Transcript 10 YEARS EXPERIENCE WITH OPEN-WINDOW THORACOSTOMY OR ELOESSER FLAP

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10 YEARS EXPERIENCE WITH
OPEN-WINDOW
THORACOSTOMY OR
ELOESSER FLAP
ERCİYES UNİVERSİTY THORACİC
SURGERY DEPARTMENT
Despite the recent advances in medical technology,
empyema thoracis (ET) remains a debilitating disease
process with considerable morbidity and mortality.
The most common cause of ET is PARAPNEUMONİC
EFFUSİONS.
Other less common causes of ET include
.Thoracic surgical procedures
.Trauma
.Malignant pleural effusion
.Esophageal perforation
.Foreign body
.Chest wall infections
.Tuberculosis and
.Subdiaphragmatic abscesses
Optimal effective treatment for ET requires control of
the infection with antibiotics, evacuation of the pus
and reexpansion of the lung.
İnitially, most patients are treated by nonsurgical
modalities including ;
.Repeat aspiration thoracentesis
.İmage- directed catheters, and
.Tube thoracostomy.
In the case of failed nonsurgical modalities or chronic,
multiloculated ET, traditional surgical approaches
including ;
.Decortication
.Video-assisted thoracoscopic surgery
In those debilitated patients with chronic empyema
thoracis, extensive thoracoplasty and sophisticated
muscle transfer techniques may be poorly tolerated.
For those patients who may be too ill to tolerate a
major thoracotomy, we advocate open surgical
drainage with the Modified Eloesser Flap (MEF).
Patients and Methods
A retrospective review was performed on the available
charts of 18 consecutive patients who underwent the
MEF procedure at Gevher Nesibe Hospital of Erciyes
University from 1998 to 2008.
Mean age was 58 ± 14 years (range 41 to 71 years old);
16 (89%) were men and
2 (11%)
were women.
Before surgical intervention, empyema thoracis was
confirmed in all patients by one of the following
criteria:
1- Aspiration of grossly purulent pleural fluid during
.Thoracentesis
.İmage- directed catheters,
.Thoracostomy
2- Biochemical evidence of plural fluid defined as
pH less than 7.20, lactate dehydrogenase level greater
than 1000IU/L, glucose level less than 40 mg /dL and
white blood cell count (WBC) greater than 500/ml or
3- Positive pleural fluid microbiology culture or gram
stain revealing organism.
Preoperatively, all patients underwent conventional
chest roentgenography, computed tomography and
standard laboratory evaluation.
Fiberoptic bronchoscopy scanning were performed
most of the patients.
All patients in this series received various therapeutic
interventions before the modified Eloesser Flap
(MEF).
Common therapeutic modalities that were used
included
.İmage-directed catheter
.Thoracente sis
.Tube thoracostomy
. VATS
.Decortication
All patients underwent the modified Eloesser
procedure as described by Symbas and associates ın
1971 for the treatment of nontuberculous pleural
empyema in adults.
The modification consisted of making an inverted “U”
base incision rather than the original “U” base incision
as proposed by Dr.Eloesser in 1935.
The inverted “U” incision is based at the most inferior
portion of the thoracic empyema space.
In brief, the patient is turned in a lateral decubitus
position, with the involved chest up.The empyema
cavity is located (fig 1), either by a previously placed
drainage tube, or through an intraoperative
posterolateral minicotomy incision after needle
localization.
An incision is made so as to create an inverted Ushaped flap of skin and subcutaneous tissue over
the empyema cavity
The base of the flap is 3 to 4 cm wide, and lies over
the most dependent part of the cavity; its length is
3 to 4 cm or equal to the width of one to two ribs
and their intercostal spaces
Portions of one or two of the ribs (dependent upon
the size of the empyema cavity and the obesity of
the patient ) just beneath the U- shaped incision are
dissected subperiosteally and removed
The soft tissue portion of the chest wall overlying
the abscessed cavity is then resected completing
the unroofing of the empyema cavity. The Ushaped skin flap is reflected onto the most
dependent portion of the abscessed cavity and
sutured to the cavity’s floor
The edges of the skin are marsupialized onto the
surrounding soft tissue, and a sterile dressing is
applied
Table 1. Surgical İndication for the Modified Eloesser Flap
Cause
Parapneumonic
Number of patients (%)
12 (% 66)
Malignant pleural effusion
4 (% 22)
Postresectional
1 (% 5 )
Tuberculosis related
1 (% 5)
The most common organisms from preoperative
pleural fluid or intraoperative empyema tissue
cultures were gram-negative organisms (mainly
Pseudomonas and E.coli ) and gram- positive
organisms (mainly Staphylococcus and
streptococcus )
Using the MEF, adequate drainage was successful
in all patients and there were no intraoperative
deaths or complications.
In all of these patients ,the MEF was viable and
granulating well or healed.
We followed –up these patients at least 3 months.
We have confirmed that in a selected patient
population the MEF is a safe , effective surgical
technique for the treatment of advanced ET.
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