Andrews Thoracoplasty as a Treatment of Post- Pneumonectomy Empyema: Experience in 23 Cases

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1 Andrews Thoracoplasty as a Treatment of Post- Pneumonectomy Empyema: Experience in 23 Cases Philippe Icard, MD, Jean Philippe Le Rochais, MD, Bertrand Rabut, MD, Sebastien Cazaban, MD, Bertrand Martel, MD, and Claude Evrard, MD Department of Thoracic Surgery, CHRU de Caen, Caen, France Background. Andrew s thoracopleuroplasty has been described for treating tuberculous empyemas with bronchopleural fistulas. We report on its utilization for treating postpneumonectomy empyemas. Methods. During a 25 year period, 23 patients underwent thoracopleuroplasty for treating postpneumonectomy empyemas, after a period of drainage-irrigation of the cavity. Seven patients presented with persistent bronchial fistula at operation. After resection of the costal arches surrounding the infected cavity, the cavity was cleaned, and the external parietal plane was sutured to the mediastinal plane. Only drainage of the subscapular space was left in place. Results. Postoperative mortality was 4.3%. Postoperative recovery was simple in 17 cases, whereas a superficial abscess was evacuated in 3 cases. The procedure failed in 3 cases, which were treated by open thoracostomy (2), and by reenlargment of the thoracopleuroplasty (1). The sequelae were mainly a diminution of the shoulder mobility, especially when the first rib was resected. Conclusions. Thoracopleuroplasty may safely treat postpneumonectomy empyemas, even those with bronchial fistulas. Most patients are definitively and rapidly cured with limited sequelae. (Ann Thorac Surg 1999;68: ) 1999 by The Society of Thoracic Surgeons horacopleuroplasty, or thoracomediastinal plication was first described by Andrews in 1961 T [1] for treating unresponsive tuberculous chronic empyemas with persistent bronchial fistulas. In brief, the ribs overlying the empyema cavity are resected, the cavity is curetted, the bronchial fistula, if present, is closed, and the parietal plane is sutured to the mediastinal plane. Because of the efficacy of antituberculous medications, this operation has almost completely disappeared. To our knowledge, its use has been only mentioned by Cornet and associates [2, 3], not only for treating tuberculous empyemas, but also for managing some cases of postpneumonectomy empyemas. The aim of our study was to review the results of this thoracopleuroplasty, performed during the last 25 years at our institution as a treatment of postpneumonectomy empyemas, including those associated with bronchial fistulas. Patients and Methods From 1971 to 1996, 23 men with an average age of 60 years (46 to 77 years old) underwent a thoracopleuroplasty according to Andrews description [1]. The patient characteristics are summarized in Table 1. The pneumonectomy had been previously performed to treat lung cancer in 18 cases and to treat various infectious diseases in 5 cases. Eleven patients presented bronchopleural fistulas, Accepted for publication March 24, Address reprint requests to Dr Icard, Department of Thoracic Surgery, CHRU de Caen, Côte de Nacre, Caen Cedex, France; lerochais-jp@chu-caen.fr. all of which occurred after the 7th postoperative day. One patient included in this series underwent a pneumonectomy at another institution, but was referred to our institution for the treatment of a postpneumonectomy empyema and bronchopleural fistula. With the exception of this case, the cases of empyemas and bronchopleural fistulas recorded after pneumonectomy represented all cases with complications which occurred after pneumonectomy at our institution during the same period. Thus, our empyema rate after pneumonectomy was 3.5% and our fistula rate was 2.5%. Fourteen cases involved the right side, and 9 the left side. Preoperative bacterial examination of empyema cavities showed a purulent fluid in all cases, and cultures were positive for various germs in 18 cases (Table 1). Appropriate antimicrobial therapy was administered in all cases. Before operation, for a median period of 1 month (from 0.5 to 3 months), all patients were treated with a drainage-irrigation method. No patient was denied thoracopleuroplasty or underwent any other method of treatment. At the end of the drainage-irrigation period, immediately before thoracopleuroplasty, 7 patients had persistent bronchial fistulas. Operative Method Thoracopleuroplasty was performed according to Andrews description [1], with a slight modification, consisting of systematic resection of the lower part of the scapula, to avoid its incarceration in the postoperative period. The resection of the midlower part of the scapula was systematically realized at the beginning of the oper by The Society of Thoracic Surgeons /99/$20.00 Published by Elsevier Science Inc PII S (99)

