Adult Chest Surgery

Chapter 72. Surgical Treatment of Bronchopleural Fistula after Pneumonectomy 

Bronchopleural fistula (BPF) after pneumonectomy is an uncommon event seen in 1.5–7% of patients. This rate may double when pneumonectomy is performed for a primary infectious etiology such as tuberculosis. When it occurs, however, the consequences can be devastating, with prolonged hospital stays involving multiple procedures for survivors and up to 50% mortality. Most BPFs are seen in the early postoperative period. Al-Kattan and colleagues reported 7 cases in 471 pneumonectomies, all occurring within 15 days of surgery.1 Late-onset BPF can be more difficult to diagnose and generally is seen in the setting of empyema. The basic principles of management include protection of the remaining lung, control of sepsis, debridement of necrotic tissue, closure of the fistula reinforced with vascularized tissue, and obliteration of the pleural space.

RISK FACTORS

Risk factors for the development of BPF after pneumonectomy include anatomic, technical, and patient factors (Table 72-1). Multiple authors have demonstrated that right pneumonectomy is associated with a four- to fivefold higher incidence of BPF than left pneumonectomy.2,3 This is likely related to anatomic differences between the right and left main stem bronchi. Specifically, there is minimal mediastinal coverage of the bronchial stump on the right side compared with the left, where the properly fashioned stump will retract underneath the aorta into the mediastinum (Fig. 72-1). The right mainstem bronchus is also oriented much more vertically than the left, which permits secretions to pool in the bronchial stump. Finally, the vascular supply to the left mainstem bronchus is augmented by direct vascular branches as the bronchus passes behind the aorta, whereas on the right the blood supply travels from the trachea and local branches in the subcarinal space, and these branches are often disrupted by lymph node removal. Technical factors can include devascularization of the bronchial stump by excessive dissection; long bronchial stump, which increases the risk of secondary infection; and closure under tension, as in the case of a thickened bronchial wall at the point of closure. Closure under tension also can be implicated in a predominance of right-sided BPFs because the diameter of the right mainstem bronchus at the point of transection generally is larger than the left.

Table 72-1. Risk Factors for Development of Bronchopleural Fistula after Pneumonectomy

Anatomic

Right pneumonectomy

 

Technical

Devascularization of bronchial stump

Long bronchial stump

Tension at stump suture or staple line

Persistent disease at bronchial stump

 

Patient

Postoperative mechanical ventilation

Poor pulmonary reserve

Diabetes

Malnutrition

Chronic steroid use

Preoperative infectious process

Preoperative chemotherapy or radiation therapy

 

 

Figure 72-1.

 

Patients with right pneumonectomy are four to five times more likely to develop a BPF owing to the anatomic differences between the right and left mainstem bronchi. The right bronchus has a more vertical orientation, which may permit collection of fluid in the stump, and lacks direct vascular branches from the aorta, relying instead on the trachea and local branches in the subcarinal space that are often disrupted during lymph node removal.

The primary patient factor associated with BPF is postoperative mechanical ventilation. Wright and colleagues reported a series of 256 patients undergoing pneumonectomy with an overall rate of BPF of 3.1%. The incidence of BPF increased to 19.3% in patients requiring postoperative ventilation.4 It is likely that prolonged high airway pressures create trauma at the level of the stump that impairs healing. The need for postoperative mechanical ventilation also may explain the association between BPF and severe chronic obstructive pulmonary disease, as well as low forced expiratory volume in 1 second (FEV1). Other patient factors include those that impair wound healing, such as preoperative radiation therapy (>45 Gy), poor nutritional status, prolonged corticosteroid use, and local infectious processes, such as tuberculosis.

In patients at increased risk for developing BPF after pneumonectomy, coverage of the bronchial stump may reduce the incidence. Sfyridis and colleagues randomized 70 diabetic patients undergoing pneumonectomy to standard resection or bronchial stump coverage with an intercostal muscle flap.5 In the patients receiving an intercostal muscle flap, no BPFs occurred. In the patients undergoing standard resection, 8.8% developed BPF. This is especially important on the right side, where the stump is exposed in the pneumonectomy space. Many groups routinely cover all right-sided stumps, covering left-sided stumps only when there is increased risk. Coverage can be provided by using a variety of local and distant tissues as vascularized flaps that are tacked over the bronchial stump. Tissues used routinely include pericardial fat pad and intercostal muscle flaps. If these tissues are inadequate, or if the patient is thought to be at extraordinary risk of stump complications, larger muscle or omental flaps are used.

