Case Report
Management of Pleural Empyema With a Vacuum-Assisted Closure Device and Reconstruction of Open Thoracic Window in a Patient With Liver Cirrhosis
Manejo del empiema con un sistema cerrado de succión y reconstrucción de ventana torácica en un paciente con cirrosis hepática
Daniel Alejandro Munguía-Canales
, Gary Kosai Vargas-Mendoza, Gustavo Álvarez-Bestoff, Moisés Cutiel Calderón-Abbo
Corresponding author
Servicio de Cirugía Torácica, Hospital de Cardiología, Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
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(B) Follow-up radiograph.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Intrathoracic use of a vacuum-assisted closure device (Vacuum Assisted Closure™, VAC™) is a novel technique, with growing evidence, obtained mainly in patients with empyema following lung resection, to suggest that its use as adjuvant treatment in patients with open thoracic window due to recurrent or persistent empyema can reduce the morbidity and hospital stay.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Observation</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 21-year-old female, diagnosed with cryptogenic cirrhosis at the age of 9, with portal hypertension syndrome and oesophageal varices. Four months before attending our department, she was diagnosed with left post-pneumonic empyema that did not remit with antimicrobial therapy. Thoracentesis and insertion of a chest drain was performed on two occasions, and evolved with infiltration of the wall and fistulization to the skin in the seventh intercostal space in the left subscapular region. She was admitted with deterioration in her general condition and pleuritic chest pain in the left hemithorax. Physical examination revealed symptoms of pleural effusion in the lower half of the left hemithorax, with heart rate 98 beats/min, respiratory rate 30 breaths/min, blood pressure 90/60<span class="elsevierStyleHsp" style=""></span>mmHg and temperature 38.2<span class="elsevierStyleHsp" style=""></span>°C; laboratory test results showed leukocytes 15<span class="elsevierStyleHsp" style=""></span>900/mm<span class="elsevierStyleSup">3</span>. The patient was classified as Child–Pugh class B liver disease. <span class="elsevierStyleItalic">Staphylococcus haemolyticus</span> was found in the empyema culture. Imaging tests (chest radiograph and computed tomography) showed a posterior-basal effusion image occupying 60% of the pleural cavity of the left hemithorax, a collapsed lung and pachypleuritis. It was decided to perform an open thoracic window procedure (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), resecting 9<span class="elsevierStyleHsp" style=""></span>cm in length from the posterolateral region of costal arches 8 and 9. Abundant purulent material and thickened visceral and parietal pleura approximately 1<span class="elsevierStyleHsp" style=""></span>cm thick were found during the procedure, but decortication was not performed. Osteomyelitis of the eighth costal arch and a fistulous tract in the seventh intercostal space were also observed. The procedure also consisted of packing the pleural cavity with dressings for 48<span class="elsevierStyleHsp" style=""></span>h, based on thromboelastography findings of prolonged reaction (R) and coagulation (K) times. The cavity was then re-examined and repacked with dressings for a further 48<span class="elsevierStyleHsp" style=""></span>h. An intrathoracic (IT) VAC™ system was applied on the fourth day and on the sixth day the patient was discharged home with a portable VAC™ system; we used an initial suction pressure of 75<span class="elsevierStyleHsp" style=""></span>mmHg and intensity of 30<span class="elsevierStyleHsp" style=""></span>mmHg for 2 days before increasing the suction to 125<span class="elsevierStyleHsp" style=""></span>mmHg and intensity to 40<span class="elsevierStyleHsp" style=""></span>mmHg. There was a gradual reduction in exudate volume, from an average of 300<span class="elsevierStyleHsp" style=""></span>ml per day during the first 2 weeks to an average of 300<span class="elsevierStyleHsp" style=""></span>ml every 4 days (after six weeks treatment). The sponge (VAC Granufoam Silver<span class="elsevierStyleSup">MR</span> Large Dressing) was changed every 4 days, observing a clear improvement after 15 days of use. An