bronchopleural fistula heals spontaneously or can be closed operatively, an attempt to close the open-window thoracostomy is desirable.1, 5 Nevertheless, this requires a second operation, though a minor one, and in many patients empyema will still recur.5, 9 The method of antibiotic irrigation and closed-chest drainage here presented, which we successfully used as primary treatment of postpneumonectomy empyema in 7 patients who had had pulmonary carcinoma, is the method reported by Provan2 with small modifications. The regimen proposed by Dieter and colleagues6 is very similar, but they used only one chest tube. We agree with Provan2 that two chest tubes along with the posturing of the patient permit the whole cavity, including the apex, to be bathed in antibiotic solution. We did not have any problems when using this method in patients with bronchopleural or esophagopleural fistula, provided that the draining chest tube was continuously kept open and that we were careful with the posturing of the patient until the fistula healed, as it did in every case. The effectiveness of the present regimen in the acute phase of empyema has been doubted by some authors,9 but in our experience it worked effectively. The duration of the treatment did not differ significantly from that reported by others1, 5* 8' 9 for open-window thoracostomy, but we consider this regimen more convenient from the patient's point of view. The recurrence rate was about the same as in the study of Stafford and Clagett.5 All the patients in whom empyema recurred had a primary bronchopleural fistula. In the present series every recurrence occurred during the first postoperative year, though it may also occur much later.5 In our experience, however, the same treatment was also effective in the case of recurrent empyema,2 though one patient died of faradvanced carcinoma during the second period of treatment. Both of the surviving patients have been followed for 1 to 2'/2 years after the successful treatment
322
Kdrkold, Kairaluoma,
Larmi
of the recurrence, and so far they are free of any signs of infection. We may conclude that the treatment of postpneumonectomy empyema, with or without bronchopleural fistula, using two tubes to irrigate and drain the cavity is both effective and convenient for the patient. A possible recurrence can be successfully managed with the same regimen. This method does not preclude the subsequent use of different modes of treatment if these prove necessary. REFERENCES 1 Clagett, O. T., and Geraci, J. F.: Procedure for the Management of Post-pneumonic Empyema, J. THORAC. CARDIOVASC. SURG. 45: 141,
1963.
2 Provan, J. L.: The Management of Postpneumonectomy Empyema, J. THORAC. CARDIOVASC. SURG. 61:
107,
1971. 3 Le Roux, B. T.: Empyema Thoracis, Br. J. Surg. 52: 89, 1965.
4 Eloesser, L.: An Operation for Tuberculous Empyema, Surg. Gynecol. Obstet. 60: 1096, 1935. 5 Stafford, E. G., and Clagett, O. T.: Postpneumonectomy Empyema: Neomycin Instillation and Definitive Closure, J. THORAC. CARDIOVASC. SURG. 63: 711,
1972.
6 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.
7 Miller, J. E., Fleming, W. H., and Hatches, C R., Jr.: Balanced Drainage of the Contaminated Pneumonectomy Space, Ann. Thorac. Surg. 19: 585, 1975. 8 Virkkula, L., and Kostiainen, S.: Postpneumonectomy Empyema in Pulmonary Carcinoma Patients, Scand. J. Thorac. Cardiovasc. Surg. 4: 267, 1970. 9 Virkkula, L., and Eerola, S.: Treatment of Postpneumonectomy Empyema, Scand. J. Thorac. Cardiovasc. Surg. 8: 133, 1974. 10 Dorman, J. P., Campbell, D., Grover, F. L., and Trinkle, J. K.: Open Thoracostomy Drainage of Postpneumonectomy Empyema With Bronchopleural Fistula, J. THORAC. CARDIOVASC SURG. 66: 979,
1973.
Pentti Karkola, M . D . , Matti I. Kairaluoma, M . D . , and T e u v o K. I. Larmi, M . D . , Oulu,
Finland
IT ostpneumonectomy empyema with bronchopleural fistula is an infrequent but serious complication. This is particularly so because most of these operations have been performed on poor-risk patients with carcinoma of the lung, for which the prognosis is unpredictable. These patients are unable to tolerate any more extensive operation, such as thoracoplasty. Open thoracostomy drainage with neomycin irrigation, originally described by Clagett and Geraci,1 has been reported as yielding very good results. However, the patient might find an open thoracostomy with daily dressings uncomfortable, and most of them will later require a second operation, though a minor one, for closure of the open thoracostomy. Since 1971 we have successfully managed postpneumonectomy empyema in 7 patients who had had pulmonary carcinoma. We used two tubes to irrigate and drain the empyema cavity, as described by ProFrom the Department of Surgery, Oulu University Central Hospital, Oulu, Finland. Received for publication Jan. 19, 1976. Accepted for publication May 4, 1976. Address for reprints: Teuvo K.I. Larmi, M.D., Department of Surgery, Oulu University Central Hospital, SF-90220 Oulu 22, Finland.