DIAGNOSIS

Many patients present early with a fulminant course, including expectoration of large amounts of serous or seropurulent fluid, respiratory distress, and sepsis. Appearance of these symptoms should raise the index of suspicion and be followed by a quick and accurate diagnosis before there is overwhelming aspiration of pleural fluid into the remaining lung. This presentation is most common in large fistulas with abundant drainage of pleural fluid into the tracheobronchial tree. Small fistulas more commonly present with productive cough with serous or purulent sputum, fever, hemoptysis, or subcutaneous emphysema. Findings on chest radiograph suggestive of BPF include progressive subcutaneous or mediastinal emphysema, development of a new air-fluid level in a previously opacified pneumonectomy space, a 2-cm drop in an existing air-fluid level with shift of the mediastinum away from the pneumonectomy space, or new development of multiple air-fluid levels. Late-onset BPF often presents with nonspecific symptoms, including low-grade fever, anorexia, fatigue, and weight loss similar to late postpneumonectomy empyema. Proving the presence of a fistula in these patients can be more problematic because the connection is often small and not identified by bronchoscopy. Nuclear medicine techniques have been used to confirm the presence of radiolabeled inhaled gas in the postpneumonectomy space.

Whether the diagnosis is apparent clinically or radiographically or suggested by advanced testing, all patients should undergo diagnostic bronchoscopy. A large fistula generally can be visualized. Fistulas smaller than 1–2 mm may be difficult to identify. Perhaps more important, bronchoscopy provides information about the length of the remaining bronchial stump and the condition of the tissue at the level of the stump that can be helpful in planning definitive repair. It is important to remove any fluid or secretions in the remaining lung to optimize pulmonary toilet.

SURGICAL TREATMENT

Draining the Pleural Space

The management of BPF begins with thorough drainage of the pleural space. This accomplishes two important objectives. Removing the remaining fluid from the pleural space prevents aspiration into the contralateral lung. Draining the pleural space also controls the septic process in conjunction with parenteral antibiotics. Drainage can be performed at the bedside with a tube thoracostomy under local anesthesia placed to either balanced drainage system or water seal but not suction. Immediate drainage is especially important for patients who present with large fistulas in which a significant volume of pleural contents is draining into the airways, potentially flooding the contralateral lung. Care must be taken to place the tube above the level of the previous thoracotomy incision because the diaphragm will be elevated as part of the normal thoracic remodeling that occurs after pneumonectomy. In addition, when the thoracostomy tube is placed, the patient should be in the supine position. Lateral positioning places the remaining lung in a dependent position and encourages further aspiration. Once the tube is in place, further positional maneuvers to prevent aspiration include maintaining the patient in as close to an upright position as possible and rotating the patient such that the pneumonectomy side is down.

Once the urgent situation is controlled and the patient is started on appropriate parenteral antibiotics, the remaining pleural debris and necrotic tissue are removed. Debridement can be accomplished by means of an open thoracic window or thoracotomy. The selection of technique depends on the patient's overall condition. At this stage, debilitated or critically ill patients can poorly tolerate a major thoracic procedure, especially a prolonged procedure involving muscle flaps or other approaches used to definitively address the fistula. These patients often benefit from a period of treatment with a simple open window thoracostomy to permit control of sepsis and nutritional support followed by delayed definitive closure.

Technique for Open Window Thoracostomy

The technique for open window thoracostomy was first described for the treatment of chronic nontuberculous and tuberculous empyema by Robinson in 1916 and Eloesser in 1935.6,7 Both described the method for open drainage of an infected intrathoracic space by using a U-shaped incision over the most dependent portion of the space (Fig. 72-2). The basic procedure has changed little since these reports. Segments of one or two ribs are removed to limit the tendency of the opening to contract and close. The skin flap then is sutured directly to the parietal pleura with interrupted absorbable sutures to create an epithelialized tract, which both maintains the patency of the window and encourages healing. One should avoid placing the window such that it would be difficult for the patient to manage, that is, too far posteriorly. Similar care is taken to avoid placing the window too far inferiorly, where it might interfere with the diaphragm. Other techniques, including placement of large-bore drainage tubes through the window as stents, also will help to maintain patency. Dressing changes with moistened gauze then are performed until the cavity is sterilized. Very small fistulas may close spontaneously once the local sepsis is eradicated. Most, however, require definitive closure. Patients in generally good condition at the time of presentation can proceed directly to simultaneous debridement of the pleural space and definitive closure.

