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PubMed1992

[Surgical treatment of pulmonary aspergilloma--with modified conservative operation].

During the past 10 years 26 patients were operated on for pulmonary aspergilloma (20 males and six females, mean age of 55.8 years). Lung resections were performed on 13 cases (Group 1). Conservative operations were performed on the remaining cases, including one bilateral operation case (Group 2). New paragraph. The operative techniques in Group 1 were: lobectomy 11 cases of lobectomy, one case of partial resection; and one case of segmental resection. The operative techniques for Group 2 were; five cases of thoracoplasty and cavernoplasty; three cases of thoracoplasty plus cavernoplasty and muscle flap; three cases of thoracoplasty and muscle flap; one case of thoracoplasty and air-plombage; and two cases of cavernoplasty. A second operation was required in four and seven cases in Groups 1 and 2, respectively, and a third operation in two and four cases respectively. The conservative technique was used in all of additional operations required. The mean operation time and amount of blood loss were 262 min and 1,943 ml for Group 1 and 170 min and 918 ml for Group 2-being shorter and lesser for Group 2. Both the operation time and blood loss were reduced during the second and third operations. Reduction of %VC after the first operation was also less remarkable for Group 2 (-9.6%, No = 9). The advantage of using a conservative technique is that successful results can be expected without insult to the hilus and mediastinal surface in cases with compromised pulmonary functions, or in those cases which pneumonectomy or resection is difficult because of the risk of massive bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Esophagopleural fistula: an early and long-term complication after pneumonectomy.

Over a 14-year period, we observed eight cases of esophagopleural fistula after pneumonectomy for cancer (n = 7) or infectious lung disease (n = 1). In 2 patients, the fistula was probably related to an intraoperative esophageal injury. Two others had mediastinal cancer recurrence, whereas a fistula developed in 4 without any malignancy. Patients presented with empyema, and a contrast swallow procedure disclosed an esophagopleural fistula. Two patients with recurrent cancer were managed conservatively with chest tube insertion and died within 3 months. A patient with chronic empyema had a delayed diagnosis of esophagopleural fistula 2 years after a presumed intraoperative injury; he was managed with thoracoplasty and feeding gastrostomy and died 12 months later. Five patients had an attempt at curative treatment. A single patient underwent thoracoplasty and bipolar exclusion of the esophagus and had secondary reconstruction with a coloplasty; he died with postoperative peritonitis. Four patients underwent thoracoplasty and muscle flap repair of the esophagus. There was 1 operative death from pulmonary embolism, whereas 3 patients recovered and are well with follow-up of 18 months, 2 years, and 5 years, respectively. We conclude that the prognosis of esophagopleural fistula is ominous when associated with cancer recurrence. A curative approach should combine direct repair of the esophagus with a muscle flap and eradication of the associated empyema with thoracoplasty. This aggressive treatment is addressed to debilitated patients and carries high rates of mortality and morbidity.

Aged↗
PubMed1994

[Omental pedicle flap for chronic empyema].

We have used the omental pedicle flap (OPF) method to treat 10 patients with chronic empyema secondary to pulmonary tuberculosis. Since 1987 they included 9 men and one woman ranging from 48 to 70 years in age. Two patients were required re-operation because of residual bronchopleural fistulas, and the additional procedures (muscle plombage and thoracoplasty) performed in order to close residual dead space produced more severe thoracic deformity and pulmonary dysfunction. In our first successful case, complete thoracoplasty combined with the OPF method also produced pulmonary dysfunction. On the other hand, thoracic deformity was avoided in 3 other patients and 4 patients without thoracoplasty showed better pulmonary function postoperatively. A comparison of the re-operated patients with the successful cases highlighted two important points regarding the OPF method. One is the need for firm fixation of the OPF to a fistula. We usually place a muscular pedicle flap over the OPF, and add limited thoracoplasty as necessary. The other important point is the control of infection. Open window thoracostomy before the OPF method is effective in patients with active infection. The OPF method is an effective radical operation for severe empyema even when residual dead space is present, and it can also be applied to patients with poor pulmonary function.

Aged↗
PubMed1997

[Delayed complications after extrapleural pneumonolysis for lung tuberculosis].

