RECONSTRUCTIVE

Single-Stage Muscle Flap Reconstruction of thePostpneumonectomy Empyema Space: TheEmory Experience

Hisham Seify, M.D.Kamal Mansour, M.D.

Joseph Miller, M.D.Trent Douglas, M.D.

Renee Burke, M.D.Albert Losken, M.D.

John Culbertson, M.D.Glyn Jones, M.D.

Foad Nahai, M.D.T. Roderick Hester, M.D.

Atlanta, Ga.

Background: Postsurgical chronic empyema continues to present a complicatedtreatment scenario for thoracic and reconstructive surgeons. Muscle flaps are animportant option in the management of complex thoracic wounds. This studywas designed to report the Emory experience with muscle flaps for the man-agement of complex postsurgical empyema. The authors also present theirtreatment algorithm for managing empyema thoracis.Methods: The authors retrospectively reviewed the charts of 55 patients requir-ing different treatment modalities, including muscle flap transposition. Patientswere divided into four groups according to the initial thoracic procedure: groupA, no surgical resection; group B, postpneumonectomy; group C, postlobec-tomy; and group D, prophylactic postpneumonectomy or postlobectomy. Thestudy included 42 men (76.4 percent) and 13 women with a mean age of 62 years(range, 39 to 77 years).Results: Fifty-one muscle flap procedures were performed in 42 patients (ser-ratus anterior flaps, 16 patients and 23 flaps; latissimus dorsi flaps, 16 patientsand 18 flaps; pectoralis major muscle flaps, intercostal muscle flaps, and rectusabdominis flaps, three patients each: omental flap, one patient). The meannumber of ribs resected before flap intervention, usually during the openwindow thoracostomy, was three. The average time from initial thoracic oper-ation to flap intervention was 4 months. Average time from flap intervention todischarge was 12.5 days. Average hospital stay was 26.6 days. The 51 muscle flapsrepresented an average of 1.2 procedures per patient.Conclusion: Because of the excellent blood supply of extrathoracic muscle flapsand their ability to reach any place in the pleural cavity, they represent an idealtissue with which to fill the contaminated pleural space. (Plast. Reconstr. Surg.120: 1886, 2007.)

Empyema continues to be an uncommon butpotentially lethal complication of resectionalpulmonary procedures in which a pyogenic

infection of the pleural space develops. Post-pneumonectomy empyema occurs in 1 to 11percent of patients. These patients are difficultto manage and can carry mortality rates as highas 50 percent.1

More than 2000 years ago, Hippocrates rec-ognized that complete evacuation of the pleural

cavity was necessary to effectively treat empyemathoracis. He later described incision and insertionof metal tubes into the pleural space to drain anempyema.2

This principle of dead space obliteration, incombination with the advent of antibiotic ther-apy in the 1940s, provides the basis of treatmentof empyema today. Traditional therapy now be-gins with thoracentesis and culture-directed an-tibiotic therapy. This is followed by tube thora-costomy and concludes with either an opendrainage procedure such as a rib resection andcreation of an open window thoracostomy or bythoracoplasty.3,4

In 1898, J. B. Murphy outlined the surgicalmanagement of chronic empyema by thoracoplasty.5At the Mayo Clinic in 1915, Robinson describedtransposition of skeletal muscles into the chest to

From the Joseph Whitehead Department of Surgery, Divisionsof Plastic Surgery and Thoracic Surgery, Emory University.Received for publication May 20, 2005; accepted September12, 2005.Presented at the 71st Annual Meeting of the American Societyof Plastic Surgeons, in San Antonio, Texas, October of 2002.Copyright ©2007 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000256051.99115.fb

www.PRSJournal.com1886

treat empyema6 and, in 1920, Kanavel describedthe treatment of the noncollapsing wound by de-bridement and obliteration of dead space withvascularized muscle flaps.7 Arnold and Pairolerofurther popularized this therapy in the 1980s.8Miller et al. reported single-stage complete muscleflap closure of postpneumonectomy empyemaspace.9 Others have reported use of the omentum,myocutaneous flaps, and free flaps.10–13

Muscle flaps have also been an important op-tion in the management of bronchopleural fistulaas first described in 1911.14 Often, these complexwounds are infected, have been previously irradi-ated, and may have an associated bony defectand/or open communication with the lung air-way. Extrathoracic muscle flaps using serratus an-terior, latissimus dorsi, and pectoralis major mus-cles have also been described.15

The goal of this study is to report the Emoryexperience with the use of muscle flaps for themanagement of complex postsurgical empyema.In addition, we present our treatment algorithmfor the management of empyema thoracis.