initial residual cavity of 18<span class="elsevierStyleHsp" style=""></span>cm×9<span class="elsevierStyleHsp" style=""></span>cm×9<span class="elsevierStyleHsp" style=""></span>cm was found, reduced to 8<span class="elsevierStyleHsp" style=""></span>cm×2<span class="elsevierStyleHsp" style=""></span>cm×2<span class="elsevierStyleHsp" style=""></span>cm after six weeks use, so it was decided to continue with VAC™-IT for a further six weeks until complete obliteration of the cavity (92 days). The radiographic image showed complete lung expansion. During the course of treatment, serial cultures were performed by biopsy after one and two months, showing growth of <span class="elsevierStyleItalic">Staphylococcus haemolyticus</span> and <span class="elsevierStyleItalic">Staphylococcus hominis</span>. The outpatient antibiotic regimen was therefore completed, with the final culture negative after three months. The patient was scheduled for chest wall reconstruction with titanium rods (STRATOS™ system), which was performed with no complications. She progressed satisfactorily and was discharged one week after the procedure. Preoperative lung function tests in our patient showed an FVC of 54% of the predicted and an FEV1 of 50% of the predicted; 4 months after chest wall construction, the FVC was 87% of the predicted and the FEV1 was 92% of the predicted. Follow-up tests in outpatients up to 8 months later did not reveal any complications (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Liver cirrhosis is considered a contraindication for lavage and decortication, due to the frequent haemostatic and nutritional abnormalities that significantly increase morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> Chen et al. recorded a mortality of 31.5%–48.4% when these patients were treated with thoracentesis or drainage catheters, and 21.1% when treated with thoracoscopy, with no significant difference in the mortality when thoracoscopic vs non-thoracoscopic treatment was applied.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In 2006, Varker and Ng<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> first described the successful use of intrathoracic VAC™ (VAC™-IT) in a post-lobectomy empyema. Since then, single cases and case series using VAC™-IT have been reported, mainly in post-lobectomy or post-pneumonectomy empyema, suggesting it as an adjuvant treatment for the management of empyemas in patients with complications, as it decreases the length of the hospital stay and potentially reduces morbidity.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6–14</span></a> We did not find reports on the use of VAC™ in open thoracic window procedures performed due to empyema in patients with liver cirrhosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The use of VAC™-IT in our case meant early hospital discharge and outpatient follow-up; neither analgesia nor sedation was required during the system sponge change, and the patient always reported tolerable pain. In comparing our results with the studies by Palmen el al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and Saadi et al.,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> which recorded a duration of VAC™ therapy of 39±17 days (range 6–66 days), it should be stressed that these authors did not describe the size of the residual cavity nor the grade of pachypleuritis. In this respect, we recorded the size of the thoracic window performed in our patient (9<span class="elsevierStyleHsp" style=""></span>cm×6.5<span class="elsevierStyleHsp" style=""></span>cm in diameter), an intrathoracic residual pleural space of 21<span class="elsevierStyleHsp" style=""></span>cm×9<span class="elsevierStyleHsp" style=""></span>cm×9<span class="elsevierStyleHsp" style=""></span>cm, a pleural rind of approximately 1<span class="elsevierStyleHsp" style=""></span>cm on average and in which decortication was not carried out, and we also decided to use VAC™-IT until obliteration of the residual cavity and complete lung expansion, factors that contributed to the total therapy time with the vacuum-assisted closure system. It is important to note that Rocco et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> reported 2 cases in which they had to discontinue the vacuum-assisted closure system permanently due to acute chest pain and hypotension, and they described one case in which the sponge used adhered to the granulation tissue and could only be removed under thoracoscopy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Chest wall reconstruction following thoracic window surgery has been reported mainly using muscle flaps (myoplasty) and thoracomyoplasty.