Thoracoplasty in the Current Practice of Thoracic Surgery: A Single-Institution 10-Year Experience

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1 Thoracoplasty in the Current Practice of Thoracic Surgery: A Single-Institution 10-Year Experience Alessandro Stefani, MD, PhD, Rami Jouni, MD, Marco Alifano, MD, PhD, Antonio Bobbio, MD, PhD, Salvatore Strano, MD, Pierre Magdeleinat, MD, and Jean-Francois Regnard, MD Department of Thoracic Surgery of the Hôtel-Dieu Hospital, Paris, France Background. We retrospectively reviewed our recent experience with thoracoplasty to define its role in the context of current surgical practice. Methods. Twenty-six patients underwent thoracoplasty in the last 10 years with the aim of obliterating a residual pleural space or pulmonary cavity. Twentyone patients had a postresectional empyema, 3 had a primary empyema and 2 had a cavernostomy performed for a pulmonary aspergilloma. A bronchopleural fistula was present in 10 cases. Infection had been previously controlled in all cases by intercostal drainage, open-window thoracostomy, or cavernostomy (in 4, 20, and 2 patients, respectively). Twenty-two extramuscoloperiosteal thoracoplasties, 3 thoracomyoplasties, and 1 Andrews thoracoplasty were performed. Intrathoracic flap transposition followed thoracoplasty in 9 cases; a second step of the Clagett procedure followed thoracoplasty in 2 cases. Results. One patient died postoperatively (3.8%). Thoracoplasty alone (n 6) or combined with a procedure to fill the residual space (n 14) was successful in achieving complete obliteration of the residual space in 77% of patients (n 20). In 4 patients thoracoplasty alone reduced the residual cavity but filling procedures were not feasible. In 1 patient thoracoplasty failed to obliterate the cavity and infection recurred. Three patients experienced chronic thoracic sequelae. Conclusions. Thoracoplasty remains an option for the treatment of residual pleural or pulmonary spaces (with or without bronchopleural fistula) once infection has been controlled, when other more conservative procedures are not effective or feasible. In our experience it was effective both when used alone in favorable conditions and when combined with other procedures to fill the residual cavity. (Ann Thorac Surg 2011;91:263 9) 2011 by The Society of Thoracic Surgeons Thoracoplasty is a surgical procedure that allows the reduction of the thoracic cavity by removing the ribs. It was originally conceived to collapse cavities of lungs affected by tuberculosis and gained worldwide acceptance in such a setting. Subsequently, indications rapidly extended to thoracic empyema. Since the 19th century, various techniques have been developed [1, 2], and finally, in 1937, Alexander [3] described the extrapleural subperiosteal thoracoplasty and popularized this surgical procedure as it is known today. During the 1950s and 1960s, thoracoplasty lost much of its popularity after the introduction of antituberculous chemotherapy and the advent of procedures of muscle transposition to fill the pleural space. Moreover, it was considered a mutilating operation, leading to undesirable anatomic, functional, and cosmetic sequelae. Thus, thoracoplasty was almost completely abandoned. However, despite the bad reputation, there remain a few cases of chronic pleural infection in which thoracoplasty is indicated. Some patients with postresectional empyema or primary empyema in which the lung fails to reexpand are potential candidates for this operation, which can be performed alone or in combination with other procedures. Accepted for publication July 28, Address correspondence to Dr Alifano, Department of Thoracic Surgery, Hôtel-Dieu Hospital, 1 Place du Parvis Notre Dame, Paris, 75004, France; marco.alifano@htd.aphp.fr. The most recent original article on thoracoplasty was published in 1999, when Icard and coworkers [4] reported a series of 23 patients affected by postpneumonectomy empyema, treated with the Andrews technique. Previously, in 1993, Peppas and colleagues [5] described their experience with thoracoplasty in the context of modern surgical practice. To our knowledge, these remain the latest articles published on this subject in the English literature. We retrospectively reviewed our recent experience on the use of thoracoplasty, providing indications, techniques, and results. Patients and Methods Patients Data of all patients undergoing thoracoplasty at the Hôtel-Dieu Hospital in Paris, between 2000 and 2009, were retrospectively reviewed. The study was carried out in agreement with French laws on biomedical research and according to the principles outlined in the Helsinki Declaration. Patients or their relatives, in the case of deceased patients, gave informed consent. All patients had thoracoplasty as part of the treatment of an infected, unresolving pleural or pulmonary space. In the case of postresectional empyema, our routine policy was intercostal drainage followed by open-window thoracos by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 264 STEFANI ET AL Ann Thorac Surg THORACOPLASTY 2011;91:263 9 tomy (OWT) if a bronchopleural fistula (BPF) was present. In the absence of BPF, when infection persisted, a videothoracoscopic debridement was first attempted, followed