5Nonresectional postsurgical empyema Esophageal surgery leak into pleural space.Subdiaphragm surgery of stomach, pancrease, spleen.Rupture of infected pleural bleb.Lung abscess.
6Empyema after lung resection In early postoperative period.Pleural space contaminated at time of pulmonary resection.Develop of bronchopleural or esophagopleural fistula.Blood-borne source.More often when the pleural space is incompletely filled by expansion of the remaining lung, mediastinum shift, elevation of diaphragm.
7Symptoms and Signs Expectoration of serosanguineous liquid. Purulent discharge from wound or drain.Radiology— Pleural opacity, air-fluid level.After pneumonectomy– Decrease fluid level early postoperatively, appearance of a new fluid level.
8General principles of treatment Patient with bronchopleural fistula---Close chest tube thoracostomy.Antibiotics.Patient stabilized– days– Close the bronchopleural fistula– By myoplasty or omentoplasty, single stage muscle flap closure the remaining space.Patient unstable– Close tube drainage change to open drainage by Eloesser’s procedure.
9General principles of treatment Only empyema space without bronchopleural fistula---．Patient stable– Irrigation with antibiotics, single stage muscle flap closure the remaining space.． Patient Unstable– Open Eloesser’s flap.
13Postpneumonectomy empyema Clagett’s procedure—1). Second small chest tube inserted into thesecond intercostals space.2). Continue inflow-outflow irrigation.3). 2g cephalosporin in 500ml D5W,rate 50ml/hour.4). Gram-negative organism % neomycin.5). Success rate achieves 50%.
14Closure of the postpneumonectomy empyema space Transposition skeletal muscle flap---Best way.Single-stage.Execellent blood supply.Pedicle flap to reach almost any location in the pleural space.Rib resected for entry.
15Muscle flap Latissimus dorsi 30-40%. Serratus anterior 10-15%. Pectoralis major 20-30%, minor 0-2%.Omentum 5-15%.Rectus abdominis 5-15%.
17Omentum flap As flap or free graft. Neovascularization within 48 hours.Excellent vascular supply.Brought up through anterior opening of diaphragm.
18Pectoralis major flapBlood supply from thoracoacromial artery and internal mammary artery.For sternal infection.
19Latissimus dorsi flap Most commonly used. Blood from thoracodorsal artery.
20Serratus anterior flap Second choice for muscle transfer flap.
21Rectus abdominis flapFor lower third sternal defect.
22Single-stage muscle flap closure For persistent postpneumonectomy empyema space.Indication: 3 months for benign disease and 6 months to 1 years for malignant disease.Two predominant point:1. No residual space.2. Sufficient number of flap.
23Single-stage muscle flap closure Six basic step:1. Appropriate antibiotics.2. Original incision open.3. Cavity debride widely.4. Close the bronchopleural fistula, with omentumflap.5. Appropriate muscle flap fill the pleural space.6. Begun with latissimus dorsi flap.
24Two-stage muscle flap closure First stage–1. Reopening the thoracotomy wound.2. Leaving open, 5-7 days.3. Bronchopleural fistula close primarily andcovered by serratur anterior muscle.4. Wound left open packed daily for 6 weeks to 3months.Second stage–1. Filling the pleural space by antibiotics solution2. Closing the wound in layers.
25Postresectional lobectomy empyema Lower lobe lobectomy--- Bronchopleural fistula close by myoplasty– By intercostals muscle, obliteration the space by LD and SA.Upper lobe lobectomy--- Reverse pectoralis major through second intercostals space.