PATIENTS AND METHODSIn this study, the authors retrospectively re-

viewed the charts of 55 patients requiring differenttreatment modalities, including muscle flap trans-position, from 1991 to 2002. Data cards were filledout retrospectively for each patient indicating age,sex, diagnosis, procedures performed, period ofhospitalization, complications, and outcome. Pa-tients were divided into four groups according tothe initial thoracic procedure performed: groupA, no surgical resection; group B, postpneumo-nectomy; group C, postlobectomy; and group D,prophylactic postpneumonectomy or postlobec-tomy (Table 1).

The diagnosis of empyema required one of thefollowing criteria: (1) grossly purulent pleuralfluid documented by thoracentesis or at thoracot-omy; (2) positive pleural fluid culture or Gram’sstain; or (3) pleural fluid pH �7.0 and lactatedehydrogenase greater than 1000 U/liter. Empy-ema was defined as multiloculated if two or more

pleural fluid collections were seen on chest com-puted tomographic scan. The results were com-pared between the different patient groups withidentification of patient morbidity and mortality.

RESULTSThe study included 42 men (76.4 percent) and

13 women; the mean age of the patients was 62years (range, 39 to 77 years). The initial thoracicsurgery was performed for lung or pleural cancerin 28 patients, following complicated pneumoniaand other inflammatory conditions in 24 patients,and following spontaneous esophageal rupture intwo patients. Bronchopleural fistula was present in20 patients, five in group A (no surgical resection),seven in group B (postpneumonectomy), andeight in group C (postlobectomy). The meannumber of ribs resected before flap intervention,usually during the open window thoracostomy,was three. Procedures performed included chesttube thoracostomy/decortication in two patients,Eloesser flap in 27 patients, and muscle flap trans-fer in 42 patients (Table 2). A total of 51 muscleflaps were performed in 42 patients as follows:serratus anterior flaps in 16 patients (23 flaps),latissimus dorsi flaps in 16 patients (18 flaps), pec-toralis flaps in three patients, intercostal flaps inthree patients, rectus abdominis flaps in three pa-tients, and an omental flap in one patient (Table3). The average time from initial thoracic surgeryto flap intervention was 4 months. The average

Table 2. Different Types of Procedures PerformedDivided According to the Initial Thoracic Procedure

Group A(n � 17)

Group B(n � 16)

Group C(n � 13)

Group D(n � 9)

Chest tubethoracotomy/decortication 2

Eloesser flap 13 6 8Muscle flaps 3 21 18 9Total 18 27 26 9

Table 3. Different Muscle Flaps Performed DividedAccording to the Initial Thoracic Procedure

Group A(n � 17)

Group B(n � 16)

Group C(n � 13)

Group D(n � 9)

Intercostal muscle 1 2Serratus muscle 1 8 7 7Latissimus muscle 1 9 6 2Pectoralis muscle 1 2Omentum 1Rectus abdominal

muscle 2 1Total 3 21 18 9

Table 1. Cause of Surgical Empyema DividedAccording to the Initial Thoracic Procedure

Group A(n � 17)

Group B(n � 16)

Group C(n � 13)

Group D(n � 9)

Neoplastic 13 7 8Inflammatory 15 3 6Other 2 1Total 17 16 13 9

Volume 120, Number 7 • Postpneumonectomy Empyema Space

1887

time from flap intervention to discharge was 12.5days. The average hospital stay was 26.6 days. Intotal, 51 flap procedures were performed, for anaverage of 1.2 procedures per patient.

Group AThe nonresectional group included 17 patients

who developed empyema from various causes: 15patients following pneumonia and two patients fol-lowing spontaneous esophageal rupture. Three pa-tients in this group underwent flap coverage (serra-tus, latissimus, and omentum).

Group BThe postpneumonectomy group included 16

patients: 13 following pneumonectomy for neo-plasms and three following pneumonectomy forcomplicated inflammatory conditions. Eleven pa-tients in this group underwent muscle flap cover-age (total, 21 flaps: one intercostal, eight serratus,nine latissimus, one pectoralis, and two rectus ab-dominis muscle flaps).

