XII. Acute and Delayed Space Problems Following Pulmonary Surgery
Joseph I. Miller, M.D., Atlanta, GA
  1. Acute Space Problems:
    1. Persistent space with or without bronchopleural fistula
      1. Apical
        1. Cause
          1. Restrictive lung disease
          2. Contracted lower lobe
          3. Excessive resection (lobe and segment)
          4. Undrained loculated effusion
        2. Management
          1. Intraoperative recognition of problem and management
            1. Phrenic nerve crush
            2. Apical pleural tent
            3. Lyman Brewer maneuver
            4. Pneumoperitenoneum
            5. Thoracoplasty
            6. Muscle flap closure
          2. Postoperative recognition and management
            1. Benign (i.e. no-leak)
              No therapy required
            2. Persistent space with bronchopleural fistula (parenchymal)
              1. Heimlich valve
              2. Thoracoplasty
              3. Completion pneumonectomy
              4. Muscle flap transfer
              5. Rib resection
              6. Eloesser procedure
      2. Inferior space
        1. Cause
          1. Restrictive lung disease
          2. Persistent undrained effusion with entrapment
          3. Excessive resection
          4. Reoperative surgery
        2. Management
          1. Intraoperative recognition of problem and management (same as superior space)
          2. Postoperative recognition and management
            1. Pneumoperitenoneum
            2. Allow fluid to fill space if no infection
            3. With infection
              1. open drainage
              2. muscle flap transfer
              3. collapse therapy
    2. Delayed Space Problems
      1. Objectives of treatment for delayed space problems
        1. Eliminate underlying disease
        2. Control infection, if present
        3. Remove purulent material
        4. Sterilize the empyema cavity, if present
        5. Obliterate the pleural space
        6. Restore normal movement of chest wall
      2. Superior (Apical Space)
        1. No bronchopleural fistula
          No therapy required
        2. With bronchopleural fistula
          1. Open drainage
          2. Muscle flap transfer
          3. Reoperation
          4. Partial thoracoplasty
      3. Inferior Space
        1. With bronchopleural fistula
          1. Reoperation
          2. Open drainage
          3. Muscle flap or thoracoplasty
        2. Without bronchopleural fistula
          1. Allow space to fill with fluid
          2. Pull tube (i.e. watch and wait)
          3. Thoracoplasty
          4. Muscle flap transfer

    References

    1. Barker WL, Langston HT, Naffah P: Postresection thoracic spaces. Ann Thorac Surg 2:299-310, 1966

    2. Kirsh MM, Rutman H, Behrendt DM, et al: Complications of pulmonary resection. Ann Thorac Surg 20:215-236, 1975

    3. Silver AW, Aspinas EE, Byron FX: The fate of the postresection space. Ann Thorac Surg 2:311-326, 1966

    4. Miller JI, Acute and delayed space problems following pulmonary resection. Chest Surgery Clinics N.Am. 1966:3, 615-620.