van,2 with small modifications. This paper reports our experience with these patients. Method We followed the method described by Provan2 in which two tubes were used to irrigate and drain the empyema cavity. Once the diagnosis of bronchopleural fistula or pleural empyema was confirmed, a large silicone rubber tube was inserted under local anesthesia through the most dependent intercostal space and was connected to an underwater-seal drainage bottle. A large Intracath was inserted by needle puncture technique through the second or third intercostal space at the midclavicular line and connected to an intravenous infusion set. The systemic antibiotic and the antibiotic for intrapleural irrigation were selected on the basis of sensitivity tests. If a resistance developed during the treatment, the antibiotic was replaced by another antibiotic to which the organism was still sensitive. The pleural space was permitted free gravity drainage, and intrapleural antibiotic drip was continued, the unaffected side of the chest being supported and the patient held in such a position that the whole cavity, including the apex, was bathed in the antibiotic solution until the bronchopleural fistula was closed spontaneously. The fistula was considered to be closed when air 3 19
The Journal of Thoracic and Cardiovascular Surgery
3 2 0 Kdrkold, Kairaluoma, Larmi
Table I. Clinical data, treatment, and results
Patient
Age
1
J. 0 .
2
Primary operation
Occurrence and identification of fistula
60, M
Right pneumonectomy for squamous carcinoma with mediastinal metastases and a localized empyema pocket in 1971
Two weeks later, at bronchoscopy, a small bronchopleural fistula
1. Gentamicin and chloramphenicol 2. Erythromycin and nystatin 3. Erythromycin and nystatin
L. S.
52, M
No fistula; Empyema occurred 5 mo. later
Cephaloridine
3
O. H.
59, M
Right pneumonectomy for malignant papilloma with no glandular involvement in 1971 Right pneumonectomy for squamous carcinoma with no glandular involvement in 1972
4
A. K.
39, M
Right pneumonectomy for squamous carcinoma with no glandular involvement in 1972
1. Cephaloridine and gentamicin 2. Cephaloridine and gentamicin Cephaloridine
5
F. B.
42, M
Right pneumonectomy for squamous carcinoma with mediastinal involvement in 1972
6
P. M.
72, M
7
P. Y.
63, M
Left pneumonectomy for anaplastic, large-cell carcinoma with no glandular involvement in 1973 Right pneumonectomy for squamous carcinoma with no glandular involvement in 1973
Postop. day 1, a large bronchopleural fistula occurred requiring tracheostomy Postop. day 1, an esophagopleural fistula requiring reoperation 3 days later Postop. day 1, a large bronchopleural fistula at bronchoscopy Three weeks later, empyema without bronchopleural fistula
Case No.
leakage stopped. Closure was also confirmed at bronchoscopy. If no fistula was initially present we proceeded rapidly within a few days to the next step. About 100 to 200 ml. of antibiotic solution was then instilled through the Intracath, and the chest drainage tube was clamped. The antibiotic solution was permitted to remain within the chest for 12 hours, and then the tube was reopened. This procedure was carried out twice a day until the initial purulent drainage converted to a serous drainage and the culture was negative for the first time. The program was then modified in that the chest tube was kept clamped for 24 hours. When three consecutive cultures were reported as negative, the thoracic cavity was filled with antibiotic solution and both chest tubes were removed. Thereafter the instillation of antibiotic by thorecentesis was continued once a day for about a week. If there was no rise in temperature during the following 2 or 3 days, the patient was permitted to leave the hospital.
One week later, at bronchoscopy, a bronchopleural fistula
Antibiotics for irrigation
Cephaloridine and gentamicin Gemtamicin
I. Bacitracin and neomycin 2. Bacitracin and neomycin
Patients and results Clinical data and treatment of the 7 patients are given in Table I. Initially, culture grew Staphylococcus aureus in every patient. Three patients died during the follow-up period of far-advanced carcinoma, but none of empyema. The remainder are now doing well, showing no sign of recurrent empyema or pulmonary malignancy. The empyema recurred once in 3 patients. Their average treatment time was shorter than for patients without such recurrence. The recurrent empyema usually required retreatment for a period of one month. In one patient whose empyema recurred twice, the subsequent cultures also grew Candida in addition to Staphylococcus aureus. Discussion Earlier, postpneumonectomy empyema usually occurred following resections for tuberculosis. Today it is most often seen in patients with pulmonary carcinoma. In the series of Le Roux,3 empyema complicated
Volume 72 Number 2 August, 1976
Treatment time
Postpneumonectomy empyema
Recurrence after discontinuation of treatment
2 wk.
I wk.
1 mo.
3 mo.
Follow-up time
10 mo.
1 mo. 1 mo.
-
2 wk.
4 mo.
1 mo.
Results
4 yr.
Died of far-advanced carcinoma Doing well
3'/2 yr.
Doing well
3yr.
Died of far-advanced carcinoma
1 yr.
Died of far-advanced carcinoma
2yr.
Doing well
2 yr.
Doing well
3 wk.
2 mo.
1 mo. 1 mo. 2 wk.
