Gonzalez, Michel

Krueger, Thorsten

Perentes, Jean Yannis

Ris, Hans-Beat

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European Journal of Cardio-Thoracic Surgery 43 (2013) 1077 LETTER TO THE EDITORdoi:10.1093/ejcts/ezs577 Advance Access publication 14 November 2012The intrathoracic vacuum-assisted closure device in case ofpost-pneumonectomy empyemaThorsten Krueger*, Jean Yannis Perentes, Hans-Beat Ris and Michel GonzalezDivision of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland* Corresponding author. Department of Thoracic and Vascular Surgery, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne, Switzerland.Tel: +41-21-3142408; fax: +41-21-3142358; e-mail: thorsten.krueger@chuv.ch (T. Krueger).Received 11 September 2012; accepted 3 October 2012Keywords: Vacuum-assisted closure • Pneumonectomy • Empyema • Broncho-pleural ﬁstulaWe have read with great interest the article by Rocco et al. [1]reporting right-sided post-pneumonectomy empyema manage-ment in 3 cases by open-window thoracostomy and the subse-quent application of the vacuum-assisted closure device (VAC).Remarkably, the intrathoracic VAC therapy was performed in anoutpatient setting with bedside changes of the wound dressingevery 3 days. The authors describe that VAC therapy was efﬁcientin draining the post-pneumonectomy space and helped obliter-ate it. No information is given about the treatment’s efﬁciency inhealing broncho-pleural ﬁstula. However, in their experience,VAC therapy was discontinued in 2 of the 3 patients because ofthe development of severe side-effects including hypotensionand intolerable chest pain. Also, in 1 patient, the VAC foam wasentrapped by granulation tissue and its removal was considereddifﬁcult through the narrow thoracostomy.We have recently published a series of 27 consecutive patientswho underwent intrathoracic VAC therapy for the managementof severe intrathoracic infections, including post-resectionempyema with or without broncho-pleural ﬁstula [2]. In our ex-perience, the intrathoracic VAC treatment was well tolerated bythese high-risk patients; in particular, we did not observehaemodynamic impairment or difﬁculties of pain control. VACtreatment was completed in all patients and allowed for efﬁcientcontrol of intrathoracic infection and closure of broncho-pleuralﬁstula when present. Our more favourable experience applyingnegative pressure wound therapy in these patients may beexplained by a difference in our technical approach: in case ofbroncho-pleural ﬁstula, the bronchial stump is debrided andclosed by a pediculated muscle transposed into the chest cavity.The intrathoracic VAC dressing is then applied as an adjunct tosurgery for efﬁcient drainage, and accelerated obliteration of thechest cavity. In contrast to Rocco et al., we feel more comfort-able keeping these critically ill patients in the hospital during thecourse of VAC therapy and performing the successive VAC dress-ing changes under a short general anaesthesia. This is convenientfor both the patient and the surgeon as the procedure is painlessand efﬁcient. General anaesthesia allows for accurate inspectionof the chest cavity, debridement if necessary and easy replace-ment of the VAC foam. Another advantage is that an open-window thoracostomy is not required, since the intrathoracicVAC dressing can be accessed by repeated opening of the thora-cotomy. Standard perioperative monitoring also permits the as-sessment and immediate correction of potential haemodynamicchanges while packing the cavity. Once the infection is con-trolled and granulation tissue is abundant throughout the cavity,the residual space, if present, is ﬁlled with an antibiotic solutionand ﬁnal chest closure is performed. In our published series,none of the patients required chest wall reconstruction proce-dures as no open-window thoracostomies had been performed.The median length of VAC therapy was 22 days and the mediannumber of VAC changes per patient was 6.We concluded from our experience that the intrathoracic VACtherapy is a safe, well tolerated and effective treatment for themanagement of severe intrathoracic infections. In our opinion, itshould be considered in selected patients as an alternative toopen-window thoracostomy. The major advantages are the pre-served integrity of the chest wall and a short and efﬁcient treat-ment course, considerably affecting patients’ satisfaction.However, we would not recommend this approach for bedsidedressing changes in an outpatient setting.REFERENCES[1] Rocco G, Cecere C, La Rocca A, Martucci N, Salvi R, Passera E et al.Caveats in using vacuum-assisted closure for post-pneumonectomyempyema. Eur J Cardiothorac Surg 2012;41:1069–71.[2] Saadi A, Perentes JY, Gonzalez M, Tempia AC, Wang Y, Demartines Net al. Vacuum-assisted closure device: a useful tool in the management ofsevere intrathoracic infections. Ann Thorac Surg 2011;91:1582–9.LETTERSTOTHEEDITORLetters to the Editor / European Journal of Cardio-Thoracic Surgery 1077

The intrathoracic vacuum-assisted closure device in case of post-pneumonectomy empyema

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