PURPOSE: We report an analysis of a personal series of 48 consecutive patients with complex space-filling procedures.
METHODS: Between 01.01.2004 –01.04.2007 we treated a number of 48 patients with complex TB pleural and pulmonary lesions not amenable to lung resection and/or decortication; large bronchial fistulae were present in 20 patients. One-stage surgery consisted in a topographic thoracopleuroplasty (personal procedure) with an average of 6,2 resected ribs/patient and mandatory preservation of rib 1, plombage of the cavity using multiple neighbourhood muscle flaps (intercostals –48 cases, latissimus dorsi –38 cases, serratus anterior 26 cases, pectorals 20 cases, subscapularis 8 cases), closure-reinforcement of bronchial fistulae using intercostal flaps in 20 cases, inclavation of the tip of the scapula in 10 cases, closed-circuit irrigation-aspiration system and external contention in all cases.
RESULTS: The average operative time was 210 minutes with no major intraoperative incident. Residual cavities requiring an open-window were encountered in 3 patients (6,25%) but there was no bronchial fistula recurrence; 2 patients presented minor skin necrosis solved by excision and secondary suture. Mortality was 6,25% (3 patients) through respiratory failure and sepsis (2 patients) and cardiac failure (1 patient). Mean postoperative hospitalization time was 38 days. Improvement of the clinical status and control of TB infection (negative cultures from sputum) was eventually achieved in all survivors. After discharge and completion of the tuberculostatic treatment all patients had a good social reinsertion with return to a normal active life.
CONCLUSION: The complex TB lesions require complex procedures in order to achieve not only collapse, but also complete filling of the pleuro-pulmonary cavities with well-vascularised tissue and safe closure of bronchial fistulae. In trained centers, this kind of life-saving surgery can be performed with an acceptable morbidity and mortality.
CLINICAL IMPLICATIONS: Thoracic surgeons must abandon the classic thoracoplasty and be familiar with more space-filling techniques and should not hesitate to combine them to adapt for each particular case in order to improve the results of this kind of surgery.
DISCLOSURE: Petre Botianu, None.