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Woo Sik Kim - One of the best experts on this subject based on the ideXlab platform.
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Treatment of Tuberculous Empyema by Intrathoracic Transposition of a Latissimus Dorsi Muscle Flap.
Archives of plastic surgery, 2016Co-Authors: Byeong Jun Kim, In Pyo Hong, Chan Min Chung, Woo Sik KimAbstract:South Korea has the highest prevalence of tuberculosis among the Organization for Economic Cooperation and Development nations [1], despite the management of pulmonary tuberculosis with antituberculosis drugs. Therefore, South Korea also has a relatively high prevalence of Tuberculous Empyema, a complication of tuberculosis that accounts for 3%#x2013;6% of all cases of Empyema [2]. A chronic, active infection of the pleural space, Tuberculous Empyema is a refractory disease requiring long-term medication and drainage [3]. We report our success in transposing the latissimus dorsi (LD) muscle into the pleural space in order to prevent the recurrence of Tuberculous Empyema. In 2012, a 53-year-old male patient diagnosed with pulmonary tuberculosis recovered completely after receiving treatment. However, he experienced recurrence of pulmonary tuberculosis in 2014, and during treatment, a computed tomography (CT) image revealed that the right lower lobe of his lung had collapsed. This led to the occurrence of Tuberculous Empyema, and the patient was hospitalized to undergo thoracic surgery to treat the Empyema. The patient's condition did not improve during the operation, despite the continuous administration of medication and chest tube drainage. The thoracic surgeon therefore performed a lung lobectomy with decortication, and we decided to transpose the LD muscle flap into the resulting cavity (Fig. 1). Fig. 1 A chest computed tomography scan shows a large dead space (white arrow) in the right thoracic area that resulted from the right lower lobectomy, as well as enhancing rims of the parietal and visceral pleurae (white arrowheads) surrounding a loculated ... We first identified the pleural space on the chest CT image and calculated the approximate volume of the space (203 cm3). The flow of the thoracodorsal artery was determined using a pencil Doppler and the latissimus border was outlined with a marker. After determining the amount of LD muscle required, we determined the necessary incision length and drew the incision lines (Fig. 2). The incision started in the posterior axillary fold and continued inferiorly and medially to expose the LD muscle. The skin and fat flaps were elevated to the extent necessary to produce a pocket allowing the adequate harvest of muscle tissue. We then identified the anterior border of the exposed LD muscle and its superior border below the inferior angle of the scapula. Fig. 2 Preoperative skin diagram. The lines depict surface projections of the latissimus dorsi (LD) muscle. The axillary incision design for harvest of the LD is shown in relation to the anterior border of the muscle. While performing a ligation of the perforators below the LD muscle from the superior border, the muscle was elevated to the midline. Once the medial portion of the muscle was reached, dissection was carried out inferiorly using electrocautery, and the desired amount of LD muscle was separated (Fig. 3). Next, we determined the viability of the separated LD muscle flap. In order to perform a LD muscle flap transposition into the pleural space, the serratus anterior muscle was split, the fifth rib was exposed, a portion was excised, and a second window was created in the pleural space. The LD muscle flap was then carefully inserted into the pleural space through this second window to prevent the vascular pedicle from being twisted or pulled (Fig. 4). Fig. 3 The separated latissimus dorsi muscle flap. Fig. 4 The latissimus dorsi muscle flap was inserted into the pleural space through a second window created by splitting the serratus anterior muscle (white arrow). Using 2-0 Vicryl sutures, the muscle was loosely tacked to the mediastinal pleura. After undermining the subcutaneous layer on both sides of the incision, the muscle donor site was closed primarily without tension, and a chest tube was placed for pleural drainage. In addition, two Jackson-Pratt drains were placed at the muscle donor site in order to prevent seroma formation. Both the tube and drains were removed four weeks after the operation. The wound healed uneventfully. Following surgery, however, the patient was treated with antibiotics for four weeks after the occurrence of pneumonia in the right lung (Fig. 5). At a later follow-up, the patient displayed no signs of functional disability or chest wall contour deformity related to the LD harvest. At a twelve-month follow-up examination, he was in good condition with no recurrence of Empyema. Fig. 5 Two weeks postoperatively, a chest computed tomography scan