7 mo. -
pneumonectomies in about 2 per cent of all cases. During the 10 year period from 1965 to 1974, 175 patients underwent pneumonectomy for pulmonary carcinoma at the Oulu University Central Hospital, and in 7 of these patients, i.e., about 4 per cent, postpneumonectomy empyema occurred. Many different methods have been used in the treatment of postpneumonectomy empyema. Initially, Eloesser,4 in 1935, used open thoracostomy in tuberculous postpneumonectomy empyema. In 1963 Clagett and Geraci1 adopted open-window thoracostomy and neomycin irrigation. They closed the thoracostomy wound after 6 to 8 weeks with instillation of neomycin solution to the pleural cavity. In 1970 Dieter and colleagues6 and the following year Provan2 reported their results with antibiotic irrigation and closed-chest drainage. Quite recently, Miller and colleagues7 have recommended balanced drainage of the contaminated pneumonectomy space. Finally, if all the aforementioned methods fail, thoracoplasty can still be used for obliteration of the residual cavity. None of these
321
methods however, has proved to be completely satisfactory or applicable in all cases. Owing to the lack of a uniform method of treatment, the number of papers directly dealing with this difficult subject is relatively small. Many authors1, s- 8~10 have reported very promising results with open-window thoracostomy drainage using neomycin irrigation. However, the series have been small, often consisting of a few cases, with the exception of the series of Virkkula and Eerola,9 which comprises 40 patients. This method requires rather long hospitalization, and the patient might find the open thoracostomy wound and daily dressings unpleasant. If the coexistent bronchopleural fistula heals spontaneously or can be closed operatively, an attempt to close the open-window thoracostomy is desirable.1, 5 Nevertheless, this requires a second operation, though a minor one, and in many patients empyema will still recur.5, 9 The method of antibiotic irrigation and closed-chest drainage here presented, which we successfully used as primary treatment of postpneumonectomy empyema in 7 patients who had had pulmonary carcinoma, is the method reported by Provan2 with small modifications. The regimen proposed by Dieter and colleagues6 is very similar, but they used only one chest tube. We agree with Provan2 that two chest tubes along with the posturing of the patient permit the whole cavity, including the apex, to be bathed in antibiotic solution. We did not have any problems when using this method in patients with bronchopleural or esophagopleural fistula, provided that the draining chest tube was continuously kept open and that we were careful with the posturing of the patient until the fistula healed, as it did in every case. The effectiveness of the present regimen in the acute phase of empyema has been doubted by some authors,9 but in our experience it worked effectively. The duration of the treatment did not differ significantly from that reported by others1, 5* 8' 9 for open-window thoracostomy, but we consider this regimen more convenient from the patient's point of view. The recurrence rate was about the same as in the study of Stafford and Clagett.5 All the patients in whom empyema recurred had a primary bronchopleural fistula. In the present series every recurrence occurred during the first postoperative year, though it may also occur much later.5 In our experience, however, the same treatment was also effective in the case of recurrent empyema,2 though one patient died of faradvanced carcinoma during the second period of treatment. Both of the surviving patients have been followed for 1 to 2'/2 years after the successful treatment
322
Kdrkold, Kairaluoma,
Larmi
of the recurrence, and so far they are free of any signs of infection. We may conclude that the treatment of postpneumonectomy empyema, with or without bronchopleural fistula, using two tubes to irrigate and drain the cavity is both effective and convenient for the patient. A possible recurrence can be successfully managed with the same regimen. This method does not preclude the subsequent use of different modes of treatment if these prove necessary. REFERENCES 1 Clagett, O. T., and Geraci, J. F.: Procedure for the Management of Post-pneumonic Empyema, J. THORAC. CARDIOVASC. SURG. 45: 141,
1963.
2 Provan, J. L.: The Management of Postpneumonectomy Empyema, J. THORAC. CARDIOVASC. SURG. 61:
107,
1971. 3 Le Roux, B. T.: Empyema Thoracis, Br. J. Surg. 52: 89, 1965.
4 Eloesser, L.: An Operation for Tuberculous Empyema, Surg. Gynecol. Obstet. 60: 1096, 1935. 5 Stafford, E. G., and Clagett, O. T.: Postpneumonectomy Empyema: Neomycin Instillation and Definitive Closure, J. THORAC. CARDIOVASC. SURG. 63: 711,
1972.
6 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.
7 Miller, J. E., Fleming, W. H., and Hatches, C R., Jr.: Balanced Drainage of the Contaminated Pneumonectomy Space, Ann. Thorac. Surg. 19: 585, 1975. 8 Virkkula, L., and Kostiainen, S.: Postpneumonectomy Empyema in Pulmonary Carcinoma Patients, Scand. J. Thorac. Cardiovasc. Surg. 4: 267, 1970. 9 Virkkula, L., and Eerola, S.: Treatment of Postpneumonectomy Empyema, Scand. J. Thorac. Cardiovasc. Surg. 8: 133, 1974. 10 Dorman, J. P., Campbell, D., Grover, F. L., and Trinkle, J. K.: Open Thoracostomy Drainage of Postpneumonectomy Empyema With Bronchopleural Fistula, J. THORAC. CARDIOVASC SURG. 66: 979,
1973.