Figure 72-2.

 

Open window thoracostomy drainage was first proposed by Eloesser. Note the U-shaped incision over the infected space and technique (inset) for securing the skin flap directly to the parietal pleura.

Closing the Bronchopleural Fistula

Most patients can tolerate early exploration and closure of the fistula, and this procedure should be undertaken as soon as the patient is medically stable. Exploration is preferentially performed by means of a posterolateral thoracotomy on the ipsilateral side, with lung isolation via selective intubation of the contralateral mainstem bronchus to prevent further soilage of the remaining lung. If not readily visible, the fistula can be identified with the aid of positive-pressure ventilation while covering the area of the bronchial stump with irrigation. The pleural space is thoroughly irrigated and debrided to remove all necrotic tissue. The bronchial stump is carefully dissected to minimize trauma to its blood supply. All attempts are made to leave a final stump that is less than 1 cm in length measured from the carina (Fig. 72-3). If sufficient length remains on initial exploration, a commercial stapling device can be used to reclose the stump. In most cases there is too much inflammation to permit stapling, however, and the mobilized bronchial stump is reclosed with interrupted monofilament sutures. A balance must be obtained between exposing enough bronchus to avoid tension on the closure and avoiding too much exposure, which could damage the blood supply.

Figure 72-3.

 

Ideally, the length of the bronchial stump should be less than 1 cm. A. If there is sufficient length on the stump after initial exploration, a stapling device can be used to reclose the stump. B. Often there is too much inflammation to permit stapling, and the mobilized bronchial stump is reclosed with interrupted monofilament sutures.

 

Reinforcing the suture line with vascularized tissue is perhaps the most important aspect of closure. Pedicled flaps of muscle or omentum are mobilized into the chest and sutured over the bronchial stump. The choice of flap depends on the quality of the tissue, damage to potential flap muscles from the previous thoracotomy, and the amount of space to be filled. The serratus anterior is used commonly. This muscle is often preserved during the initial operation because of its utility in dealing with potential complications. The flap is based on the vascular pedicle that runs on the lateral undersurface of the scapula. The muscle is mobilized and inserted between the ribs in either the second or third interspace, where it will generally reach the hilum with no tension whatsoever. If the interspaces are tight, possibly compromising the vascular supply of the flap, a segment of the third rib can be removed to allow the flap to comfortably enter the pleural space. The flap generally is secured with interrupted absorbable sutures to the peribronchial or mediastinal areolar tissue. This tissue aids in healing and infection control because its blood supply emanates from regions beyond the inflamed field. In some cases, when the stump is frankly necrotic or densely scarred into the mediastinum, it may not be possible to close the fistula directly. In this event, a muscle or omental flap is sutured to the freshened edges of the open fistula or surrounding mediastinum to occlude the communication and permit healing. An advantage to using a relatively large muscle such as the serratus anterior to close the fistula is that it also contributes bulk to fill some of the dead space in the chest.

In severely ill patients with difficult bronchial stumps, it may be useful to simultaneously place a temporary tracheostomy with a long cuffed tube in the contralateral mainstem bronchus. The tracheostomy is left in place for several weeks to permit the flap to become fixed over the opening of the fistula without the stress of positive-pressure ventilation, which can slow healing.

Once the fistula is closed, the pleural space must be sterilized. In early-onset BPF, when there has been minimal contamination, thorough operative debridement and irrigation may be sufficient. In more advanced cases with greater contamination, sterilization can be accomplished by creating an open window with dressing changes as described earlier or by closure over irrigation catheters after the fistula has been repaired. Chest tubes or other irrigation catheters can be placed and irrigated either continuously or several times daily with antibiotic solution. When there is no remaining evidence of infection within the space, on the basis of either Gram stain of granulation tissue or culture of irrigation fluid, definitive closure is performed.