The epidemic spread of tuberculosis after World War II and the deficiency of appropriate antituberculotic drugs led to a renaissance of surgical procedure such as plombage thoracoplasty, initiated in 1891 by Tuffier. Especially in Germany the insertion of paraffin and polyethylene was used in order to achieve an extrapleural pneumothorax in order to collapse the tuberculous cavities in the upper lobes. Due to a high rate of early complications and the assumed cancerogenicity, in a considerable number of cases the material was removed soon after its deployment. In some cases with the filling remaining in place, 30-40 years later infections and/or neoplasms occurred. From 1985 to 1996 in two centers of thoracic surgery 13 patients underwent procedures for removal of filling material. The patients suffered from infections (n = 11), malignant lymphoma associated with infection of the plombage (n = 1) and bronchial carcinoma (n = 1). Technically, we performed the thoracoplasty described by Schede (n = 9). Schede's thoracoplasty in combination with a muscle flap repair (n = 1) or partial resection of the thoracic wall (n = 1), an empyemectomy (n = 1), and an en-bloc pleuropneumonectomy (n = 1). All patients suffered from multiple underlying diseases (COPD, coronary heart disease, diabetes mellitus). However, apart from beside two procedure related deaths (pulmonary embolism n = 1, pneumonia complicated by multi-organ failure n = 1) no other major complications were observed. The plombage material in the case of malignant lymphoma is probably carcinogenic in relation to the time of exposure and should be removed in all cases.

Adult↗
PubMed1992

Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment.

From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.

Adolescent↗
PubMed1995

Decortication is a valuable option for late empyema after collapse therapy.

BACKGROUND: Infection of previous collapse therapy spaces may raise challenging problems. This study evaluated a conservative surgical approach based on decortication. METHODS: Since 1979, 28 patients (mean age, 60 +/- 6 years) have presented at an average of 37 +/- 7 years after artificial pneumothorax for tuberculosis. Diagnosis of empyema was made on follow-up in 12 patients and on symptoms in 16 patients. Mean vital capacity was 66% +/- 16% of normal. Microorganisms were isolated in 13 patients (Aspergillus fumigatus in 5, Mycobacterium tuberculosis in 4, anaerobes in 4). Decortication was made in 24 patients, associated with thoracoplasty in 4, and with partial lung resection in 2 patients. Thoracoplasty alone was performed in 2 patients, and 2 patients underwent an extrapleural pneumonectomy. RESULTS: Both extrapleural pneumonectomies were complicated with empyema requiring thoracoplasty, resulting in one postoperative death. Operative mortality after decortication was nil. Mean intraoperative blood loss during decortication was 1,830 +/- 1,310 mL. All patients were extubated within 24 hours, except 1 patient who was ventilator-dependent preoperatively. Prolonged air leaks were common (mean duration of drainage, 16 +/- 11 days), but ultimately sealed. Existence of symptoms was predictive of prolonged air leaks (p < 0.01). CONCLUSIONS: We conclude that decortication may provide a one-stage cure avoiding the hazards of extrapleural pneumonectomy; the nonfunctioning remaining lung may resolve the space problem.

Aged↗
PubMed1990

Treatment of postpneumonectomy empyema.

Postpneumonectomy empyema with or without (bronchopleural) fistula is an infrequent but serious, and often life-threatening complication. In 20 of our patients postpneumonectomy empyema was discovered. The time interval between original operation and discovery of the empyema varied from 9 days to 9 years. In two cases, the empyema had been found and treated initially at another hospital but not adequately, so that at the time of treatment by us the bronchopleural fistula had already been present for 8 and 19 years. In 13 cases a bronchial stump fistula was discovered. In five patients the fistula was successfully closed endoscopically with glue. In one patient closure was performed by transmediastinal stump resection, in three patients with a fistula thoracoplasty was performed. In three patients we achieved closure by transposition of pedicled muscle flaps. In one of these patients a septic condition could be mastered by performing window thoracotomy. Two patients without fistula were successfully treated with irrigation, and two further patients with thoracostomy. In one patient recovery was achieved by medication after puncture. Two patients died of sepsis and after thoracoplasty. If a fistula is present, drainage with irrigation and endoscopical glueing should be the initial treatment. This should be followed by resection of the bronchial stump. If there is no fistula or if the stump is too short thoracostomy is the treatment of choice. If it is not successful thoracoplasty has to be performed.