by OWT in case the debridement procedure failed. Once infection was controlled and the cavity reduced, we proposed thoracoplasty to further reduce the residual space, if a simple filling procedure was considered not feasible or insufficient, provided that the patient s conditions allowed further surgery and that there were no signs of tumor recurrence. In cases of primary empyema, we performed thoracoplasty only in patients with persistent pleural space when decortication either was not feasible or had failed. Intercostal drainage and, when needed, OWT were first used to achieve control of the infection. Finally, we proposed thoracoplasty in rare cases of unresolving cavernostomy, with persistent multiple bronchiolar fistulas, to obliterate the residual space and to seal the fistulas. In all cases, when complete obliteration was obtained and the BPF was sealed, thoracoplasty proved to be the definitive treatment. Otherwise a further step was undertaken by filling techniques, such as intrathoracic muscular transposition, omentopexy, or the second step of the Clagett procedure [6]. We generally performed thoracoplasty and the filling procedure at different times. Surgical Technique All thoracoplasties were performed in one stage. An extramusculoperiosteal thoracoplasty, as originally described by Alexander [3], was our technique of choice. A posterolateral incision was made and extended vertically upward to expose the upper ribs. The scapula was elevated to expose the costal grill. To achieve satisfactory collapse of the cavity, a sufficient number of ribs were resected in a subperiosteal extrapleural manner (Fig 1). A sloping resection of the anterior portion of the costal arches was performed, with progressively less anterior rib being removed as the resection progressed downward. When performed in a patient with OWT, which was usually located in the lateral chest wall, the incision extended backward and upward from the posterior limit of the thoracostomy. Special care was taken to avoid entering the thoracostomy cavity. The first rib was removed, when possible, in all patients with apical space. Apicolysis, as described by Semb [7], was performed in all cases with apical space: it consisted of extrapleural division of adhesions between the pleural dome at the apex and the soft tissues to achieve vertical collapse and to approximate the soft tissues to the mediastinum. The transverse process was never resected. However, special care was taken to remove the back ends of the ribs, and in case of large posterior spaces, ribs were disarticulated from the costovertebral joint. The lower third of the scapula was resected when it tended to lock on the uppermost residual rib. In case of a small thoracostomy cavity, a limited intrapleural thoracoplasty was performed in combination with an intrathoracic muscular transposition to totally obliterate the cavity in one stage. In this operation, called thoracomyoplasty by Garcia-Yuste and associates [8], thoracoplasty consisted of the resection of the costal bony Fig 1. Alexander thoracoplasty. Exposure is maintained by a chest retractor. Ribs from 1 to 4 have been resected. Periosteum, intercostal bundles, and parietal pleura have been left in place. Reprinted from Fell SC. Thoracoplasty: indications and surgical considerations. In: Shields TW, Locicero J III, Reed CE, Feins RH, eds. General thoracic surgery, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2009: 814, with permission. extremities of the thoracostomy borders and resection of the two ribs above and below the thoracostomy, together with the intercostal muscles, neurovascular bundles, and parietal pleura, as described by Schede [1]. An Andrews thoracoplasty [9] was exceptionally performed to obliterate a postpneumonectomy cavity with a large BPF, causing an intolerable loss of tidal volume. A parietal drainage in the subscapular space was left in place in case of extramusculoperiosteal thoracoplasty. In case of thoracomyoplasty, drainage of the pleural space was continued until total obliteration of the space was obtained. Mobilization of the shoulder and arm was not allowed during the early postoperative days; thereafter, physical rehabilitation to ensure shoulder mobility was started. The safety of thoracoplasty was evaluated in terms of postoperative morbidity and mortality. The effectiveness of thoracoplasty was evaluated in terms of reduction or complete obliteration of the pleural space, control of the infection, and healing of BPF, when present. When further procedures to fill the residual space were performed, the outcome analysis focused on the final result at the end of the combined treatment. When closure of BPF, complete obliteration of the pleural space, and definitive skin closure were obtained, thoracoplasty (with or without myoplasty) was considered successful. Related chronic side effects were also investigated, such as chest wall and shoulder deformity, scoliosis, restriction of shoulder mobility, frozen shoulder syndrome with fixation of the scapula, chronic postoperative pain, and progressive pulmonary failure. The appearance and development of side effects were followed up by periodic office visits, chest roentgenograms, and, when necessary, pulmonary function tests.