2 1160 ICARD ET AL Ann Thorac Surg ANDREWS THORACOPLASTY AND EMPYEMA 1999;68: Table 1. Characteristics of Patients Patient Sex (Age) Histological Type-Side Drainage- Irrigation/ Time Bacteriology BPF Extent of Costal Resection Postoperative Recovery Follow-up 1 M (46) Epidermoid-right 1.5 months P aeruginosa, Yes 2 8 Uneventful Deceased after 6 years Pneumococcus 2 M (67) Epidermoid-left 1 month Pneumococcus Streptococcus No 2 8 Uneventful Deceased after 3 years 3 M (58) Epidermoid-right No drainage Staphylococcus No 1 8 Uneventful Deceased after 6 years 4 M (51) Epidermoid-left No drainage Purulent fluid No 1 7 Uneventful Deceased after 1.5 years 5 M (62) Adenocarcinomaright 1.5 months Staphylococcus No 1 8 Parietal Deceased after 3 years 6 M (61) Epidermoid-right 1.5 months Purulent fluid No 1 8 Uneventful Deceased after 6 years 7 M (59) Epidermoid-left 1 month Purulent fluid No 1 7 Uneventful Lost to follow-up after 1 year 8 M (57) Epidermoid-right 1.5 months Streptococcus Yes 1 9 myoplasty Parietal Deceased after 4 years 9 M (77) Epidermoid-left 0.5 month E coli - Yes 1 7 myoplasty Cachexia Deceased after 1 month Streptococcus 10 M (50) Epidermoid-right 1 month Pneumococcus No 3 6 Uneventful Deceased after 11 years 11 M (63) Epidermoid-right 1 month Pneumococcus Yes 2 6 myoplasty Uneventful Alive after 10 years 12 M (59) Epidermoid-right 1.5 months Staphylococcus- No 3 7 Uneventful Alive after 9 years Candida 13 M (58) Epidermoid-right 1.5 months Purulent fluid Yes 3 7 myoplasty Uneventful Deceased after 8 months 14 M (62) Epidermoid-right 1.5 months Pneumococcus No 2 6 Uneventful Alive after 2 years 15 M (65) Epidermoid-left 0.5 month Staphylococcus No 2 7 Reinfection failure Thoracostomy, alive after 2 years 16 M (77) Epidermoid-right 1.5 months Staphylococcus No 4 6 Reinfection failure Thoracostomy, alive after 1.5 years 17 M (69) Epidermoid-left 1.5 months Staphylococcus- No 3 9 Uneventful Alive after 1.5 years Pneumococcus 18 M (77) Epidermoid-left 1 month Staphylococcus No 2 7 Uneventful Alive after 1 year 19 M (48) Tuberculosisright 3 months MT Streptococcus No 2 5 Failure reoperation Lost to follow-up after 2 years 20 M (48) Tuberculosisright 3 months MT Streptococcus No 2 6 myoplasty Parietal Alive after 2 years 21 M (43) Tuberculosis-left 1 month Fusobacterium No 1 7 Uneventful Deceased after 4 years 22 M (60) Tuberculosisright 1.5 months Purulent fluid Yes 1 7 Uneventful Lost to follow-up after 1 year 23 M (62) Abscess-left 1 month Staphylococcus Yes 2 6 pericardial flap Parietal Deceased after 1 year BPF bronchopleural fistula after drainage-irrigation period; MT mycobacterium tuberculosis. ation, in order to prevent the incarceration of the scapula in the parietal defect postoperatively. Furthermore, this resection facilitated the exposure of the upper costal arches and the resection of the first rib when performed. The first rib was resected in 9 cases, whereas in other cases resection was judged unnecessary, and a limited apicolysis was considered sufficient. In all cases, a large part of all costal arches surrounding the infected cavity was removed, with a mean resection of 5 costal arches (from 3 to 8). However, the head, neck, and transverse processes of each removed rib were never resected. After opening the infected cavity through an incision overlying a rib bed, the entire cavity was exposed and the products of empyema were removed by careful lavage, curretage of all granulations, and even sharp scalpel dissection of all fibrous infected tissues, creating a pliable and cleansed external parietal flap. The pliable and cleansed flap consisted of vascularized pleural peel, intercostal muscles, endothoracic fascial and subperiosteal tissues, and might be of sufficient size to obliterate the entire empyema space, including the apex of the chest when necessary. The pleuromusculoperiosteal flap was placed in juxtaposition to the mediastinal surface of the empyema space, and both were secured together using absorbable sutures, therefore obliterating the interspace and buttressing any fistula closure, without drainage (Fig 1). An attempt to close the bronchial fistulas directly, was made in 2 cases, with absorbable suture material, whereas in other cases, five muscle flaps were used to close the