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–19</span></a> Having observed adequate lung expansion in our patient following the use of VAC™-IT, we decided to perform chest wall reconstruction with rib restoration using titanium plates and clips (STRATOS™ system), which we believe is a more physiological restoration of the wall. We did not find any previous reports of a reconstruction using this system in a similar case.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The high mortality of empyema in patients with liver disease requires searching for and implementing new adjuvant therapies, such as the use of VAC™-IT and possible reconstruction with titanium rods. Controlled studies with extensive case series are required for proper evaluation.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of Interests</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interests with respect to the present article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres276936" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec258815" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres276935" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec258814" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Observation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of Interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-10-22" "fechaAceptado" => "2012-11-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec258815" "palabras" => array:3 [ 0 => "Liver cirrhosis" 1 => "Pleural empyema" 2 => "Vacuum-assisted closure device" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec258814" "palabras" => array:3 [ 0 => "Cirrosis hepática" 1 => "Empiema pleural" 2 => "Sistema cerrado de succión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The patient is a 21-year-old female, diagnosed with cryptogenic cirrhosis at the age of 9. She presented with left post-pneumonic empyema that did not remit with conventional medical management and evolved with fistulization to the skin in the 7th intercostal space in the left subscapular region. We performed an open thoracic window procedure, and on the 6th day the patient was sent home with a portable vacuum-assisted closure device, with changes of the material every 4 days until the cavity was completed obliterated (92 days). Imaging tests showed full expansion of the lung, and chest wall reconstruction was performed with titanium rods. The high mortality of empyema in patients with liver disease requires both implementing and searching for new adjuvant therapies, like the use of vacuum-assisted closure systems and reconstruction with titanium rods. Controlled studies with a wide range of cases are needed for proper evaluation.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mujer de 21 años diagnosticada de cirrosis criptogénica desde los 9 años de edad, que presentó empiema izquierdo posneumónico que no remitió con el tratamiento médico convencional y evolucionó con fistulización hacia la piel en el séptimo espacio intercostal a nivel subescapular izquierdo. Se realizó una ventana torácica abierta y al sexto día se envió a su domicilio con colocación de sistema cerrado de succión portátil, con cambios cada 4<span class="elsevierStyleHsp" style=""></span>días del material hasta la obliteración total de la cavidad (92 días). Se observó por imagen una expansión completa del pulmón y se realizó reconstrucción de la pared torácica con barras de titanio. La alta mortalidad del empiema, en los pacientes con hepatopatías, requiere la implementación y la búsqueda de nuevas terapias adyuvantes, como la utilización del sistema cerrado de succión y la reconstrucción con barras de titanio. Para una adecuada evaluación, se requieren estudios controlados con una serie de casos amplia.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Munguía-Canales DA, et al. Manejo del empiema con un sistema cerrado de succión y reconstrucción de ventana torácica en un paciente con cirrosis hepática. Arch Bronconeumol. 2013;49:447–9.