Adhesives↗
PubMed1953

Primary pulmonary resection for tuberculosis; medical and economic aspects in a small sanatorium.

Twenty-eight patients with pulmonary tuberculosis in a small, tax-supported sanatorium were treated by primary pulmonary resection. In a comparison of results with those obtained in the same sanatorium by thoracoplasty and extrapleural pneumothorax, it was noted that in general the patients who had resection had earlier conversion of sputum to "negative" and had a shorter stay in hospital. Complications were not of sufficient frequency to contraindicate use of resection in cases in which there was doubt that thoracoplasty would be effective. The cost of hospitalization for surgical treatment and postoperative care was considerably less when resection was done than it was for either three-stage or two-stage thoracoplasty.

Humans↗
PubMed1989

[A case of empyema after plastic ball plombage cured by air-plombage method].

Conventionally, thoracoplasty has been conducted for empyema space after removal of plastic ball for empyema cases after plastic ball plombage. We applied air-plombage method for empyema as a new operative technique. The patient was a 56-year-old man who had had 37 plastic balls implanted for the treatment of pulmonary tuberculosis 39 years ago. In April 1988 he was admitted to our department complaining bloody sputum and high fever. Roentogenographic findings revealed residual middle lobe with normal size and plastic balls some with niveau. From these findings, the case was diagnosed as partial empyema after plastic ball plombage. In June 1988 air-plombage method was performed. At 5 months after operation, reinflation of the residual pulmonary lobe was seen accompanying improvement of pulmonary functions; FVC increased from 1780 ml to 1910 ml and blood gas PaO2 from 75.0 mmHg to 88.3 mmHg. Blood loss during operation was about 2,000 ml, which was smaller than the conventionally experienced amount of blood loss. Because of residual right middle lobe, pulmonary decortication was impossible and significant reinflation of the collapsed pulmonary lobe could not be expected. We selected air-plombage method rather than thoracoplasty as postoperative worsening of pulmonary functions was anticipated by the latter. Postoperative improvement of pulmonary functions could be explained by reinflation of the residual lobe due to removal of plastic balls and the capsule. When conventional thoracoplasty is carried out to obtain satisfying closure of the empyema cavity, pulmonary functions are always deteriorated, while air-plombage method is followed by slight improvement of pulmonary functions.(ABSTRACT TRUNCATED AT 250 WORDS)

Empyema, Tuberculous↗
PubMed1989

[Surgical interventions in diffuse pulmonary tuberculosis in undisciplined patients].

The experience with surgical treatment of 134 patients with extended destructive tuberculosis of the lungs was studied. Among them 79 patients were subjected to lung resection in combination with thoracoplasty, 14 patients were subjected to thoracoplasty and 41 patients were subjected to various forms of cavernoplasty. It was shown that corrective thoracoplasty carried out simultaneously with lung resection lowered the risk of tuberculosis aggravation.

Adult↗
PubMed1994

[Surgical tactics in bilateral destructive pulmonary tuberculosis].

43 patients with pulmonary tuberculosis (mean age 36.8 years) were treated surgically. All the patients had disseminated bilateral disease with destruction. Preoperative bacteriological examination identified M.tuberculosis in 67.5% of the examinees. In two-thirds of them x-ray evidenced total pulmonary lesion. 40 subjects of all surgical patients underwent operation for bilateral fibrous-cavernous tuberculosis with caverns location in the upper lobe or upper lobe and 6 segment. The disease was diagnosed to be 1-3 years in duration. The interventions developed in the Novosibirsk Research Institute of Tuberculosis included: osteoplastic thoracoplasty, resection following osteoplastic thoracoplasty, atypical extrapleural resection with limited thoracoplasty, open treatment of the caverns. The surgery resulted in marked improvement (abacillation, cavernous healing) in 42 patients. Long-term follow-up recorded cure in 41 patients (95.3%).

Adult↗
PubMed1995

[Ways to expand indications for surgical treatment of patients with fibro-cavernous pulmonary tuberculosis].