3 Ann Thorac Surg STEFANI ET AL 2011;91:263 9 THORACOPLASTY 265 Table 1. Previous Efforts to Control Infection in Patients With Empyema (n 24) Procedure Results Successful No. of Patients Failed Intercostal drainage 4 20 Thoracoscopic debridement a 0 3 Decortication b 0 2 Open-window thoracostomy 20 0 a Performed in 3 cases of postpneumonectomy empyema. b Performed in 2 cases of primary empyema. Twenty-six patients underwent thoracoplasty. There were 24 men (92%) and 2 women, with a mean age of 58 years (range, 42 to 81 years). Twenty-one patients (81%) received thoracoplasty in the treatment of a postresectional empyema with residual cavity. Original operations were pneumonectomy and lobectomy in 13 and 8 patients, respectively. Fourteen of these patients (67%) had received the pulmonary resection for lung cancer, 4 for aspergilloma, and 1 each for lung sequestration, bronchiectasis, and mesothelioma. Tumor pathologic stage for patients treated for non small cell lung cancer was as follows: stage I in 5 patients (36%), stage II in 2 (14%), stage IIIA in 5, and stage IIIB in 2. The delay between resection and empyema onset ranged from 6 days to 56 months, with a median of 13 days; 13 patients (62%) presented an early empyema ( 30 days). All patients were initially treated by intercostal drainage. In 3 cases of postlobectomy empyema without BPF the intercostal drainage was successful in achieving control of the infection, whereas in the remaining 5 patients the infection persisted and OWT was necessary. All patients with postpneumonectomy empyema subsequently treated by thoracoplasty underwent prior OWT, in 7 cases because of the presence of BPF and in 3 cases because of the persistence of infection after a thoracoscopic debridement had been attempted. A BPF was present in 10 patients (48%) at the time of detection of empyema, but OWT allowed spontaneous closure of the fistula in 4 (3 postpneumonectomy and 1 postlobectomy). No attempts to resuture the bronchus for direct closure of the fistula were made. Three patients (11%) underwent thoracoplasty for primary nontuberculous empyema with persistent pleural space. Multiple bronchiolar fistulas were present in 2 patients. In 1 patient intercostal drainage successfully controlled the infection, but subsequent decortication failed to reexpand the lung. Two patients needed OWT because of uncontrolled infection; in 1 patient decortication was attempted before OWT, but it was unsuccessful. Table 1 reports the procedures performed in the attempt to control infection in the 24 patients with empyema. Two patients (8%) received thoracoplasty to obliterate a cavernostomy previously performed to treat a pulmonary aspergilloma. Infection was controlled in both cases, but the presence of multiple bronchiolar fistulas prevented the spontaneous obliteration of the cavity. The delay between drainage of the infected cavity and thoracoplasty ranged from 8 days to 20 months (median, 97 days). An extramusculoperiosteal thoracoplasty was per- Fig 2. (A) Chest roentgenogram after left open-window thoracostomy shows a large postpneumonectomy cavity. (B) Chest roentgenogram after successful extramusculoperiosteal thoracoplasty shows chest wall collapse and obliteration of the cavity. The degree of scoliosis is acceptable.