shows the pleural space filled by the intrathoracic transposition of the latissimus dorsi muscle flap (white arrow). A chest computed tomography scan of the right upper lobe shows pneumonia (black ... Sufficient drainage, infection control, and optimal nutrition play a crucial role in the treatment of Empyema [4]. However, if these strategies do not succeed in curing the Empyema, surgery must be considered. In particular, when lung lobectomy is performed, a large cavity occurs, which may lead to potentially life-threatening Empyema or secondary infection. The LD muscle flap was used simply to fill the dead space, but with the goal of producing well vascularized tissue resistant to chronic infection and disposed to angiogenesis and healing. The LD muscle has a blood supply with a type V pattern. Most of the supply comes through a thoracodorsal artery pedicle, along with lesser flows through perforators from the thoracic intercostal and lumbar arteries. Since the LD muscle is able to produce the largest extrathoracic muscle flap that can be harvested as a single vascular pedicle (up to 20 cm×40 cm), it is utilized by many plastic and reconstructive surgeons. Although the LD muscle enables extension, adduction, and internal rotation of the shoulder joint, it does not function independently. Since it moves in synchrony with a number of synergistic shoulder girdle muscles, the LD muscle can be sacrificed safely without affecting shoulder or arm action [5]. A major surgical advantage of using the LD muscle flap in the field of thoracic surgery is the fact that, because it is an extrathoracic muscle, ipsilateral lung surgery can be performed while simultaneously obtaining the LD muscle through a single posterolateral thoracotomy incision. Furthermore, due to its large bulk and long vascular pedicle, the LD muscle flap can move in apical or mid-thoracic dead space easily with minimal tension, obliterating the pleural space. However, because a LD flap based on the thoracodorsal artery can be short, alternative flaps (e.g., a rectus abdominis flap) should be considered for movement to the lower, supra-diaphragmatic recess of the pleural space. Various flaps can also be used depending on the location of the dead space, such as a serratus anterior flap for the upper region of the thorax and a pectoralis flap or a trapezius flap for the apical region. Tuberculous Empyema is uncommon and, unlike other types of Empyema, difficult to treat. We performed a lobectomy and used the intrathoracic transposition of a LD muscle flap into the resulting cavity to treat a Tuberculous Empyema patient who had not improved from the administration of antituberculosis drugs and chest tube drainage. This operation was relatively easy and the patient had no recurrence of Empyema or other complications.
Jayashree Sood - One of the best experts on this subject based on the ideXlab platform.
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thoracoscopic decortication of stage iii Tuberculous Empyema is effective and safe in selected cases
The Annals of Thoracic Surgery, 2017Co-Authors: Arvind Kumar, Belal Bin Asaf, Vijay C Lingaraju, Sai Yendamuri, Mohan Venkatesh Pulle, Jayashree SoodAbstract:Background Open decortication of advanced Tuberculous Empyema remains standard of care. As with other aspects of thoracic surgery, minimally invasive approaches are making inroads into procedures traditionally performed open. In this retrospective analysis, we sought to examine feasibility, efficacy, and outcomes of thoracoscopic decortication of stage III Tuberculous Empyema in our experience. Methods The records of all patients in whom thoracoscopic decortication of stage III Tuberculous Empyema was performed between March 2012 and December 2015 were examined. Demographic and perioperative data were analyzed to assess the surgical outcomes of this study group. To assess long-term efficacy, patients were followed for a minimum of 6 months. Results One hundred patients fit the study criteria, of these 67 were men. Ninety cases were successfully completed thoracoscopically. Mean operative time was 204 ± 34.2 minutes with mean blood loss of 384 ± 28 mL. Median chest drain duration and hospital stay was 7 days. There was no perioperative deaths. Morbidity rate was 33%, composed mostly of prolonged air leak (29%). Six-month follow-up revealed completely expanded lung in all patients except one with small apical asymptomatic air space. Intraoperative cultures were positive for mycobacteria in 25% patients. Six (6%) of these patients had multidrug-resistant tuberculosis and required a modification in their antiTuberculous therapy. Conclusions Thoracoscopic decortication of advanced Tuberculous Empyema is feasible, safe, and effective with good short- and long-term results in selected patients. In a substantial portion of patients, operative cultures required modifying drug treatment to treat underlying tuberculosis.
