PURPOSE: Managing the infected apical pleural space remains a rare but significant challenge for the thoracic surgeon. Decortication of the infected space is usually unsuccessful. Empyema tube or open (Eloesser) thoracostomy is poorly tolerated by patients in the apical position. Muscle transposition may be helpful, but options can be limited in the reoperative setting. Poor underlying lung function often makes completion pneumonectomy with Eloesser and subsequent closure (Clagett procedure) untenable. Herein we report our experience with axillary (apical) thoracoplasty through a limited incision with minimal morbidity. We demonstrate the advantage of this technique in obliterating the infected apical pleural space while preserving ipsilateral lung function.
METHODS: From March 1997 to January 2010 all patients who underwent axillary (apical) thoracoplasty for treatment of complex apical pleural space infections were included in the study. Medical records were reviewed and outcomes analyzed.
RESULTS: Seven patients were identified, average age 61 years. Five (71%) had a prior thoracotomy. Nontuberculous mycobacterial infections were present in five patients (71%), multidrug resistant tuberculosis in one (14%) and Pseudomonas aeruginosa in one (14%). Bronchopleural fistulae were present in four patients (57%). A subperiosteal resection technique was used for thoracoplasty, removing ribs 1 thru 4 in five patients and ribs 2 thru 4 in two patients. Muscle transposition was utilized in five patients (71%). Three patients underwent thoracoplasty after failed myoplasty. There was no operative mortality. Morbidity was minimal with surprisingly good range of motion and function of the involved upper extremity. The average hospital stay was 11 days. Successful obliteration of the space and resolution of the infection was accomplished in all patients.
CONCLUSIONS: The infected apical pleural space is a complex problem and a unique surgical challenge. Axillary (apical) thoracoplasty combined with muscle transposition can successfully treat and collapse the infected space while preserving valuable ipsilateral lung function.
CLINICAL IMPLICATIONS: Management of the infected apical pleural space with axillary (apical) thoracoplasty obliterates the infected pleural space while preserving valuable ipsilateral lung function.
DISCLOSURE: The following authors have nothing to disclose: Jessica Yu, Marvin Pomerantz, Amy Bishop, Michael Weyant, John Mitchell
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