Group CThe postlobectomy group included 13 pa-

tients: seven following lobectomy for neoplasmsand six following lobectomy for complicated in-flammatory conditions. Ten patients in this groupunderwent muscle flap coverage (total, 18 flaps:two intercostal, seven serratus, six latissimus, twopectoralis, and one rectus abdominis).

Group DThe prophylactic postpneumonectomy and

postlobectomy group included nine patients, andall underwent muscle flap coverage.

ComplicationsTwo patients developed persistent empyema

(8.7 percent). One patient required treatment bymeans of computed tomography–guided drain-age and the other patient was treated with opendrainage. One patient developed partial necrosisof a rectus abdominis muscle flap requiring de-bridement and local flap closure. One patient

died 10 days after surgery as a result of sepsis(Table 4).

DISCUSSIONThe optimum treatment strategy for the man-

agement of empyema thoracis remains elusive. Asstated by Thurer, “The goals of appropriate ther-apy for empyema are to limit morbidity and mor-tality, shorten hospital stay, and return pulmonaryfunction to baseline.”16 This is often easier in prin-ciple than in practice, and surgical input is oftendelayed until the failure of “medical manage-ment” with the advent of image-directed catheterplacement and concomitant use of fibrinolytics.

In a recent report by Thourani et al., patientsundergoing a decortication procedure had theshortest hospital stay when compared with pa-tients having image-directed catheters or tube tho-racostomy. In this series, 45 percent (nine of 20)of image-directed catheters failed, which resultedin this group having the longest hospital stay andthe highest hospital charges.17 These data havepersuaded Emory University thoracic surgeons toopt for early surgical intervention in the manage-ment of thoracic empyema.

Treatment strategies for empyema thoracisuse a variety of methods. The method is selectedon the basis of the stage of the empyema, thegeneral condition of the patient, and response tothe initial therapy. Ideally, the patients who hadold, thick pleura and did not respond to tubethoracostomy would require early surgical thera-pies such as decortication. However, these oper-ations often carry an increased risk of perioperativemorbidity to the debilitated patient, as describedby Kaplan and Light.18,19 Although open drainage,advocated by Eloesser and modified by Clagettand Geraci20 with instillation of antibiotics at thetime of closure, is an alternative choice, the timerequired to sterilize the empyema cavity is longand additional surgery is necessary to close thefenestration. Virkkula et al. reported that the in-terval between the construction of the fenestra-tion and its closure was on average 6 months(range, 1.5 to 28 months) for postpneumonec-tomy chronic empyema.21

Table 4. Outcome Measurements Divided According to the Initial Thoracic Procedure

Group A(n � 17)

Group B(n � 16)

Group C(n � 13)

Group D(n � 9)

Average stay 28 days 34 days 14 days 6 daysComplications 2 (recurrent empyema) 1 (partial flap necrosis)Mortality 1

Plastic and Reconstructive Surgery • December 2007

1888

Advances in the transposition of vascularizedtissue offered another alternative for the manage-ment of chronic wounds of the chest. Arnold andPairolero have described their extensive experi-ence with the intrathoracic transposition of ex-trathoracic skeletal muscles. Multiple flaps, in-cluding the omentum, have been described in thetreatment of these patients.22 Michaels et al. re-cently reviewed the closure of 16 cases of post-pneumonectomy empyema cavities with flaps. Theaverage number of flaps per patient was 2.1, and11 patients required combined thoracoplasty. Twopatients in this series had free flaps transferredmicrosurgically, with the remaining tissues trans-ferred as pedicled flaps.23 Perkins et al. describedthe successful management of five patients withintrathoracic sepsis by the transfer of free flaps.One transverse rectus abdominis musculocutane-ous and four latissimus dorsi flaps were used in thecare of these patients.24

Chronic thoracic wounds are prevented fromshrinking by secondary intention by the rigidity ofthe surrounding chest wall and are especially com-plicated when associated with radiation fibrosisand recurrent infection. Nevertheless, conven-

tional thoracic surgical techniques such as theClagett procedure are usually successful in resolv-ing these problems. However, further measuresmust occasionally be instituted, such as flaptransposition.13 Ideally, it would be advantageousto close these patients with tissue transpositionalone and avoid thoracoplasty. In cases of totalpneumonectomy, a significant volume is requiredto fill the empyema cavity. Multiple flaps are usu-ally required to fill the defect (Figs. 1 and 2).According to our study, the serratus muscle flapand the latissimus muscle flap were the flapsmost frequently used for empyema cavity oblit-eration. The choice of flap was a decision madeby the reconstructive surgeon based on the an-atomical defect and the availability of variousflaps.

