Phrenoplasty, A New Operation for the Management of Pleural Dead Space Following Pulmonary Resection Lyman A. Brewer 111, M.D., and Alan B. Gazzaniga, M.D.#
ailure of the remaining pulmonary tissue to fill the pleural cavity after lobectomy creates a dead space. Both compensatory mechanisms of the body and current surgical techniques to eliminate this defect tend to decrease diaphragmatic and chest wall action. In 1962 the procedure of phrenoplasty was devised by one of us (L. A. B.) to increase the rise and mobility of the diaphragm on the operated side after lobectomy in order to minimize the pleural dead space. The term phrenoplusty is derived from the Greek phren, “diaphragm,” and plassein, “to shape or mold.” The following report introduces this technique and considers the indications and results in 40 patients. One of the most serious side effects of a large, persistent pleural dead space after lobectomy is the formation of pleural fluid, which may result in a captive lung and a fixed diaphragm. Current methods to obviate these problems have certain disadvantages: 1. Phrenic crush produces immediate paralysis and rise of the diaphragm, with loss of coughing and ventilatory efficiency during the postoperative period. This loss of function may become permanent if the phrenic nerve fails to regenerate or if adhesions form [l]. 2. Thoracoplasty causes paradoxical movement of the chest wall postoperatively, rendering coughing and ventilation less effective. 3. Plombage introduces the chance of infection . 4. Pneumoperitoneum may decrease ventilation and effective coughing. 5 . Pleural partitions, though effective in our hands [2, 41 theoretically increase the chance of infection in the superior apical space. Eventually, this superior pleural space fills with fibrous and fatty tissue. 6. Reattaching the diaphragm at a higher level [l] is rarely employed. From the Department of Surgery, University of California at Irvine, California College of Medicine, Los Angeles, Calif. Presented at the Fourth Annual Meeting of The Society of Thoracic Surgeons, January 29-31, 1968, New Orleans, La. *Present address: Peter Bent Brigham Hospital, Boston, Mass. Address reprint requests to Dr. Brewer, 658 So. Bonnie Brae St., Los Angeles, Calif. 90057.
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T h e freeing of the central portion of the diaphragm from the pericardium increases its surface area by 15 to 40%, thus permitting it to rise higher when negative pressure is applied. Since the phrenic nerve is not disturbed, the contractility of the diaphragmatic musculature remains unimpaired (Fig. lA, B). The technique is simple: After lobectomy, the rib spreaders are removed, and the rib cage is approximated. After the remaining lobe is forcibly expanded, the amount of physiological saline that can be introduced into the pleural cavity will indicate the volume of the dead space. A normally elastic lung will expand to accommodate a residual space of approximately 500 ml., particularly in younger people. However, in older patients with fibrosis or emphysema in the remaining lobe, pleural defects of more than 500 ml. may lead to complications. By dissecting the pericardial fat pad from the cardiophrenic angle (Fig. ZA), the line of dissection is exposed. We have used this pericardial fat pad since 1953 to reinforce the bronchial stump and have not had a bronchial fistula following lobectomy [3, 51. The diaphragm is freed from the pericardium by blunt and sharp dissection, avoiding injury to the thin central portion of the diaphragm. Actually the pericardium is more easily repaired than the diaphragm. The more thorough the dissection, the higher will be the subsequent rise of the diaphragm. I
FIG. 1. (A) B y subpericardial freeing of the diaphragm, the fulcrum of the diaphragmatic attachment is moved to the opposite side of the pericardium. T h e amount of diaphragm available for elevation is increased by 15 t o 40%. ( B ) The shifting of the mesial fulcrum of the diaphragm to the opposite side of the pericardium permits the diaphragm to rise suficiently to minimize the pleural dead space. 120
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Pericardial fat bronchial stump araft \
Rt. pulmonary a .