The authors present original operative techniques developed in the Novosibirsk Tuberculosis Research Institute for management of fibro-cavernous pulmonary tuberculosis. These include: a 4-5-rib variant of osteoplastic thoracoplasty as an independent intervention and as a stage followed by pulmonary resection, atypical extrapleural pneumolysis with open tamponade followed by local thoracoplasty. A complex of combined surgical adjuvant procedures comprises extrapleural pneumolysis with open tamponade, dissection of cavernous part of the lung prior to selective thoracoplasty. Indications to the use of the above techniques are provided. Their use in addition to conventional interventions gives one more chance of cure in fibro-cavernous tuberculosis of the lungs.

Humans↗
PubMed1997

[Surgery of thoracic and pulmonary tuberculosis and the sequelae of its treatment in adults].

Surgery for tuberculosis was the starting point for thoracic and cardiovascular surgery in the modern day, but its place was more and more restricted to the treatment of the disease. Excisions (lobectomies, pneumonectomies, segmentestomies) currently represent the majority of operations, after this come operations on the pleura (decortication) and rarely those on the thoracic wall (thoracoplasty, parietectomy). The indications for excision are principally encountered with disease of the parenchyma itself: progressive disease under treatment or with resistant tubercle bacilli, sequelae of parenchymal complications (infections, aspergilloma or haemoptysis) and certain forms of atypical mycobacteria, and also a small but significant group in which excisions are aimed at diagnosis. Sometimes excisions are associated by necessity with decortication for pleural disease which may or may not have originally been intended for the underlying parenchyma or the lesions may be the sequelae of previous complications of treatment such as collapse therapy. Occasionally surgery is indicated in the treatment of lymph node masses in the mediastinum which have not responded to antituberculous therapy and during the treatment bronchial complications have evolved or there have been other sequelae. As for the indications for surgery of the thoracic wall such as thoracoplasty, they appear more than ever obsolete and even if they are still used in certain complications of surgery, they have apart from a few exceptions, lost their original therapeutic role in tuberculosis. However, currently there is a recrudescence of tuberculosis favoured by certain socio-economic situations and strengthened by the appearance of TB cultures which are more and more resistant. The surgery of tuberculosis in its oldest forms (thoracoplasty and removal of cavities) can no longer be said to be the surgery of the past. They proved in the old days that they could cure. Surgery has once more its place in the therapeutic arsenal of new forms of the disease and indirectly in limiting the risk of spread it has a role to play in prevention.

Adult↗
PubMed1993

Evaluation of surgical treatment of pyothorax with special reference to the usefulness of the omental pedicle flap method.

The operative results in a series of 17 patients with pyothorax were reviewed. Of these, 10 had chronic empyema (group 1), and 7 had postoperative empyema (group 2). A single-stage operation was performed in eight patients in group 1 (decortication in six, thoracoplasty in one, omental plombage in one) and in all patients in group 2 (omentopexy in five, thoracoplasty in two). Two-stage procedures were performed in two patients in group 1. We obtained favorable postoperative results in eight patients in group 1, and in four patients in group 2. In our series, good results were not obtained by thoracoplasty alone; however, satisfactory results were achieved by short-term management in patients treated with the omental method. We think this series demonstrates the value of the omental pedicle flap method, which prevents loss of function due to a defective organ and offers excellent therapeutic results following an easy operative procedure. Further active application of this method can be expected in the management of thoracic disorders.

Adult↗
PubMed2002

Treatment of pectus excavatum with bioabsorbable polylactide plates: Preliminary results.

BACKGROUND/PURPOSE: Pectus excavatum usually is corrected by thoracoplasty using metal plates. Recently bioabsorbabe polylactide plates have been developed. The aim of this study was to compare outcome after use of metal and bioasorbable plates in thoracoplasty performed for correction of pectus excavatum. METHODS: Eighty-three children (<16 years old) underwent thoracoplasty (Sulamaa's technique). In 75 patients, metallic plates, and in 8 patients, self-reinforced poly-L-lactide (SR-PLLA) plates, were used. Seven patients in the SR-PLLA group and 13 patients in the metal plate group were assessed 0.5 to 13 years postoperatively. RESULTS: The mean operating time was 121 minutes in the metal plate group, and 87 minutes in the SR-PLLA plate group. In the metal plate group, complications were pain caused by instability of the metal plates (n = 17), wound infection (n = 3), recurrence of deformity (n = 3), postoperative pain (n = 3), pneumothorax (n = 1), and nonspecific postoperative fever (n = 1). Thirteen patients underwent reoperation to refix the position of the metallic plates. In the SR-PLLA group, one case of pneumothorax occurred, and plate fragment palpability caused local pain in one patient. Cosmetic results and lung function values were similar. CONCLUSION: Our preliminary results show that bioabsorbable plates are a useful option in the treatment of pectus excavatum in children.