Occasionally, it is impossible to access the bronchial stump for effective repair, especially on the left side when the stump is retracted underneath the aorta (Fig. 72-4). In such cases, fistula closure can be approached via median sternotomy.8 This approach permits exposure of the carina in a previously nonoperated field between the superior vena cava and the aorta, and the mainstem bronchus can be redivided and closed in a field free of infection. After median sternotomy, the pericardium is opened, and dissection between the superior vena cava and aorta exposes the carina. If possible, a segment of the mainstem bronchus should be resected to provide a fresh edge for stapling or suture closure and to avoid contamination from the distal bronchial remnant. Another approach to the carina is through the right chest for a left-sided fistula.9

Figure 72-4.

 

A median sternotomy approach can be used when the left mainstem bronchus is retracted underneath the aorta, limiting access to the bronchial stump. This approach exposes the carina between the superior vena cava and the aorta and permits operation in a sterile field.

Obliterating the Remaining Pleural Cavity

The final step in the treatment of BPF is obliteration of the remaining pleural space. Before taking this final step, it is important to reevaluate the patient's overall condition and suitability for complete closure. Most failures of closure are related to persistent or recurrent BPF. Patients with a chronic fistula, carcinomatosis within the space, persistent infection within the space, or poor nutritional status should not undergo obliteration maneuvers unless or until these issues have been addressed. A period of treatment with open thoracic window and adequate nutritional support can improve the patient's likelihood of a positive long-term outcome.10

Obliteration of the pleural space can be accomplished by one or a combination of three techniques. The first option is to fill the sterilized cavity with antibiotic solution (Clagett maneuver). If the chest was closed initially over irrigation catheters, obliteration is a simple procedure. Antibiotic solution is infused into the cavity until it is completely filled, the irrigation catheters are removed, and the site is sutured closed. If the patient was treated initially with an open thoracic window, the skin edges are excised, and flaps are mobilized to permit closure without tension. The chest is filled with antibiotic solution in a similar fashion, and the window then is closed in multiple layers to prevent leakage of fluid. Antibiotic selection is tailored to culture and sensitivity tests rather than to a set of standard antibiotics. It is important to avoid excessive doses of intrapleural antibiotics because this can result in renal failure or other systemic complications. This technique was described originally by Clagett and Geraci in 1963 as a two-stage procedure in which open window drainage was followed by obliteration of the space with antibiotic fluid without direct fistula closure.11 The technique is used rarely in its original form today, however, because of recurrences related to persistence of the fistula. The more common approach is the modified version with an intermediate step of fistula closure with muscle flap as described earlier.

The second technique involves transposition of muscle flaps that fill the pleural space with vascularized tissue (Fig. 72-5). Muscle flaps are an excellent choice because of their rich blood supply and ability to extend to almost any region of the pleural space. The choice of flaps depends on the availability and suitability of local muscles. Latissimus dorsi is often the largest muscle available in this location, but it is frequently transected at the time of the original thoracotomy. Previously transected latissimus dorsi is unlikely to survive as a transposed flap. Many groups intentionally preserve the serratus anterior at initial operation for later use as a flap (Fig. 72-6). The serratus anterior is mobilized, but its attachments to the upper scapula are maintained. It is passed into the chest between the ribs or through a window created by resecting a segment of the second or third rib. Other useful local muscles include pectoralis major for the anterior portion, trapezius for the apical portion, and rectus abdominis for the caudal portion of the space. The number of muscles required relates to both the size of the remaining cavity and the quality and bulk of the muscles. Many patients with BPF have diminished muscle bulk from chronic debilitation and may not have sufficient muscle tissue to fill the space. In such cases, the highly vascularized omentum is an excellent replacement for or addition to local muscle flaps and can be mobilized from the abdomen through a substernal tunnel (Fig. 72-7).

Figure 72-5.

 

Muscle flaps available for transposition into the pleural space. The serratus anterior is ideal for filling small defects, such as BPF. It takes its blood supply from the lateral thoracic artery, and entrance into the chest is made from the primary incision. The pectoralis major receives blood from two sources, the thoracoacromial artery and the internal mammary artery. Entry into the chest is made through a 5-cm rib resection. It is used most commonly for sternal infections and for BPFs that originate from an upper lobe bronchus. The trapezius is used to fill the apical pleural space, and the rectus abdominis provides tissue for the caudal pleural space.

 

Figure 72-6.

 

The serratus anterior is often preserved at initial operation by maintaining its attachment to the upper scapula and used later as a muscle pedicle. The free end is passed into the chest between a rib or through a window created by resecting a segment of rib.

 

Figure 72-7.