4 266 STEFANI ET AL Ann Thorac Surg THORACOPLASTY 2011;91:263 9 Fig 3. Computed tomographic scan of the same patient as in Figure 2 shows complete collapse of the left chest wall, after thoracoplasty right lung overexpansion, and mediastinal shift, with aortic arch (A) and heart (B) coming in contact with the parietal flap. formed in 22 patients (85%) after OWT (Figs 2, 3), intercostal drainage, and cavernostomy in 16, 4, and 2 patients, respectively. Thoracomyoplasty was undertaken in 3 cases of postresectional empyema after OWT. Andrews thoracoplasty was performed in only 1 case of postpneumonectomy empyema with large BPF after OWT. A median of seven costal arches were removed (range, 3 to 10); in 7 cases nine ribs were removed. The first rib was removed in 21 patients (81%). In 2 patients ribs were disarticulated from the costovertebral joint. In 1 patient the lower third of the scapula was also resected. In 14 patients (54%), thoracoplasty was associated with techniques to fill the residual pleural space: 10 intrathoracic muscular transpositions (including 3 thoracomyoplasties), 2 omentopexies, and 2 second steps of the Clagett procedure. In 11 patients the filling procedure followed thoracoplasty, with a delay ranging from 62 days to 28 months (median, 143 days). Postoperative mortality was 3.8%: 1 patient (who had empyema after extrapleural pneumonectomy for mesothelioma) died 21 days after thoracoplasty of adult respiratory distress syndrome. Five patients (19%) experienced postoperative complications, in all cases after extramusculoperiosteal thoracoplasty with resection of more than five ribs: acute pneumonia in 2 patients, subscapular abscess, atelectasis, and blood loss in 1 each. Median hospital stay was 15 days (range, 7 to 82 days). Thoracoplasty was successful in 20 patients, alone in 6 and combined with a procedure to fill the residual space in 14. The overall success rate was 80%, 77% if death is included. With respect to the indications, thoracoplasty was successful in 17 of 21 (81%) postresectional empyemas (11 of 13 postpneumonectomy and 6 of 8 postlobectomy), in all primary empyemas, and in 1 case of cavernostomy. Regarding techniques, extramusculoperiosteal thoracoplasty showed a 77% success rate and thoracomyoplasty a 100% success rate. Andrews thoracoplasty was successful in the only case in which it was performed. Combined thoracoplasty and filling procedures were successful in all 14 cases. Five procedures failed (20%). In a man with ankylosing spondylitis, extramusculoperiosteal thoracoplasty was performed after intercostal drainage but failed to achieve adequate obliteration of the cavity, and infection recurred. In 4 patients extramusculoperiosteal thoracoplasty alone did not achieve complete obliteration of the cavity, but filling procedures were not carried out because of patient refusal, impaired clinical status, cancer recurrence, and lack of viable muscles. In all these cases, however, infection was controlled, and a significant reduction of the cavity was obtained. Patients were easily treated by local care in an outpatient setting, with improvement of the quality of life. Mean follow-up was 45 months (range, 1 to 111 months). All patients presented with some degree of thoracic deformity and scoliosis. However, in 23 cases (88%) morphologic sequelae were neither severe nor symptomatic and the cosmetic result was considered acceptable by the patients. In only 1 patient was the thoracic deformity severe, and in another patient scoliosis was symptomatic: both patients had extramusculoperiosteal thoracoplasty with resection of ribs 1 to 9. All patients complained of a restriction in shoulder mobility during the early postoperative period, which progressively improved with intensive physical rehabilitation. A residual reduction in shoulder mobility was generally well accepted by the patients. Only 1 patient experienced a frozen shoulder syndrome, with disability and chronic pain (resection of ribs 2 to 8). None of our patients showed progressive pulmonary failure related to thoracoplasty. Twenty-one patients were alive at the end of follow-up, 2 died of pneumonia 5 and 16 months after thoracoplasty, and 2 died as a result of cancer recurrence 10 and 39 months after thoracoplasty. Overall 5-year survival from the date of thoracoplasty was 76%; cancer-specific 5-year survival was 78% and 80% from the date of thoracoplasty and pulmonary resection, respectively.