Absorbable Implants↗
PubMed1999

Surgical treatment of pleural empyema--changing priorities.

The surgical management of pleural empyema and post-traumatic clotted haemothorax is described. The study included 15 cases of post-thoracotomy empyema, 23 of empyema of other aetiology and five of post-traumatic haemothorax. Chest-tube drainage was the first measure in most cases. Post-pneumonectomy empyema was treated with partial thoracoplasty plus omentoplasty (8 cases) or plus myoplasty (1 case). Empyema after lobectomy or bilobectomy (4 cases) or after failed decortication (1 case) was managed with thoracoplasty or, in cases of concomitant wound infection, with open-window thoracostomy followed by thoracoplasty. Empyema after subclavian artery reconstruction (1 case) was cleared by removal of a previously unrecognized foreign body. For early empyema of other aetiology or haemothorax (10 cases in total), treatment comprised debridement by video-assisted thoracoscopic surgery (VATS). VATS was also used to establish suitable pleural drainage prior to elective thoracotomy (2 cases). Decortication and partial parietal pleurectomy were performed for organizing-stage empyema (16 cases). Three of the 15 patients with post-thoracotomy empyema died perioperatively, one died two months postoperatively and one had recurrence of bronchopleural fistula during follow-up. One patient with VATS debridement subsequently required thoracotomy and lobectomy for lung abscess. All the others with VATS or decortication recovered without complications. During follow-up there was no mortality or recurrence of empyema.

Adult↗
PubMed1985

Management of recalcitrant bronchopleural fistulas with muscle flap obliteration.

Use of muscle flap obliteration for bronchopleural fistulas appears to be indicated with (1) failure of a previous thoracoplasty, (2) anticipated failure of a thoracoplasty alone, and (3) the need to obviate a formal debilitating thoracoplasty. With the use of well-vascularized muscle flaps to fully obliterate the densely scarred cavities associated with persistent bronchopleural fistulas, we may hope to see improved healing in the bronchial stump and, in cases of residual infection, better resistance of the flap to necrosis, as well as improved delivery of chemotherapeutic agents to the local tissues. These factors may confer improved cure rates for bronchopleural fistulas similar to those seen in lower extremity salvage surgery for osteomyelitis following the introduction of vascularized pedicle and free muscle flaps. In this article we have described the versatility of the island pedicle latissimus dorsi muscle flap for closure of recalcitrant bronchopleural fistulas and associated empyema cavities. Utilizing either the dominant thoracodorsal or the minor paraspinal pedicle(s), it can reach any intrathoracic cavity by means of the appropriate thoracotomy incision.

Aged↗
PubMed1997

Treatment of long-standing thoracostoma and bronchopleural fistula without pulmonary resection in high risk patients.

A chronic bronchopleural fistula and a fibrotic postthoracotomy space in a patient with poor functional respiratory reserve is a difficult problem. The classic management of bronchopleural cutaneous fistulas has been with further pulmonary resection to healthy bronchus, repair of the bronchus directly, and a thoracoplasty or myoplasty technique to obliterate the cavity. In a high risk patient, further pulmonary resection and thoracoplasty may be contraindicated. Myoplasty techniques alone without control of the fistula have limited success. In the last 4 years, we have treated six patients with right-sided thoracostomas after a primary open drainage procedure for bronchopleural fistula and empyema. The air leak was controlled with inversion of the sinus tract, fibrin glue, and muscle flap cavity obliteration. An average of two muscle flaps per patient were used, including the contralateral latissimus dorsi muscle. An 83 percent success rate has been achieved with this procedure in patients who otherwise would not be considered surgical candidates. Attention to the details described, including direct suture closure of the bronchial sinus, obliteration of the cavity by local muscle flaps, and avoidance of mechanical positive pressure ventilation, will make extended thoracotomy, pulmonary resection, and thoracoplasty unnecessary in these high risk patients.

Adult↗