Thoracoplasty

Langston and Sampson point out that the sine qua non of empyema management is early, adequate, and dependent drainage. Diagnostic thoracentesis followed by closed tube thoracostomy and conversion to open drainage, either by a large-bore tube or a rib-resection with a pleurocutaneous fistula, are initial procedures that may be continued for an extended period to control infection, obliterate loculations, and heal co-apted pleural surfaces secondarily. Clagett and Geraci have noted that postpneumonectomy empyema spaces can be "sterilized" and the initial drainage site can be closed after antibiotic instillation. Miller, however, reports success rates for this procedure only in the range of 25% to 33%. Our results are somewhat higher. Obliteration of the persistent space after control of infection by drainage can be accomplished by interposition of muscle flaps with closure of any bronchopleural fistulas and/or by thoracoplasty. As stated previously, myoplastic techniques to obliterate empyemas and close bronchial fistulas in tuberculous disease have a success rate of approximately 75%. Such techniques, however, not only assist in limiting the extent of thoracoplasty, but also may avoid the procedure entirely in some cases. Virkkula has emphasized that use of pedicled myoplasty does not necessarily obviate the need for thoracoplasty. Pairolero and colleagues reported that the use of selected thoracoplasty combined with muscle transposition afforded a 73% success rate for postpneumonectomy empyema and a 64% success rate for closure of persistent bronchopleural fistulas and precludes protracted drainage and/or extended thoracoplasty. Young and Ungerleider concluded that (1) thoracoplasty is more successful if it is applied for patients with parapneumonic rather than postresectional empyemas; (2) concomitant tailoring thoracoplasty has a higher rate of failure; (3) preliminary drainage followed by thoracoplasty has a higher success rate in eliminating the empyema than thoracoplasty alone; (4) first rib resection is indicated for apical collapse only; (5) preoperative preparation is important to control and manage underlying suppurative processes; and (6) thoracoplasty of any type should not be used as a desperation modality of therapy in which uncontrolled sepsis and inadequate drainage are present or in which cancer or unidentified sites of hemorrhage exist. Sequential management of the residual infected space can proceed along several pathways. Many patients with empyema are well-controlled with simple open drainage and with underlying lung reexpansion, either spontaneously or in association with decortication, and may never need thoracoplasty. Drainage and thoracoplasty alone may be effective not only in obliterating an empyema space but also in sealing a bronchopleural fistula.(ABSTRACT TRUNCATED AT 400 WORDS)