A Per i t a rd i a I
FIG. 2. ( A ) T h e technique of phrenoplasty. Following the removal of a lobe (right upper in this case), the pericardial fat is freed from the pericardiophrenic angle t o expose the line of dissection between the diaphragm and pericardium. The pericardial fat is used as a viable, airtight reinforcement of the bronchial stump. (B) T h e diaphragm is freed from the pericardium to the contralateral pleuropericardial reflection, avoiding the vena cava. Downward pressure o n the diaphragm exposes the line of dissection. ( C ) T h e subpericardial lysis permits increased rise of the diaphragm. VOL.
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Care is taken not to injure the inferior vena cava (Fig. 2B). T h e contralateral pleural cavity has been entered on several occasions without any demonstrable physiological effect, but in such cases a small contralateral pneumothorax has been seen on the postoperative x-ray. T h e rise of the diaphragm postoperatively is higher than one might expect from the amount of diaphragm that has been freed (Fig. 2C). T h e increased surface area enables the diaphragm to accommodate more accurately to the contour of the remaining lung. CLINICAL M A T E R I A L The majority of our patients were in the older age group, in which emphysema, chronic bronchitis, and pulmonary fibrosis are common. Thirty-four of the 40 patients (85%)were over 55 years of age. The 2 patients under 40 years of age had chronic inflammatory disease with fibrosis of the remaining lobes and pleural dead spaces of 750 and 1,000 ml., respectively. Carcinoma was present in 16 patients, chronic granuloma in 14, bronchiectasis in 3, and chronic abscess in 3. The remaining diagnoses were: hamartoma, silicosis, pulmonary infarct, and lipid pneumonia. Chronic cough was present in two-thirds of the patients. Thus, this series of patients had limited expansibility of the remaining lobe or lobes primarily because of pulmonary fibrosis or emphysema. In 75% of the patients the postresection pleural dead space was large, ranging from 750 to 1,500 ml.; it was 600 to 750 ml. in the other patients. CLINICAL RESULTS
No patients died and none had bronchopleural fistulas or empyema postoperatively. Although we had anticipated that these older patients might have greater difficulty in raising secretions following operation, such was not the case. No patient had atelectasis or retention of secretions serious enough to necessitate bronchoscopy. One elderly patient had a chest wall infection which required drainage; however, the pleural space was not involved. In one patient multiple pulmonary emboli required vena cava clip plication. In three patients with severe emphysema of the interlobar fissures, air leak continued more than five days. Lung expansion was accomplished in all cases. X-rays taken postoperatively generally showed clear diaphragmatic sulci on the operated side (Fig. 3A, B). Only five patients showed cloudy costophrenic sinuses or appreciable tenting of the diaphragm. There was no impairment of movement of the contralateral diaphragm. Movement averaged 5.1 cm. on the operated side and 6.6 cm. on the contralateral side. The cardiac shift was minimal, averaging 1.8 cm. toward the operated side. PULMONARY FUNCTION
Pulmonary function studies were carried out in 17 patients after surgery. I n Group I, composed of 7 patients with a 14-month follow-up, studies of pulmonary function were done preoperatively and the results correlated with those obtained postoperatively. In Group 11, composed of 10 patients with a 24-month follow-up, the pulmonary function measured postoperatively was compared with preoperative values predicted from standard nomograms. Both groups were comparable in age, the mean being 56 years in Group I and 55 years in Group 11; the size of the pleural defect in both groups ranged from 600 ml. to 1,000 ml. 122
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FIG. 3 . ( A ) Preoperative chest x-ray of an 80-year-old m a n with a left upper lobe squamous cell carcinoma. ( B ) Immediately following left upper lobe lobectomy and phrenoplasty o n this patient, the elevation of the left hemidiaphragm has eliminated the 800 ml. pleural dead space. ( C ) Fifteen months after surgery, both hemidiaphragms descend well o n inspiration and the costophrenic angles are clear. T h e left lower lobe now shows increased expansion. (D) Expiration x-ray taken at this time shows satisfactory ascent of both hemidiaphragms. In general, the findings in the Group I1 patients paralleled those in Group I, in which absolute preoperative values had been obtained. The results of the postoperative pulmonary function studies in Group I may be summarized as follows: There was an average postoperative reduction of 0.5 liters in vital capacity as compared to the preoperative value; the reduction in forced expiratory volume was .37 liters; the maximum breathing capacity was reduced by 12 liters per minute; and the maximum expiratory flow rate was reduced by 75 liters per minute. The moderate reduction in ventilation in these patients indicates that lobectomy with phrenoplasty is well tolerated, even in the eighth decade of life. All patients who were employed before operation returned to work. The pulmonary function values obtained postoperatively tend to be corroborated by the x-ray studies which demonstrate satisfactory bilateral mobility of the diaphragm. More detailed and longer term studies of the postoperative pulmonary function are in progress. VOL.
