Die pleurale Residualhöhle nach Lungenresektion

Zusammenfassung

Bei ca. 10% der Patienten kommt es nach anatomischer Lungenresektion zu einer pleuralen Residualhöhle. Die häufigsten Ursachen sind die Lungenparenchymerkrankung mit verminderter Compliance und die Luftfistel. Tritt bis zum Ende der 4. Woche keine Komplikation auf, ist mit einem unkomplizierten Verlauf (Resorption der Luft) zu rechnen. Bei einer Infektion der Höhle und einer bronchopleuralen Fistel besteht die Gefahr der inneren Aspiration mit Ausbildung einer lebensbedrohlichen Pneumonie. In diesen Fällen ist ein operatives Vorgehen indiziert. Die Wahl des operativen Verfahrens ist eine individuelle Entscheidung, wobei der Allgemeinzustand, Nebenerkrankungen, die Mobilität und Motivation des Patienten, die respiratorische Funktion, die Qualität des Lungengewebes, das Grundleiden sowie dessen Prognose und lokale wie auch systemische Auswirkungen der chronischen Höhleninfektion berücksichtigt werden müssen. Für die operative Therapie einer pleuralen Residualhöhle stehen folgende Verfahren zur Verfügung: Pleuradrainage, Pneumoperitoneum, Pleurazelt, Dekortikation der Lunge, Muskeltransposition, Thorakoplastik, Thorakostoma, Kombinationsverfahren. Die Drainage- oder Dekortikationsverfahren setzen eine ausdehnungsfähige Restlunge voraus. Eine besondere Herausforderung stellt das Postpneumonektomieempyem dar. Zur Vermeidung einer pleuralen Residualhöhle können bereits beim Ersteingriff prophylaktische Maßnahmen (Pleurazelt, Pneumoperitoneum, N.-phrenicus-Blockade) erfolgen.

Abstract

Approximately 10% of patients exhibit a residual pleural space after anatomical lung resection. The most common causes are related to interstitial lung diseases associated with reduced compliance and air leaks. If no complication occurs by the end of the 4th week, an uncomplicated course (absorption of air) can be expected. In the event of pleural space infection and/or bronchopleural fistula, there is a risk of aspiration, with the development of life-threatening pneumonia. In such cases, surgical treatment is indicated. The choice of surgical procedure is an individual decision, whereby the general condition, coexisting diseases, patientʼs mobility and motivation, pulmonary function, the lung tissue quality, the underlying disease with its prognosis and local as well as systemic effects of the pleural space infection must be taken into account. For the surgical therapy of the residual pleural space, the following methods are available: pleural drainage, pneumoperitoneum, pleura tent, lung decortication, space filling muscle transposition, thoracoplasty, thoracostomy, or combined procedures. Pleural drainage and decortication require an expandable lung. Postpneumonectomy empyema poses a particular challenge. To avoid a pleural space in cases of high risk conditions, prophylactic measures (pleural tent, pneumoperitoneum, N. phrenicus blockage) can already be performed during initial intervention.

Schlüsselwörter

Operationsstrategie - Thoraxchirurgie - pleurale Residualhöhle - Thorakoplastik - Muskeltransposition - Dekortikation

Key words

lung resection - residual pleural space - thoracoplasty - muscle flap transposition - decortication