Soumya Das - One of the best experts on this subject based on the ideXlab platform.
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adult thoracic Empyema a comparative analysis of Tuberculous and nonTuberculous etiology in 75 patients
European Respiratory Journal, 2011Co-Authors: Somenath Kundu, Subhra Mitra, Subhasis Mukherjee, Soumya DasAbstract:Background: Thoracic Empyema is a disease of significant morbidity and mortality in the developing world where tuberculosis is a common cause. Clinical outcomes in Tuberculous Empyema are complicated by fibrocavitary disease and bronchopleural fistulae. A prospective study to compare the clinical profiles and outcomes of patients with Tuberculous and nonTuberculous Empyema was performed. Materials and methods: A prospective study of adult nonsurgical thoracic Empyema cases admitted in a teaching hospital in India was performed over a period of 18 months. A comparative analysis of clinical characteristics, treatment modalities, and outcomes of patients with Tuberculous and nonTuberculous Empyema was carried out. Results: 75 cases of Empyema were seen during the study period, of which 46 (61.3%) were of nonTuberculous etiology while tuberculosis constituted 29 (38.7%) cases. Among the nonTuberculous Empyema patients, Staphylococcus aureus (11, 23.93%) was the most frequent pathogen isolated. Tuberculous Empyema was more frequent in younger population compared to nonTuberculous Empyema (mean age of 32.7 years vs. 46.5 years). Duration of illness and mean duration of chest tube drainage were longer (48.7 vs. 23.2 days) in patients with Tuberculous Empyema. Also the presence of parenchymal lesions and bronchopleural fistula often requiring surgical drainage procedures was more in Tuberculous Empyema patients. Conclusion: Tuberculous is a common cause of Empyema thoracis in a developing country. Tuberculous Empyema differs from nonTuberculous Empyema in the age profile, clinical presentation, management issues, and has a significantly poorer outcome.
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adult thoracic Empyema a comparative analysis of Tuberculous and nonTuberculous etiology in 75 patients
Lung India, 2010Co-Authors: Somenath Kundu, Subhra Mitra, Subhasis Mukherjee, Soumya DasAbstract:Background: Thoracic Empyema is a disease of significant morbidity and mortality, especially in the developing world where tuberculosis remains a common cause. Clinical outcomes in Tuberculous Empyema are complicated by the presence of concomitant fibrocavitary parenchymal disease and frequent bronchopleural fistulae. We performed a prospective study over a one-and-a-half-year period with the objective of comparing the clinical profiles and outcomes of patients with Tuberculous and nonTuberculous Empyema. Materials and Methods: A prospective study of adult cases of nonsurgical thoracic Empyema admitted in a tertiary care hospital in eastern India was performed over a period of 18 months. A comparative analysis of clinical characteristics, treatment modalities, and outcomes of patients with Tuberculous and nonTuberculous Empyema was carried out. Results: Seventy-five cases of Empyema were seen during the study period, of which 46 (61.3%) were of nonTuberculous etiology while tuberculosis constituted 29 (38.7%) cases. Among the nonTuberculous Empyema patients, Staphylococcus aureus (11, 23.93%) was the most frequent pathogen isolated, followed by Gram-negative bacilli. Tuberculous Empyema was more frequent in younger population compared to nonTuberculous Empyema (mean age of 32.7 years vs. 46.5 years). Duration of illness and mean duration of chest tube drainage were longer (48.7 vs. 23.2 days) in patients with Tuberculous Empyema. Also the presence of parenchymal lesions and bronchopleural fistula often requiring surgical drainage procedures was more in Tuberculous Empyema patients. Conclusion: Tuberculous Empyema remains a common cause of Empyema thoracis in a country like India. Tuberculous Empyema differs from nonTuberculous Empyema in the age profile, clinical presentation, management issues, and has a significantly poorer outcome.
Gening Jiang - One of the best experts on this subject based on the ideXlab platform.