5 Ann Thorac Surg STEFANI ET AL 2011;91:263 9 THORACOPLASTY 267 Comment The purpose of thoracoplasty is to achieve pleural space obliteration. At present, persistent pleural space in postresectional empyema and unresolving primary empyema with trapped lung are the more common indications for thoracoplasty. Available studies in the last 25 years have shown that thoracoplasty can be an excellent therapeutic option, in selected patients, used alone [4, 5, 10 12] or in combination with flap transposition to fill the residual space [8]. An adequate drainage of the space for the control of infection is mandatory for successful thoracoplasty [5, 10, 13]. In our experience postresectional empyema was the most common indication for thoracoplasty, and postpneumonectomy empyema represented the largest group. In all patients treated with thoracoplasty for postpneumonectomy empyema, an OWT was first undertaken. Although some authors have proposed a more aggressive approach to postpneumonectomy empyema with BPF [14, 15], we advocate OWT as an intermediate step because it limits surgical trauma in severely ill patients and because BPF can spontaneously close [16]. Thoracoplasty may be used to obliterate the residual space after OWT, although intrathoracic flap transposition or Clagett procedure may also be indicated. The Clagett method is simple and safe, but the results can vary and it is unsuitable when BPF is present [14, 17, 18]. Muscular flap transposition was reported as safe and effective [8, 16, 19 22], but there are cases, especially after pneumonectomy, in which the cavity is too large to be filled with muscles or in which there are no muscles available. We believe that thoracoplasty may be used, especially in such cases, as an intermediate step to reduce the residual cavity. In our experience we observed 28 cases of postpneumonectomy empyemas between 2000 and Nineteen patients needed OWT to control infection and BPF: in 4 patients myoplasty alone was adequate to obtain complete closure of the cavity, whereas 13 patients underwent thoracoplasty (43%), which was associated with a further filling procedure in 8 cases. The remaining 2 patients maintained their thoracostomy and never underwent subsequent obliteration procedure because of poor general conditions and uncontrolled infection. In no cases did postpneumonectomy thoracostomy close spontaneously. In cases of postlobectomy empyema the need for a thoracoplasty may be questionable. Owing to a smaller cavity and the presence of residual lung, treatment with drainage, thoracoscopic debridement, or OWT often might be more successful. In our experience, among the 19 cases of postlobectomy empyema observed between 2000 and 2009, an OWT was necessary in 17 cases: it closed spontaneously in 2 patients, was filled by a muscular flap in 7 cases, and required a thoracoplasty in 8 cases. The percentage of thoracoplasty is relatively high (42%) and indicates that spontaneous closure of thoracostomy occurred rarely and simple filling with a flap was not always feasible, even in cases of postlobectomy empyema. The indication of thoracoplasty for primary empyema is accepted but uncommon [5]. If infection is controlled but the lung does not reexpand and decortication is not feasible or has failed, thoracoplasty can be indicated. In the event that OWT is necessary to control infection, subsequent myoplasty should be taken into account because the residual space is often small and easy to fill. Alternatively or if myoplasty is not feasible, thoracoplasty may be indicated. In our experience thoracoplasty was rarely performed for this indication. During the period of observation, 341 patients underwent surgery for primary empyema: 216 procedures were carried out by video-assisted thoracoscopy (pleural debridement) and 122 by thoracotomy (pleural debridement and lung decortication), whereas only 3 patients required a tailored thoracoplasty (0.8%), in 1 case also associated with myoplasty. In our series, thoracoplasty was combined with a filling procedure in 14 patients (54%). The timing of combined procedures is of great importance. Regarding the timing to close OWT, we believe that space obliteration should be performed as soon as the objectives of thoracostomy are achieved. For neoplastic patients, however, we undertook thoracoplasty after a minimal delay of 4 to 5 months from cancer resection (the median delay was 9 months), provided that the absence of tumor recurrence was assessed. We usually preferred to perform thoracoplasty and filling procedure at different times to limit surgical trauma in weak patients. Flap transposition, after thoracoplasty, should be proposed as soon as permitted by the patient s general and local conditions. In 3 patients, we simultaneously performed thoracomyoplasty but with limited rib resection and for patients in good general conditions. Many different types of thoracoplasty have been described [13]. The Alexander thoracoplasty remains our preferred technique because it is simple and safe, it can be easily adapted to the dimensions of