• Literatur

• 1 Solak O, Sayar A, Metin M. et al. Definition of postresectional residual pleural space. Can J Surg 2007; 50: 39-42
• 2 Misthos P, Kokotsakis J, Konstantinou M. et al. Postoperative residual pleura spaces: characteristics and natural history. Asian Cardiovasc Thorac Ann 2007; 15: 54-58
• 3 Linder A. Drainagemanagement nach Lungenresektion. Zentralbl Chir 2014; 139 (Suppl. 01) S50-S58
• 4 Brunelli A, Monteverde M, Borri A. et al. A Comparison of water seal and suction after pulmonary lobectomy: a prospective, randomized trial. Ann Thorac Surg 2004; 77: 1932-1937
• 5 Zhou J, Chen N, Hai Y. et al. External suction versus simple water-seal on chest drainage following pulmonary surgery: an updated meta-analysis. Interact Cardiovasc Thorac Surg 2019; 28: 29-36 doi:10.1093/icvts/ivy216
• 6 Okur E, Kir A, Halezeroglu S. et al. Pleural tenting following upper lobectomies or bilobectomies of the lung to prevent residual air space and prolonged air leak. Eur J Cardiothorac Surg 2001; 20: 1012-1015
• 7 Bardell T, Petsikas D. What keeps postpulmonary resection patients in hospital?. Can Respir J 2003; 10: 86-89
• 8 Mueller MR, Marzluf BA. The anticipation and management of air leaks and residual spaces post lung resection. J Thorac Dis 2014; 6: 271-284
• 9 Sirbu H, Busch T, Aleksic I. et al. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001; 7: 330-336
• 10 Klepetko W, Taghavi S, Pereszlenyi A. et al. Impact of different coverage techniques on incidence of postpneumonectomy stump fistula. Eur J Cardiothorac Surg 1999; 15: 758-763
• 11 Deschamps C, Bernard A, Nichols FC. et al. Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence. Ann Thorac Surg 2001; 7: 243-247
• 12 Algar FJ, Alvarez A, Aranda JL. et al. Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis. Ann Thorac Surg 2001; 72: 1662-1667
• 13 Asamura H, Naruke T, Tsuchiya R. et al. Bronchopleural fistulas associated with lung cancer operations. Univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992; 104: 1456-1464
• 14 Wain JC. Management of late postpneumonectomy empyema and bronchopleural fistula. Chest Surg Clin N Am 1996; 6: 529-541
• 15 Schneiter D, Cassina P, Korom S. et al. Accelerated treatment for early and late postpneumonectomy empyema. Ann Thorac Surg 2001; 72: 1668-1672
• 16 Staub LJ, Biscaro RRM, Kaszubowski E. et al. Chest ultrasonography for the emergency diagnosis of traumatic pneumothorax and haemothorax: a systematic review and meta-analysis. Injury 2018; 49: 457-466
• 17 Barker WL. Natural history of residual air spaces after pulmonary resection. Chest Surg Clin N Am 1996; 6: 585-613
• 18 Ponn RB. Complications of pulmonary Resection. In: Shields TW, LoCicero III J, Ponn RB, Rusch VW. eds. General thoracic Surgery, Vol. 1. Philadelphia: Lippincott Williams & Wilkins; 2005: 572
• 19 De Giacomo T, Diso D, Ferrazza G. et al. Successful treatment of infected residual pleural space after pulmonary resection with autologous platelet-leukocyte gel. Ann Thorac Surg 2009; 88: 1689-1691
• 20 Chambers A, Routledge D, Billè A. et al. Is blood pleurodesis effective for determining the cessation of persistent air leak?. Interact Cardiovasc Thorac Surg 2010; 11: 468-472
• 21 Majid A, de Lima A, Parikh M. et al. Tunneled pleural catheters for patients with chronic pleural infection and nonexpandable lung. J Bronchology Interv Pulmonol 2019; 26: 132-136 doi:10.1097/LBR.0000000000000553
• 22 Carbognani P, Spaggiari L, Solli P. et al. Pneumoperitoneum for prolonged air leaks after lower lobectomies. Ann Thorac Surg 1998; 66: 604-605