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uniportal thoracoscopic decortication for stage iii Tuberculous Empyema with severe rib crowding
The Annals of Thoracic Surgery, 2021Co-Authors: Yiming Zhou, Jie Dai, Lei Lin, Xuegang Cao, Xiaoyu Liu, Gening JiangAbstract:Background This study explored the safety and feasibility of uniportal video-assisted thoracoscopic (VATS) decortication in patients presenting with stage III Tuberculous Empyema with severe rib crowding. Methods From August 2017 to January /2019, 33 patients with stage III Tuberculous Empyema and severe rib crowding underwent uniportal VATS decortication with partial rib resection and the use of a customized periosteal stripper. Preoperative and postoperative chest computed tomography (CT) imaging and pulmonary function testing were analyzed to evaluate the clinical significance of certain imaging findings and surgical efficacy. Results There was 1 conversion to open thoracotomy. Median operative time was 3.5 hours (range, 2.1-4.5 hours) and the median blood loss was 500 mL (range, 250-1000 mL). There were no perioperative mortalities. The incidence of prolonged air leaks (>5 days) was 81.8%. Median postoperative hospital stay was 4 days (range, 4-5 days). All patients were discharged with 2 chest tubes, and median duration drainage was 39 days (range, 30-60 days). The presence of a low-density line between the parietal fibrous pleural rind and chest wall was demonstrated on chest CT in 13 patients. Intraoperative blood loss was considerably lower in these patients compared with those without this imaging finding. Follow-up was complete in all patients over a median of 8 months (range, 6-11.5 months). All patients recovered well and achieved notable improvement in pulmonary function. Conclusions Uniportal VATS decortication is safe and effective. Patients presenting with a low-density line around the thickened fibrous pleural rind on preoperative chest CT scan may be good candidates.
Byeong Jun Kim - One of the best experts on this subject based on the ideXlab platform.
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Treatment of Tuberculous Empyema by Intrathoracic Transposition of a Latissimus Dorsi Muscle Flap.
Archives of plastic surgery, 2016Co-Authors: Byeong Jun Kim, In Pyo Hong, Chan Min Chung, Woo Sik KimAbstract:South Korea has the highest prevalence of tuberculosis among the Organization for Economic Cooperation and Development nations [1], despite the management of pulmonary tuberculosis with antituberculosis drugs. Therefore, South Korea also has a relatively high prevalence of Tuberculous Empyema, a complication of tuberculosis that accounts for 3%#x2013;6% of all cases of Empyema [2]. A chronic, active infection of the pleural space, Tuberculous Empyema is a refractory disease requiring long-term medication and drainage [3]. We report our success in transposing the latissimus dorsi (LD) muscle into the pleural space in order to prevent the recurrence of Tuberculous Empyema. In 2012, a 53-year-old male patient diagnosed with pulmonary tuberculosis recovered completely after receiving treatment. However, he experienced recurrence of pulmonary tuberculosis in 2014, and during treatment, a computed tomography (CT) image revealed that the right lower lobe of his lung had collapsed. This led to the occurrence of Tuberculous Empyema, and the patient was hospitalized to undergo thoracic surgery to treat the Empyema. The patient's condition did not improve during the operation, despite the continuous administration of medication and chest tube drainage. The thoracic surgeon therefore performed a lung lobectomy with decortication, and we decided to transpose the LD muscle flap into the resulting cavity (Fig. 1). Fig. 1 A chest computed tomography scan shows a large dead space (white arrow) in the right thoracic area that resulted from the right lower lobectomy, as well as enhancing rims of the parietal and visceral pleurae (white arrowheads) surrounding a loculated ... We first identified the pleural space on the chest CT image and calculated the approximate volume of the space (203 cm3). The flow of the thoracodorsal artery was determined using a pencil Doppler and the latissimus border was outlined with a marker. After determining the amount of LD muscle required, we determined the necessary incision length and drew the incision lines (Fig. 2). The incision started in the posterior axillary fold and continued inferiorly and medially to expose the LD muscle. The skin and fat flaps were elevated to the extent necessary to produce a pocket allowing the adequate harvest of muscle tissue. We then identified the anterior border of the exposed LD muscle and its superior border below the inferior angle of the scapula. Fig. 2 Preoperative skin diagram. The lines depict surface projections of the