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vena cava, and j ust inferior to the left innominate vein.

The most common cause of late bronchopleural fistula after pneumonectomy is infection; less common is recurrent carcinoma, even as long as 2 years later. The most common cause of early bronchopleural fistula is technical error, and this is why repair immediately after an early bronchopleural fistula is identified is indicated.

For space filling procedures, a latissimus dorsi muscle flap is the most commonly used and most versatile muscle for reconstruction. Entry into the chest is obtained by excising ribs 6 to 7 at the mid-lateral position. The pectoralis muscle flap is achieved by resecting several centimeters of the 2nd and 3rd ribs at the mid-lateral position. It should also be noted that empyema after lobectomy can usually be managed simply with chest tube and perhaps rib resection for drain age. Lower lobes have larger residual space, and so there is an increased risk of empyema with lower lobectomies. On occasion, Clagett procedures and myoplasty/ omentoplasty may be necessary.

The therapy for post-resection empyema can be calssified as drainage procedures, air space filling procedures and management of bronchopleural fistula after surgery. The drainage procedures can be chest tube, rib resection or Clagett/ Eloesser flap. Air space filling procedures include thoracoplasty which is basically resection of ribs to permit collapse of the chest wall to obliterate the dead space. Another air space filling procedure is, as mentioned, filling the space with muscle, omentum or even pericardium. For bronchopleural fistula after surgery, early reoperation is indicated if found early on. For later bronchopleural fistula, muscle flaps may be used over the fistula, and if all else fails, a paratranssternal transpericardial approach may be employed to close the fistula.

Suggested Reading

1. Lemmer JH, Botham JH, Orringer MB. Modern management of adult thoracic empyema. J Thoracic Cardiovasc Surg 1985; 90:849-855.

2. Clagett OT, Geraci JE. A procedure for the management of post-pneumonec-tomy empyema. J Thorac Cardiovasc Surg 1963; 45:141.

3. Hankins JR et al. Bronchopleural fistula: Thirteen year experience with 77 cases. J Thorac Cardiovasc Surg 1978; 76:755.

4. Lai I, Unruh H. Management of empyema thoracis. Ann Thorac Surg 1990; 50:355.

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