• 23 De Gioacomo T, Rendina EA, Venuta F. et al. Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections. Ann Thorac Surg 2001; 72: 1716-1719
• 24 Korasidis S, Andreetti C, DʼAndrilli A. et al. Management of residual pleural space and air leaks after major pulmonary resection. Interact Cardiovasc Thorac Surg 2010; 10: 923-925
• 25 Brunelli A, Al Refai M, Monteverde M. et al. Pleural tent after upper lobectomy: a randomized study of efficacy and duration of effect. Ann Thorac Surg 2002; 74: 1958-1962
• 26 Rocco G. Pleural partition with intrathoracic muscle transposition (muscle tent) to manage residual spaces after subtotal pulmonary resection. Ann Thorac Surg 2004; 78: e74-e76
• 27 Engelmann C. Septische Thoraxchirurgie. Lengerich, Berlin, Düsseldorf, Leipzig, Riga, Scottsdale, Wien, Zagreb: Pabst Science Publishers; 1998: 84-180
• 28 Delorme E. Nouveau traitement des empyemes chroniques. Gaz des hôpitaux 1894; 67: 94-101
• 29 Ried M, Graml J, Großer C. et al. [Para- and postpneumonic pleural empyema: current treatment strategies in children and adults]. Zentralbl Chir 2015; 140 (Suppl. 01) S22-S28
• 30 Klopp M, Pfannschmidt J, Dienemann H. Behandlung des Pleuraempyems. Chirurg 2008; 79: 83-96
• 31 Tong BC, Hanna J, Toloza EM. et al. Outcomes of video-assisted thoracoscopic decortication. Ann Thorac Surg 2010; 89: 220-225
• 32 Tian Y, Zheng W, Zha N. et al. Thoracoscopic decortication for the management of trapped lung caused by 14-year pneumothorax: a case report. Thorac Cancer 2018; 9: 1074-1077
• 33 Rathinam S, Waller DA. Pleurectomy decortication in the treatment of the “trapped lung” in benign and malignant pleural effusions. Thorac Surg Clin 2013; 23: 51-61
• 34 Woo E, Tan BK, Lim CH. Treatment of recalcitrant air leaks: the combined latissimus dorsi-serratus anterior flap. Ann Plast Surg 2009; 63: 188-192
• 35 Gaucher S, Lococo F, Guinet C. et al. Indications and results of reconstructive techniques with flaps transposition in patients requiring complex thoracic surgery: a 12-year experience. Lung 2016; 194: 855-863
• 36 Lesser T, Will U, Krellmann M. et al. [Jejunobronchial fistula as a complication after an alloplastic diaphragm substitute]. Zentralbl Chir 2009; 134: 573-575
• 37 Yang X, Yang X, Xie T. et al. Omentum transplantation in thorax to cover bronchial stump as treatment of bronchopleural fistula after pulmonary resection: report of 6 casesʼ experience. Zhongguo Fei Ai Za Zhi 2018; 21: 235-238
• 38 Hopkins RA, Ungerleider RM, Staub EW. et al. The modern use of thoracoplasty. Ann Thorac Surg 1985; 40: 181-187
• 39 Stefani A, Jouni R, Alifano M. et al. Thoracoplasty in the current practice of thoracic surgery: a single-institution 10-year experience. Ann Thorac Surg 2011; 91: 263-268
• 40 Salzer GM. Operative Therapie septischer Erkrankungen der Pleurahöhle; Abb. 220 und 221. In: Kremer H, Lierse W, Platzer W, Schreiber HW, Weller S. Chirurgische Operationslehre. Band 2 Thorax. Stuttgart, New York: Thieme; 1991: 268
• 41 Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 1963; 45: 141-145
• 42 Bayes AJ, Wilson JA, Chiu RC. et al. Clagett open-window thoracostomy in patients with empyema who had and had not undergone pneumonectomy. Can J Surg 1987; 30: 329-331
• 43 Massera F, Robustellini M, Pona CD. et al. Predictors of successful closure of open window thoracostomy for postpneumonectomy empyema. Ann Thorac Surg 2006; 82: 288-292