Previous thoracic incisions could compromiseflap choice, especially the latissimus dorsi muscleflap. The omentum is used only when a significantvolume is required together with other flaps or asa salvage procedure. In this series, the only flapmorbidity was a partial necrosis in a rectus muscleflap that required local flap closure. There was nouse of free tissue transfer in this series, and it

Fig. 1. Different pedicled flaps used in the obliteration of theempyema space. Reprinted with permission from Miller, J. I.,Mansour, K. A., Nahai, F., et al. Single stage complete muscle flapclosure of the postpneumonectomy space: A new method andpossible solution to a disturbing complication. Ann. Thorac. Surg.38: 227, 1984.

Fig. 2. Total obliteration of the empyema space with multipleflaps (PM, pectoralis major; LD, latissimus dorsi; REC, rectus ab-dominis; SA, serratus anterior). Reprinted with permission fromMiller, J. I., Mansour, K. A., Nahai, F., et al. Single stage completemuscle flap closure of the postpneumonectomy space: A newmethod and possible solution to a disturbing complication. Ann.Thorac. Surg. 38: 227, 1984.

Volume 120, Number 7 • Postpneumonectomy Empyema Space

1889

would be indicated in cases where no regionalmuscle flap option is available.

In this series, muscle flap closure was used inconjunction with other modalities. It is to be notedthat the number of complicated empyema caseshas declined over the years as a result of earlysurgical management and culture-directed antibi-otic management. The Emory algorithm, as out-lined by Miller et al., consists of prompt pleuraldrainage by closed tube thoracostomy once thediagnosis of postpneumonectomy empyema, withor without bronchopleural fistula, has been estab-lished.

Chest tube drainage is continued until themediastinum becomes stabilized, generally afterapproximately 2 weeks. Thereafter, open drainageor another therapy for the empyema space can beundertaken safely without the mediastinum shifting.

Once the patient is medically stable and hasentered into the chronic phase at 3 to 4 weeks, amodified Clagett’s procedure is performed if nobronchopleural fistula is present. This is per-formed by placement of a second small chest tube

inserted into the second intercostal space with acontinuous inflow-outflow irrigation system estab-lished through the pleural cavity. The irrigant isbased on antibiotic sensitivities to the pleuraldrainage. If this method is successful and the re-turn is culture-negative on three consecutive daysafter 2 weeks of irrigation, the chest tubes can beremoved and the pleural fluid is allowed to reac-cumulate to fill the remaining space. If the mod-ified Clagett’s technique fails, a complete muscleflap closure of the pneumonectomy space can beperformed.

If a patient with postpneumonectomy empy-ema has a bronchopleural fistula, it is likewisetreated during the acute phase with closed chesttube thoracostomy, with conversion to open drain-age at the appropriate time when mediastinal sta-bilization has occurred. If the fistula closes, onecan attempt the modified Clagett’s procedure. Ifthe fistula persists, the space is managed by sur-gical closure of the fistula and muscle flaptransposition9 (Fig. 3).

Fig. 3. Algorithm for the management of postpneumonectomy empyema.

Plastic and Reconstructive Surgery • December 2007

1890

CONCLUSIONSThe management of postpneumonectomy

empyema remains a challenge in the fields of tho-racic and reconstructive surgery. It is an uncom-mon but disturbing complication. Several meth-ods have been described historically, ranging fromrib resection to complete thoracoplasty and tissuetransfer. Because of the excellent blood supply ofextrathoracic muscle flaps and their ability toreach any place in the pleural cavity, they repre-sent an ideal tissue with which to fill a contami-nated space.

Hisham Seify, M.D.Joseph Whitehead Department of Surgery

Divisions of Plastic Surgery and Thoracic SurgeryEmory University

92 Via CandelariaCoto de Caza 92679, Calif.

habdelk@emory.edu hseifymd@gmail.com

DISCLOSURENone of the authors has a financial interest in any

of the products, devices, or drugs mentioned in thisarticle.

REFERENCES1. Ashbaugh, D. G. Empyema thoracis: Factors influencing

morbidity and mortality. Chest 99: 1162, 1991.2. Hippocrates. Writings. In R. M. Hutchins (Ed.), Great Books

of the Western World. Chicago: Encyclopedia Britannica, 1952.29: 142.