 

Patients with BPF may be severely debilitated from long-term illness that leaves a paucity of muscle bulk. In these patients, the omentum is an excellent substitute for a pedicled muscle flap and has a rich vascular supply. It is mobilized from the abdomen through a substernal tunnel.

 

The third technique is thoracoplasty. Thoracoplasty was described originally by Alexander in 1937 for the therapy of tuberculosis (see Chap. 92). It involved resection of 10 or 11 ribs, after which the soft tissues of the chest wall collapsed inward to fill the pneumonectomy space.12 This procedure not only was highly morbid and disfiguring, but it also had a profoundly negative impact on the physiologic function of the remaining lung. Most postpneumonectomy spaces can be completely filled by removing ribs 2–8; however, this is still significantly disfiguring, may limit arm and shoulder function, causes chest wall paresthesias, and requires prolonged convalescence. In the current era, thoracoplasty has found a limited role in combination with muscle flap transposition (Fig. 72-8). Available muscle flaps are transposed to fill as much space as possible. Then, simultaneously or in a separate procedure, a limited thoracoplasty (often involving only two to three ribs) is performed to obliterate any remaining space.

Figure 72-8.

 

Limited thoracoplasty involving as few as two or three ribs has a limited role in combination with muscle flap transposition.

OUTCOMES

Outcomes after BPF are related most strongly to the underlying disease and condition of the patient at the time of presentation. The reported overall mortality for this complication remains distressingly high. However, the main cause of death in these patients is aspiration pneumonia of the contralateral side, and a large number never stabilize enough to permit repair of the fistula. A second group of patients survives the initial insult long enough to receive a drainage procedure, such as open window thoracostomy, but never progresses to closure. Regnard and colleagues described the treatment of 30 postpneumonectomy patients with initial open window thoracostomy. Of those, 7 (23%) received open window thoracostomy with dressing changes as their only definitive treatment. Full repair was not accomplished in this group because of patient death, other major illnesses, locally recurrent or metastatic cancer, or patient choice.13

The modified Clagett technique is the simplest method of definitive treatment and limits the operative morbidity associated with flap harvest; however, the outcomes reported have been suboptimal. Pairolero and colleagues reported their results with a three-step modified Clagett procedure including muscle flap reinforcement of the bronchial stump in 45 patients. They reported an ultimately successful outcome in 26 patients (58%), with an average of 5 surgical procedures per patient over 34 hospitalization days and 6 operative deaths.14 Fry reported failure in more than half the attempts at closure using a modified Clagett technique.15 If the Clagett technique fails, the open window thoracostomy is recreated, and a more complex method of closure is attempted, such as muscle flaps.

Better results have been noted after muscle flap transposition. Miller and colleagues reported 5 patients treated with multiple muscle flaps, where an average of two muscles were used per patient, as well as limited thoracoplasty, with success in all 5 patients.16 Regnard and colleagues treated 23 pneumonectomy patients with open window thoracostomy followed by flap transposition.13 Seventeen patients had initial successful closure, of which there were 6 failures. Three of those initial failures underwent successful reoperation with additional muscle or omental flaps for an overall success rate of 87%. The remaining 3 patients with initial failure were not considered to be suitable for further attempts and were converted back to definitive therapy with open window drainage. Michaels and colleagues used a combination of open window thoracostomy, repair of the fistula with muscle flap reinforcement, additional intrathoracic muscle transposition, and limited thoracoplasty to treat 16 patients.17 Four (25%) had initial failure with recurrence of empyema but eventually were treated successfully after additional procedures. Of the 15 patients who survived the perioperative period, 5 died of their lung cancer, 2 were alive with metastatic disease, and 8 had no evidence of recurrent cancer at a median follow-up of 19 months. These data highlight the importance of minimizing the number of operative interventions and maximizing the quality of life in this patient population with limited life expectancy as a consequence of their underlying disease.

SUMMARY

It is important to recognize that BPF is not a problem of historical interest only but continues to be a frustrating complication of pneumonectomy in the modern era, leading to significant morbidity and mortality. Progress in the care of critically ill patients has given formerly inoperative patients the chance for curative resection. With recent improvements in induction therapy for lung cancer, more postinduction patients may become candidates for resection. The rising incidence of multidrug-resistant tuberculosis is also creating a resurgence of surgical intervention for tuberculosis, which carries a high risk of postresectional BPF. These shifts in the patient population may lead to a rising incidence of BPF in the future. As is often the case, the large number of approaches to this problem reported in the literature is reflective of the complexity of the problem and lack of a successful, easily applied solution. A comprehensive plan must be established when caring for these patients, including nutritional support, control of sepsis, closure of the fistula, and obliteration of any remaining space.