3 Ann Thorac Surg ICARD ET AL 1999;68: ANDREWS THORACOPLASTY AND EMPYEMA 1161 fistulas as patches, the flap being sutured around the fistula which was left open. There were two intercostal flaps, two serratius anterior flaps, one pectoralis major flap and one pericardial flap. The two serratius anterior flaps and this one pectoralis major muscle flap helped to completely fill the cavity, avoiding greatly extended rib resections. Only a parietal drainage in the subscapular space was left in place, and then removed as quickly as possible. After closure of the skin incision, a compressive bandage was used to reinforce the fixation of the parietal flap to the mediastinal surface, securing the stabilization of the mediastinum, and thereby avoiding an immediate paradox and the need for postoperative ventilation. All patients were extubated at the end of the operation. Mobilization of the shoulder and abduction of the arm were not allowed until the 10th postoperative day. Results Operative mortality was 4.3%, composed of a 77-year-old patient (patient 9), who died of cachexia 30 days after the operation, although his parietal chest and fistula were healed. Empyemas and fistulas were cured in 19 other patients, with a very simple postoperative recovery in 15 patients, discharged after removal of their parietal drainage before the 6th postoperative day. No fistula recurred. Three patients needed a surgical evacuation of a subscapular abcess. The procedure failed in 3 patients (12.5%) who demonstrated persistence or recurrence of their empyemas. One of these patients had a persistent tuberculosis empyema which was treated successfully using reinforcing antituberculosis therapy, reenlargement of the thoracoplasty and using muscle flaps to fill the cavity. The two remaining patients, presenting staphylococci empyemas, were treated by open thoracostomy. During follow-up, no patient experienced a recurrent empyema or a reopening of a bronchopleural fistula. Three patients were lost to follow-up, 1 to 2 years Fig 2. Front view of the cosmetic result. postoperatively. Eleven patients died, with a median survival of 4 years (from 8 months to 11 years). Eight patients were currently alive with a median survival time of 2 years, ranging from 1 to 10 years. All these patients were revisited recently; none suffered for severe dyspnea, none complained of particular discomfort, and all presented limited thoracic sequelae (Figs 2 and 3). They mainly complained of a diminution of their shoulder mobility with restricted abduction in arm movement, especially where the first rib had been resected. Fig 1. Schematic drawing showing the thoracomediastinal plication after resection of the ribs, curettage of the empyema cavity, and closure of bronchial fistula, if present [Reprinted, with permission, from Andrews NC. Thoraco-mediastinal plication. (A surgical technique for chronic empyema). J Thorac Surg 1961;41: ]. Comment Postpneumonectomy empyema is a life-threatening complication, especially in cases of associated bronchial fistula [4]. The objectives of the different methods of treatment include: evacuation and drainage of empyema, administration of appropriate antimicrobial therapy, closure of bronchial fistula, and prevention of reinfection of postpneumonectomy cavity. Except for the very rare case of an early postoperative bronchial fistula, with unstable mediastinum needing special care with appropriate ventilation, currently the most popular sequence of treatment is open drainage thoracostomy [5]. This is then directly closed later with antibiotic solution as first described by Clagett [6], filled