3. Mandal, A. K., and Thadepalli, H. Treatment of spontaneousbacterial empyema thoracis. J. Thorac. Cardiovasc. Surg. 94:414, 1987.

4. Weber, J., Grabner, D., Al-Zand, K., and Beyer, D. Empyemaafter pneumonectomy: Empyema window or thoracoplasty.Thorac. Cardiovasc. Surg. 38: 355, 1990.

5. Milloy, F. The contributions of John B. Murphy to thoracicsurgery. Surg. Gynecol. Obstet. 171: 421, 1990.

6. Robinson, S. The treatment of chronic non-tuberculous em-pyema. Surg. Gynecol. Obstet. 22: 557, 1916.

7. Kanavel, A. B. Plastic procedures for obliteration of cavitieswith non-collapsible walls. Chicago Surgical Society Meeting,April of 1920.

8. Arnold, P. G., and Pairolero, P. C. Chest wall reconstruction:Experience with 100 consecutive patients. Ann. Surg. 199:725, 1984.

9. Miller, J. I., Mansour, K. A., Nahai, F., et al. Single stagecomplete muscle flap closure of the postpneumonectomyspace: A new method and possible solution to a disturbingcomplication. Ann. Thorac. Surg. 38: 227, 1984.

10. Jurkiewicz, M. J., and Arnold, P. G. The omentum: An ac-count of its use in the reconstruction of the chest wall. Ann.Surg. 185: 548, 1977.

11. Iverson, L. I. G., Young, J. N., Ecker, R. R., et al. Closure ofbronchopleural fistulas by an omental pedicle flap. Am.J. Surg. 152: 40, 1986.

12. Hallock, G. G. Intrathoracic application of the transverserectus abdominis musculocutaneous flap. Ann. Plast. Surg.29: 357, 1992.

13. Mathes, S. J., Alpert, B. S., and Chang, N. Use of muscle flapin chronic osteomyelitis: Experimental and clinical correla-tion. Plast. Reconstr. Surg. 69: 815, 1982.

14. Abrashanoff, H. Plastische Methode der Schliessung vonFistelgangen, welche von inneren Organen kommen. Zen-tralbl. Chir. 38: 186, 1911.

15. Chen, H., Tang, Y., Noordhoff, M. S., and Chang, C. Micro-vascular free muscle flaps for chronic empyema with bron-chopleural fistula when the major local muscles have beendivided: One stage operations with primary wound closure.Ann. Plast. Surg. 24: 510, 1990.

16. Thurer, R. J. Decortication in thoracic empyema: Indicationsand surgical technique. Chest Surg. Clin. North Am. 6: 461,1996.

17. Thourani, V. H., Brady, K. M., Mansour, K. A., et al. Evalu-ation of treatment modalities for thoracic empyema: A cost-effectiveness analysis. Ann. Thorac. Surg. 66: 1121, 1998.

18. Kaplan, D. K. Treatment of empyema thoracis. Thorax 49:845, 1994.

19. Light, R. W. Pleural Diseases, 3rd Ed. Baltimore, Md.: Williams& Wilkins, 1995. Pp. 129–153.

20. Clagett, O., and Geraci, J. E. A procedure for the manage-ment of postpneumonectomy empyema. J. Thorac. Cardio-vasc. Surg. 45: 141, 1963.

21. Virkkula, L., Eerola, S., and Varstela, E. Surgical approach tothe chronic empyema: Space sterilization. In J. Deslauriersand L. K. Lacquet (Eds.), Thoracic Surgery: Surgical Manage-ment of Pleural Diseases; International Trends in General ThoracicSurgery, Vol. 6. St. Louis, Mo.: Mosby, 1990. Pp. 263–268.

22. Arnold, P. G., and Pairolero, P. C. Intrathoracic muscle flaps:A 10-year experience in the management of life-threateninginfections. Plast. Reconstr. Surg. 84: 92, 1989.

23. Michaels, B. M., Orgill, D. P., Decamp, M. M., et al. Flapclosure of postpneumonectomy empyema. Plast. Reconstr.Surg. 99: 437, 1997.

24. Perkins, D. J., Lee, K. K., Pennington, D. G., et al. Free flapsin the management of intrathoracic sepsis. Br. J. Plast. Surg.48: 546, 1995.

Volume 120, Number 7 • Postpneumonectomy Empyema Space

1891