Thoracomyoplasty in the treatment of empyema: current indications, basic principles, and results

Abstract

Empyema remains a challenge for modern medicine. Cases not amenable to lung decortication are particularly difficult to treat, requiring prolonged hospitalizations and mutilating procedures. This paper presents the current role of thoracomyoplasty procedures, which allow complete and definitive obliteration of the infected pleural space by a combination of thoracoplasty and the use of neighbourhood muscle flaps (latissimus dorsi, serratus anterior, pectoralis, rectus abdominis, omentum, etc). Recent publications show an overall rate of success of 90%, with a quick and definitive healing. Although rarely indicated in our days, this kind of procedures remain in the armamentarium of modern thoracic surgery. The importance of thoracomyoplasty derives from the fact that it may be a simple and definitive solution for complicated cases of chronic empyema not amenable to standard decortication.

Figure 1

Anatomic drawing of the blood supply of the most used extrathoracic muscle flaps that are transposed inside the chest to obliterate infected spaces. From Miller et al.—Single-stage complete muscle flap closure of the postpneumonectomy space: a new method and possible solution to a disturbing complication, Ann Thorac Surg 1984; 38 : 227-31.

Figure 2

TB empyema with multiple bronchial fistulae solved by thoracomyoplasty— personal collection. (a) Aspect of the cavity with multiple large bronchial fistulae (encircled area). (b) The latissimus dorsi and serratus anterior flaps. (c) Closure-reinforcement of the bronchial fistulae. (d) Final aspect at the end of the procedure. Note the associated rib resection and the complete obliteration of the empyema cavity with the use of the muscle flaps.