the cavity, and it is especially appropriate in the presence of OWT. The Schede intrapleural thoracoplasty is indicated in patients with thick, fibrotic, and calcified endothoracic layers because merely removing the ribs cannot adequately collapse the chest wall. This is usually not found in postresectional or in primary nonspecific empyema. Thus, at present, Schede thoracoplasty is rarely needed. Andrews thoracoplasty was reviewed as an effective technique to treat postpneumonectomy empyema after drainage, without prior OWT [4]. We performed Andrews thoracoplasty in 1 case of large BPF, which caused severe respiratory failure after the loss of tidal volume. Originally it had been recommended that thoracoplasty be performed in two or three stages to reduce surgical trauma [13]. Nowadays, improved surgical and anesthesiologic techniques, as well as perioperative care, allow thoracoplasty to be safely performed in one stage [5, 10 12]. Controversy exists as to whether the first rib should be resected [5, 11]. In agreement with others [23 25], we believe that excision of the first rib allows good collapse of the apex without causing significant scoliosis. However, whether or not the first rib is resected, extrafascial apicolysis is fundamental to collapse the apex and should always be performed [5, 13]. In our experience, the combination of resection of the first rib and apicolysis obtained adequate apical collapse in all cases. To maximize paravertebral collapse, the resection of transverse

6 268 STEFANI ET AL Ann Thorac Surg THORACOPLASTY 2011;91:263 9 processes has been advocated [3, 10, 12], but such a procedure has been also related to development of severe scoliosis [23, 24]. In our patients we obtained satisfying posterior collapse leaving transverse processes in place, as already reported by others [4, 5]. In our experience, all 14 patients undergoing thoracoplasty combined with filling procedures achieved successful obliteration of the space and BPF. The 5 patients who were treated by extramusculoperiosteal thoracoplasty alone presented favorable conditions for a predictable success of thoracoplasty, with small residual cavities after drainage and controlled infection. Among the 5 patients who did not achieve obliteration of the pleural space, in only 1 case can thoracoplasty be considered to have failed. In this case the inadequate obliteration of the space was attributable to a particular anatomic condition (ankylosing spondylitis) and a failure to control infection completely by simple intercostal drainage. Our policy of performing a multistep treatment may partly explain the low mortality (3.8%) and morbidity rates (19%). One patient died because thoracoplasty was undertaken as a salvage operation in a clinical setting of uncontrolled sepsis and progressive respiratory insufficiency. Some authors reported physiologic changes negatively affecting the function of the contralateral lung [24, 25], especially in case of thoracoplasty after pneumonectomy. We did not observe cases of progressive pulmonary failure. Moreover, as reported in recent series [4, 12], in our patients the frequency of long-term side effects is favorably low (12%). Meticulous surgical technique, tailored thoracoplasty, and early postoperative rehabilitation are important in limiting such problems. In conclusion, properly performed thoracoplasty still remains a safe and effective solution for difficult intrathoracic space problems, especially in combination with other filling procedures and provided that infection is controlled. Postresectional empyema, mostly postpneumonectomy, with or without BPF, represents the main indication today. References 1. Schede M. Die behandlung der empyeme. Verh Cong Innere Med Wiesbaden 1890;9: Sauerbruch F. Die chirurgie der brustograne. Vol 11. Berlin: Springer, Alexander J. The collapse therapy of pulmonary tuberculosis. Springfield, IL: Charles C Thomas, Icard P, Le Rochais JP, Rabut B, Cazaban S, Martel B, Evrard C. Andrews thoracoplasty as a treatment of postpneumonectomy empyema: experience in 23 cases. Ann Thorac Surg 1999;68: Peppas G, Molnar TF, Jeyasingham K, Kirk AB. Thoracoplasty in the context of current surgical practice. Ann Thorac Surg 1993;56: Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. 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Progressive changes in pulmonary function after pneumonectomy: the influence of thoracoplasty, pneumothorax, oleothorax and plastic sponge plombage on the side of the pneumonectomy. J Thorac Surg 1951;22:1 34. INVITED COMMENTARY Disease processes involving the pleural space, especially empyema, are some of the most difficult and vexing problems in thoracic surgery. Treatment defies algorithmic application and must instead be chosen with consideration of the underlying etiology, the stage of the pleural process, the overall condition of the patient, and a host of complicating factors, including previous interventions and associated complications, especially bronchopleural 2011 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur