Complex space-filling procedures for intrathoracic infections - personal experience with 76 consecutive cases

The objective of our article is to analyse the results of complex space-filling procedures for chronic intrathoracic suppurations.

We performed a retrospective analysis of 76 consecutive patients operated in our unit between 1 January 2003 and 31 December 2008, who presented pleural and/or pulmonary suppurations not amenable to decortication or resection; 36 patients (47%) had tuberculosis (TB) lesions (28 with positive cultures at the moment of surgery, seven with multi-drug-resistant (MDR) infections), 13 patients (17%) had postoperative empyema, 18 patients (24%) presented with frank intrapleural rupture of a pulmonary cavity and 26 patients (34%) presented with bronchial fistula. In these patients, we performed a combination of thoracoplasty (5.3+/-1.3 resected ribs) and intrathoracic transposition of extrathoracic muscles - 148 flaps (60 serratus anterior, 55 latissimus dorsi, 27 pectoralis and 6 subscapularis) with an average of 1.9 flaps per patient; in all patients, we used a closed-circuit irrigation-aspiration system and primary closure of the wound.

The overall mortality was 5% (four patients) and four other patients (5%) presented recurrence of infection requiring a modified open-window thoracostomy; other local complications included minor skin necrosis solved through excision (three cases) and external thoracic fistula closed through local lavages (two cases). Postoperative hospitalisation ranged between 4 and 180 days, with an average of 40+/-5 days; all patients were discharged with healed wounds. Statistical analysis performed with the Fischer's exact test suggested that the flap or combination of flaps used to obliterate the space did not influence the rate of recurrence or the incidence of other major postoperative complications (p>0.05). Mild impairment of shoulder function was encountered in five patients. A comparative evaluation of the pre- and postoperative VC and forced expiratory volume of 1s (FEV1) showed no statistically significant difference (Wilcoxon signed-rank test -p>0.05).

Patients with complex intrathoracic suppurations not amenable to decortication or lung resection require complex space-filling procedures to achieve complete obliteration of the infected space. The association between thoracoplasty and intrathoracic muscle transposition is a safe and simple solution allowing a quick recovery with good functional and aesthetic postoperative outcome.