latissimus dorsi (LD) muscle. The axillary incision design for harvest of the LD is shown in relation to the anterior border of the muscle. While performing a ligation of the perforators below the LD muscle from the superior border, the muscle was elevated to the midline. Once the medial portion of the muscle was reached, dissection was carried out inferiorly using electrocautery, and the desired amount of LD muscle was separated (Fig. 3). Next, we determined the viability of the separated LD muscle flap. In order to perform a LD muscle flap transposition into the pleural space, the serratus anterior muscle was split, the fifth rib was exposed, a portion was excised, and a second window was created in the pleural space. The LD muscle flap was then carefully inserted into the pleural space through this second window to prevent the vascular pedicle from being twisted or pulled (Fig. 4). Fig. 3 The separated latissimus dorsi muscle flap. Fig. 4 The latissimus dorsi muscle flap was inserted into the pleural space through a second window created by splitting the serratus anterior muscle (white arrow). Using 2-0 Vicryl sutures, the muscle was loosely tacked to the mediastinal pleura. After undermining the subcutaneous layer on both sides of the incision, the muscle donor site was closed primarily without tension, and a chest tube was placed for pleural drainage. In addition, two Jackson-Pratt drains were placed at the muscle donor site in order to prevent seroma formation. Both the tube and drains were removed four weeks after the operation. The wound healed uneventfully. Following surgery, however, the patient was treated with antibiotics for four weeks after the occurrence of pneumonia in the right lung (Fig. 5). At a later follow-up, the patient displayed no signs of functional disability or chest wall contour deformity related to the LD harvest. At a twelve-month follow-up examination, he was in good condition with no recurrence of Empyema. Fig. 5 Two weeks postoperatively, a chest computed tomography scan shows the pleural space filled by the intrathoracic transposition of the latissimus dorsi muscle flap (white arrow). A chest computed tomography scan of the right upper lobe shows pneumonia (black ... Sufficient drainage, infection control, and optimal nutrition play a crucial role in the treatment of Empyema [4]. However, if these strategies do not succeed in curing the Empyema, surgery must be considered. In particular, when lung lobectomy is performed, a large cavity occurs, which may lead to potentially life-threatening Empyema or secondary infection. The LD muscle flap was used simply to fill the dead space, but with the goal of producing well vascularized tissue resistant to chronic infection and disposed to angiogenesis and healing. The LD muscle has a blood supply with a type V pattern. Most of the supply comes through a thoracodorsal artery pedicle, along with lesser flows through perforators from the thoracic intercostal and lumbar arteries. Since the LD muscle is able to produce the largest extrathoracic muscle flap that can be harvested as a single vascular pedicle (up to 20 cm×40 cm), it is utilized by many plastic and reconstructive surgeons. Although the LD muscle enables extension, adduction, and internal rotation of the shoulder joint, it does not function independently. Since it moves in synchrony with a number of synergistic shoulder girdle muscles, the LD muscle can be sacrificed safely without affecting shoulder or arm action [5]. A major surgical advantage of using the LD muscle flap in the field of thoracic surgery is the fact that, because it is an extrathoracic muscle, ipsilateral lung surgery can be performed while simultaneously obtaining the LD muscle through a single posterolateral thoracotomy incision. Furthermore, due to its large bulk and long vascular pedicle, the LD muscle flap can move in apical or mid-thoracic dead space easily with minimal tension, obliterating the pleural space. However, because a LD flap based on the thoracodorsal artery can be short, alternative flaps (e.g., a rectus abdominis flap) should be considered for movement to the lower, supra-diaphragmatic recess of the pleural space. Various flaps can also be used depending on the location of the dead space, such as a serratus anterior flap for the upper region of the thorax and a pectoralis flap or a trapezius flap for the apical region. Tuberculous Empyema is uncommon and, unlike other types of Empyema, difficult to treat. We performed a lobectomy and used the intrathoracic transposition of a LD muscle flap into the resulting cavity to treat a Tuberculous Empyema patient who had not improved from the administration of antituberculosis drugs and chest tube drainage. This operation was relatively easy and the patient had no recurrence of Empyema or other complications.