4 1162 ICARD ET AL Ann Thorac Surg ANDREWS THORACOPLASTY AND EMPYEMA 1999;68: Fig 3. Back view of the cosmetic result. with pedicled muscle flaps [7], or filled with omental flaps [8]. In case of large fistula, an attempt at closure, either through a transternal approach [9] or through thoracostomy, with apposition of a muscle flap packed against the fistula, is now recommended at the same time as open thoracostomy [7]. Classically, the closure of open thoracostomy is not performed for several months, a delay [10, 11] that allows the evaluation of the occurrence or recurrence of cancer dissemination, and that allows diminishment of the size of the open cavity by the spontaneous healing process. However, muscle flaps, including those associated with omental flaps, may not be able to sufficiently and completely fill the residual cavity, and so a tailored thoracoplasty may be required to definitively close the open thoracostomy. Finally, it is not rare that in such pneumonectomized patients, who frequently had a poor general condition and limited hope of survival, thoracostomy remains definitively open, with daily bandaging having to be performed indefinitely. In any case, all methods of closure failed, in all cases, to achieve a complete closure of thoracostomy, which remains definitively open, in a relatively high percentage of cases. In fact, the Clagett procedure has been reported to fail in 20% of cases after a second attempt by Stafford and Clagett [12], whereas Miller and associates [13] have only reported a 20% rate of definitive closure after the Clagett procedure, especially in cases of multiple germ infections and of staphylococcus empyemas. In closure using muscle flaps, Pairolero and associates [7] reported that thoracostomy was not closed in one-third of their patients. Even when successful, the procedure was painstaking, necessitating an average of 5 operations per patient, with several hospital stays, to definitively close the cavity. In our series of 23 post-pneumonectomy empyemas, the mortality rate was 4.3%, the cure of empyema was 87% (20/23), and the closure of fistula was achieved in 100% of cases. The series of Cornet and associates [3] involved 73 patients who underwent the Andrews procedure mainly for the management of unresponsive chronic tuberculous empyemas. Of these, 12 patients underwent the procedure for treating postpneumonectomy empyemas, with 4 presenting a bronchopleural fistula. The overall mortality of the entire series was 5.4%, but no specific details were described in the subgroup of patients undergoing pneumonectomy. In the aforementioned series of Pairolero and coworkers [7] involving 45 postpneumonectomy empyemas, the postoperative mortality was 13.3% (6/45). Most of deaths occurred in patients in whom attempts to close the bronchial fistulas by an early myoplasty failed, with a failure rate of 14.3% (4/28). Among the 39 surviving patients, 8 patients (20.5%) never had final closure of their open thoracostomy. Thus, our results using Andrews thoracopleuroplasty may compare with those series using other popular methods for treating postpneumonectomy empyemas and bronchopleural fistulas. Nevertheless, the use of thoracoplasty in the management of empyema complicating pneumonectomy has been rarely reported and is controversial [14 19]. Thoracoplasty inherited the bad reputation of traditional extended thoracoplasty, referred to as Schede or Estlander thoracoplasties [17, 19], that combined excision of the wall of the empyema cavity with the resection of most of the costal archs in two or three distinct sequences, resulting in substantial mutilating chest deformations and respiratory sequelae. Andrew s thoracopleuroplasty employs many of the elements of previously established thoracoplasties, but has the advantage of limited rib resection. For large empyema cavities, such as those seen after pneumonectomy, we think that it is better to perform this thoracoplasty after a period of drainage-irrigation, allowing reduction of the size of the cavity (and therefore the extent of rib resection). This may sometimes allow the spontaneous closure of a small fistula, as it occurred in 4 cases of our series. Furthermore, the period of drainage-irrigation lets us avoid performing thoracoplasty during the initial period of unstable mediastinum, limiting the risk of major paradox respiratory insufficiency in the postoperative period. Thus, it is possible to perform