EDITOR'S COMMENT

Postpneumonectomy BPF is a dreaded complication associated with a high mortality. Although many preventive steps, such as using muscle flaps when surgery is performed after preoperative chemoradiation, may help to minimize these complications, their management can be quite challenging. Early intervention with adequate drainage and airway control can permit a safe, stepwise approach to these lesions in an orderly manner. Performing an Eloesser flap or use of a Clagett procedure are two conservative options. Occasionally, primary control of the bronchial stump is difficult to achieve through the previous thoracotomy. In these cases a transsternal approach and intrapericardial stapling is an elegant, decisive solution. The goals of adequate drainage, stump control, and interposition of vascularized tissue using either muscle, omentum, or a combination of both must be met to ensure a successful outcome.

–MJK

REFERENCES

1. Al-Kattan K, Cattelani L, Goldstraw P: Bronchopleural fistula after pneumonectomy for lung cancer. Eur J Cardiothorac Surg 9:479–82, 1995.[PubMed: 8800695]

2. Algar FJ, Alvarez A, Aranda JL, et al: Prediction of early bronchopleural fistula after pneumonectomy: A multivariate analysis. Ann Thorac Surg 72:1662–7, 2001.[PubMed: 11722062]

3. Haraguchi S, Koizumi K, Hioki M, et al: Analysis of risk factors for postpneumonectomy bronchopleural fistulas in patients with lung cancer. J Nippon Med Sch 73:314–9, 2006.[PubMed: 17220581]

4. Wright CD, Wain JC, Mathisen DJ, Grillo HC: Postpneumonectomy bronchopleural fistula after sutured bronchial closure: Incidence, risk factors, and management. J Thorac Cardiovasc Surg 112:1367–71, 1996.[PubMed: 8911336]

5. Sfyridis PG, Kapetanakis EI, Baltayiannis NE, et al: Bronchial stump buttressing with an intercostal muscle flap in diabetic patients. Ann Thorac Surg 84:967–71, 2007.[PubMed: 17720409]

6. Robinson S: The treatment of chronic non-tuberculous empyema. Surg Gynecol Obstet 22:557–71, 1916. 

7. Eloesser L: An operation for tuberculous empyema. Surg Gynecol Obstet 60:1096–7, 1935. 

8. Ginsberg RJ, Pearson FG, Cooper JD, et al: Closure of chronic postpneumonectomy bronchopleural fistula using the transsternal transpericardial approach. Ann Thorac Surg 47:231–5, 1989.[PubMed: 2919907]

9. Perelman M, Rymko L, Ambatiello G: Bronchopleural Fistula: Surgery after Pneumonectomy. Philadelphia, Saunders, 1987:407–12.

10. Shamji FM, Ginsberg RJ, Cooper JD, et al: Open window thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula. J Thorac Cardiovasc Surg 86:818–22, 1983.[PubMed: 6645587]

11. Clagett OT, Geraci JE: A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 45:141–5, 1963.[PubMed: 14021469]

12. Alexander J: The Collapse Therapy of Pulmonary Tuberculosis. Springfield, Charles C Thomas, 1937.

13. Regnard JF, Alifano M, Puyo P, et al: Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection. J Thorac Cardiovasc Surg 120:270–5, 2000.[PubMed: 10917941]

14. Pairolero PC, Arnold PG, Trastek VF, et al: Postpneumonectomy empyema: The role of intrathoracic muscle transposition. J Thorac Cardiovasc Surg 99:958–66; discussion 966–8, 1990. 

15. Fry W: Surgical Management of Empyema. Philadelphia, Lippincott-Raven, 1998:254.

16. Miller JI, Mansour KA, Nahai F, et al: Single-stage complete muscle flap closure of the postpneumonectomy empyema space: A new method and possible solution to a disturbing complication. Ann Thorac Surg 38:227–31, 1984.[PubMed: 6236761]

17. Michaels BM, Orgill DP, Decamp MM, et al: Flap closure of postpneumonectomy empyema. Plast Reconstr Surg 99:437–42, 1997.[PubMed: 9030151]



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!