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 703 "Ancho" => 1345 "Tamanyo" => 122379 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Open thoracic window; 9<span class="elsevierStyleHsp" style=""></span>cm in length were resected from costal arches 8 and 9. (B) Window with VAC™ system.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 725 "Ancho" => 1342 "Tamanyo" => 129812 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Patient 6 months after chest wall reconstruction. (B) Follow-up radiograph.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intrathoracic application of a vacuum-assisted closure device in managing pleural space infection after lung resection: is it an option?" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 4 | 9 |
| 2024 October | 46 | 36 | 82 |
| 2024 September | 50 | 20 | 70 |
| 2024 August | 69 | 49 | 118 |
| 2024 July | 45 | 22 | 67 |
| 2024 June | 63 | 40 | 103 |
| 2024 May | 78 | 37 | 115 |
| 2024 April | 43 | 31 | 74 |
| 2024 March | 45 | 25 | 70 |
| 2024 February | 37 | 35 | 72 |
| 2023 March | 11 | 2 | 13 |
| 2023 February | 73 | 20 | 93 |
| 2023 January | 59 | 28 | 87 |
| 2022 December | 54 | 36 | 90 |
| 2022 November | 67 | 25 | 92 |
| 2022 October | 68 | 35 | 103 |
| 2022 September | 46 | 31 | 77 |
| 2022 August | 61 | 36 | 97 |
| 2022 July | 61 | 48 | 109 |
| 2022 June | 68 | 34 | 102 |
| 2022 May | 60 | 36 | 96 |
| 2022 April | 60 | 24 | 84 |
| 2022 March | 66 | 36 | 102 |
| 2022 February | 69 | 29 | 98 |
| 2022 January | 102 | 36 | 138 |
| 2021 December | 55 | 29 | 84 |
| 2021 November | 56 | 44 | 100 |
| 2021 October | 58 | 41 | 99 |
| 2021 September | 43 | 41 | 84 |
| 2021 August | 40 | 25 | 65 |
| 2021 July | 45 | 31 | 76 |
| 2021 June | 70 | 27 | 97 |
| 2021 May | 74 | 44 | 118 |
| 2021 April | 156 | 83 | 239 |
| 2021 March | 100 | 30 | 130 |
| 2021 February | 52 | 30 | 82 |
| 2021 January | 29 | 12 | 41 |
| 2020 December | 42 | 31 | 73 |
| 2020 November | 51 | 11 | 62 |
| 2020 October | 45 | 18 | 63 |
| 2020 September | 45 | 17 | 62 |
| 2020 August | 57 | 25 | 82 |
| 2020 July | 40 | 17 | 57 |
| 2020 June | 45 | 9 | 54 |
| 2020 May | 28 | 12 | 40 |
| 2020 April | 53 | 20 | 73 |
| 2020 March | 37 | 11 | 48 |
| 2020 February | 53 | 12 | 65 |
| 2020 January | 58 | 30 | 88 |
| 2019 December | 56 | 23 | 79 |
| 2019 November | 31 | 21 | 52 |
| 2019 October | 42 | 10 | 52 |
| 2019 September | 52 | 15 | 67 |
| 2019 August | 34 | 9 | 43 |
| 2019 July | 52 | 13 | 65 |
| 2019 June | 52 | 13 | 65 |
| 2019 May | 49 | 24 | 73 |
| 2019 April | 39 | 61 | 100 |
| 2019 March | 63 | 32 | 95 |
| 2019 February | 45 | 23 | 68 |
| 2019 January | 37 | 22 | 59 |
| 2018 December | 58 | 23 | 81 |
| 2018 November | 58 | 17 | 75 |
| 2018 October | 81 | 17 | 98 |
| 2018 September | 56 | 15 | 71 |
| 2018 May | 19 | 2 | 21 |
| 2018 April | 45 | 5 | 50 |
| 2018 March | 32 | 3 | 35 |
| 2018 February | 34 | 5 | 39 |
| 2018 January | 29 | 8 | 37 |
| 2017 December | 44 | 4 | 48 |
| 2017 November | 39 | 6 | 45 |
| 2017 October | 36 | 6 | 42 |
| 2017 September | 38 | 12 | 50 |
| 2017 August | 51 | 11 | 62 |
| 2017 July | 53 | 17 | 70 |
| 2017 June | 66 | 27 | 93 |
| 2017 May | 65 | 18 | 83 |
| 2017 April | 59 | 7 | 66 |
| 2017 March | 57 | 13 | 70 |
| 2017 February | 37 | 11 | 48 |
| 2017 January | 28 | 6 | 34 |
| 2016 December | 41 | 10 | 51 |
| 2016 November | 79 | 17 | 96 |
| 2016 October | 111 | 10 | 121 |
| 2016 September | 108 | 14 | 122 |
| 2016 August | 51 | 10 | 61 |
| 2016 July | 52 | 19 | 71 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 3 | 0 | 3 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 86 | 7 | 93 |
| 2015 September | 61 | 14 | 75 |
| 2015 August | 49 | 22 | 71 |
| 2015 July | 66 | 17 | 83 |
| 2015 June | 55 | 17 | 72 |
| 2015 May | 88 | 37 | 125 |
| 2015 April | 109 | 25 | 134 |
| 2015 March | 57 | 10 | 67 |
| 2015 February | 45 | 19 | 64 |
| 2015 January | 51 | 23 | 74 |
| 2014 December | 38 | 6 | 44 |
| 2014 November | 54 | 14 | 68 |
| 2014 October | 95 | 16 | 111 |
| 2014 September | 101 | 13 | 114 |
| 2014 August | 94 | 14 | 108 |
| 2014 July | 71 | 12 | 83 |
| 2014 June | 93 | 14 | 107 |
| 2014 May | 94 | 13 | 107 |
| 2014 April | 82 | 16 | 98 |
| 2014 March | 90 | 18 | 108 |
| 2014 February | 68 | 11 | 79 |
| 2014 January | 45 | 15 | 60 |
| 2013 December | 2 | 0 | 2 |
| 2013 November | 0 | 1 | 1 |
| 2013 October | 0 | 2 | 2 |
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