• 44 Sziklavari Z, Ried M, Zeman F. et al. Short-term and long-term outcomes of intrathoracic vacuum therapy of empyema in debilitated patients. J Cardiothorac Surg 2016; 11: 148-155
• 45 Sziklavari Z, Ried M, Hofmann HS. [Intrathoracic vacuum-assisted closure in the treatment of pleural empyema and lung abscess]. Zentralbl Chir 2015; 140: 321-327
• 46 Denlinger CE. Eloesser flap thoracostomy window. Oper Tech Thorac Cardiovasc Surg 2010; 15: 61-69 doi:https://doi.org/10.1053/j.optechstcvs.2010.03.003
• 47 Smolle-Jüttner F, Beuster W, Pinter H. et al. Open-window thoracostomy in pleural empyema. Eur J Cardiothorac Surg 1992; 6: 635-638
• 48 Bribriesco A, Patterson A. Management of postpneumonectomy bronchopleural fistula. From thoracoplasty to transsternal closure. Thorac Surg Clin 2018; 28: 323-335
• 49 Pairolero PC, Arnold PG, Trastek VF. et al. Postpneumonectomy empyema. The role of intrathoracic muscle transposition. J Thorac Cardiovasc Surg 1990; 99: 958-966
• 50 Zaheer S, Allen MS, Cassivi SD. et al. Postpneumonectomy empyema: results after the Clagett procedure. Ann Thorac Surg 2006; 82: 279-286
• 51 Schneiter D, Grodzki T, Lardinois D. et al. Accelerated treatment of postpneumonectomy empyema: a binational long-term study. J Thorac Cardiovasc Surg 2008; 136: 179-185
• 52 Perentes JY, Abdelnour-Berchtold E, Blatter J. et al. Vacuum-assisted closure device for the management of infected postpneumonectomy chest cavities. J Thorac Cardiovasc Surg 2015; 149: 745-750
• 53 Lewis CW, Wolfe WG. Thoracoplasty in the new millennium. Oper Tech Thorac Cardiovasc Surg 2000; 5: 135-143
• 54 Deslauriers J, Gregoire J. Thoracoplasty. In: Patterson GA, Pearson FG, Cooper JD, Deslauriers J, Rice TW, Luketich JD, Lerut AEMR. eds. Pearsonʼs thoracic and esophageal Surgery. 3rd ed.. Philadelphia: Churchill Livingston Elsevier; 2008: 1159-1169
• 55 Kuhtin O, Veith M, Alghanem M. et al. Thoracoplasty–current view on indication and technique. Thorac Cardiovasc Surg 2018;
• 56 Kuhtin O, Kenanidis T, Haas V. et al. [Differential treatment strategy of pleural empyema in a post-pneumonectomy cavity]. Pneumologie 2015; 69: 463-468
• 57 Hysi I, Rousse N, Claret A. et al. Open window thoracostomy and thoracoplasty to manage 90 postpneumonectomy empyemas. Ann Thorac Surg 2011; 92: 1833-1839
• 58 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 2000; 120: 270-275
• 59 Belda-Sanchís J, Serra-Mitjans M, Iglesias Sentis M. et al. Surgical sealant for preventing air leaks after pulmonary resections in patients with lung cancer. Cochrane Database Syst Rev 2010; (01) CD003051
• 60 Singhal S, Ferraris VA, Bridges CR. et al. Management of alveolar air leaks after pulmonary resection. Ann Thorac Surg 2010; 89: 1327-1335
• 61 Patella M, Saporito A, Mongelli F. et al. Management of residual pleural space after lung resection: fully controllable paralysis of the diaphragm through continuous phrenic nerve block. J Thorac Dis 2018; 10: 4883-4890
• 62 Pan XJ, Ou DB, Lin X. et al. Management of pleural space after lung resection by cryoneuroablation of phrenic nerve: a randomized study. Surg Innov 2017; 24: 240-244
• 63 Okur E, Arisoy Y, Baysungur V. et al. Prophylactic intraoperative pneumoperitoneum decreases pleural space problems after lower lobectomy or bilobectomy of the lung. Thorac Cardiovasc Surg 2009; 57: 160-164
• 64 Bölükbas S, Eberlein M, Schirren J. Thoracic shaping technique to avoid residual space after extended pleurectomy/decortication. Eur J Cardiothorac Surg 2013; 44: 563-564