the one-stage thoracopleuroplasty after a delay of 15 days to one month, without removing substantial portions of the costal archs. In fact, an average of 5 ribs was resected in our study. The fixation of the prepared flap to the mediastinal surface provides immediate rigidity. If necessary, the use of a muscle flap in connection with limited thoracoplasty may help the closure of bronchial fistula and obviates the need for extended thoracoplasty. By confining the rib removal to the costal arch in front of the empyema, leaving in place the posterior part of each rib with its transverse process, and by preserving the intercostal bundles, we did not observe the severe deformity

5 Ann Thorac Surg ICARD ET AL 1999;68: ANDREWS THORACOPLASTY AND EMPYEMA 1163 that characterized most descriptions of traditional thoracoplasties [17]. Because of the transverse processes, the head and the neck of the ribs are kept in place, and the degree of scoliosis is reduced. When the first rib can be kept in place, scoliosis would be minimal [18]. Like Horrigan and Snow [16], we never observed symptoms of progressive pulmonary failure, which were reported after extended traditional thoracoplasties [17, 19]. The cosmetic result is generally well accepted and well tolerated, with none of our patients complaining of unacceptable sequelae or of chronic chest wall pain. The most troublesome complaint is the restriction of shoulder mobility, especially when the first rib has been resected. Like Horrigan and associates [19], we observed in this case that abduction and elevation of the arm are generally accomplished by tilting the torso away from the involved side. However, in 60% of our cases, we were able to perform an adequate apicolysis that kept the first rib in place. Perhaps the first rib could be preserved more often, as suggested by the experiences of Gregoire and associates [15]. They reported that they were able to achieve adequate apicolysis and complete collapse, leaving the first rib in place, in a series of 17 patients who underwent thoracoplasty to treat postpneumonectomy empyema. Functional and cosmetic sequealae are not only seen after thoracopleuroplasties; they may also be observed after all kinds of myoplasties (for closure of open thoracostomies) such as the scapula rocking after performing a serratius anterior flap. We agree with other authors [2, 3, 15, 16] that these sequelae are not of primary importance in patients who have undergone pneumonectomy, generally in an advanced stage of cancer, presenting a fragile general condition, with limited hope of survival. Thoracopleuroplasty assures them an immediate closure and avoidance of daily bandaging and recurrent hospitalization for the iterative intervention necessary to ensure an aleatory closure. For long-term survivors, most activities can be accomplished satisfactorily. Cornet and associates [3] reported that 75% of their patients (who were younger than those in our series and mainly tuberculous) started to work again. Finally, we agree with other authors [2, 3, 15, 16] who emphasized that limited thoracoplasty is an excellent therapeutic option for treating postpneumonectomy empyemas, avoiding multiple operative procedures and the psychological drawbacks of prolonged hospitalization or of definitive open drainage. Thoracopleuroplasty as, described by Andrews, allows a good control of infection with complete evacuation of the products of empyema under direct vision, an immediate closure of any bronchial fistula, a one stage-procedure, and a rapid and most often simple postoperative recovery. These results and the quality of life after this thorapleuroplasty should support the rediscovery of this time-honored procedure in properly selected patients. This surgical procedure could be at least an alternative method to open thoracostomy every time a secondary closure seems to be uncertain, or used in case of failure of other treatments. References 1. Andrews NC. Thoraco-mediastinal plication. (A surgical technique for chronic empyema). J Thorac Surg 1961;41: Cornet E, Dupon H, Coiffard P, Rembeaux A. Thoracopleuroplasties pour empyème selon la méthode d Andrews (18 observations) [Thoracoplasty in empyema using Andrew s technique (18 observations)]. 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