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CONTRAINDZCATZONS T O PHRENOPLASTY
An active infection in the pleura is a contraindication to phrenoplasty because it is unwise to open up new tissue spaces to infection. In the presence of extensive fibrosis and scarring of the diaphragm or a fixed fibrous pleural membrane, phrenoplasty would be ineffectual. Of course, phrenoplasty is not necessary in a young individual whose lungs have great expansive powers and usually is unnecessary when the resected lobe is atelectatic. We have not done a phrenoplasty in an adult whose pleural dead space was less than 500 ml. SUMMARY
Phrenoplasty has been devised to control a large pleural dead space after lobectomy. It is performed when the pleural dead space is found to be 500 ml. or more in an adult at surgery. T h e procedure consists of dissecting the central portion of the diaphragm from the pericardium, which increases the amount of diaphragm available for elevation by 15 to 40%. Results in 40 patients indicate control of residual dead space of as much as 1,500 ml., satisfactory pulmonary function, and adequate diaphragmatic action on the operated and contralateral sides. T h e rise of the diaphragm parallels that following diaphragmatic paralysis; however, diaphragmatic action is preserved. T h e simplicity of the technique and its ability to effectively eliminate pleural dead space while preserving diaphragmatic action are significant advantages of this procedure. General evaluation seems indicated. REFERENCES 1. Bjork, V. 0. Present indications for space-diminishing procedures after pulmonary resections for tuberculosis. Acta Chir. Scand. 112:454, 1957. 2. Brewer, L. A., 111. Pleural partition procedure: A technic for management of large intrapleural dead space following lobectomy. Bull. SOC. Znt. Chir. 17:305, 1958. 3. Brewer, L. A., 111, and Bai, A. F. Surgery of the trachea and bronchi: Experience with the pedicled pericardial fat graft reinforcement. Amer. J. Surg. 89:331, 1955. 4. Brewer, L. A., 111, Bai, A. F., and Jones, W. M. G. The development of the pleural partition to prevent overexpansion of the lung following partial pulmonary resection. J. Thorac. Surg. 31: 165, 1956. 5. Brewer, L. A., 111, King, E. L., Lilly, L. J., and Bai, A. F. Bronchial closure in pulmonary resection: A clinical and experimental study using a pedicled pericardial fat reinforcement. J. Thorac. Surg. 26:507, 1953. 6. Bridge, E. V., Allen, G. S., Ellis, F. H., Jr., and Clagett, 0. T. Complications associated with polyvinyl-formal sponge prosthesis and lombage in the surgical management of pulmonary diseases. Amer. Rev. T u ere. 74:581, 1956.
Editor’s Note: For another method of “assuring” the filling of the residual pleural space after subtotal pulmonary resection, see the editorial on page 196. 124
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Phrenoplasty DISCUSSION DR. PETERPARNASSA (Brooklyn, N.Y.): Dr. B. Burbank and I have attempted to solve the problem of residual space after lobectomy by a different method. For the past two years, all patients undergoing thoracotomy have a nasal endotracheal tube left in place postoperatively for control of respiration by a controlled volume respirator, specifically, the Emerson. This control is maintained for 6 to 48 hours postoperatively. We have found that the residual lung promptly fills the space. DR. DAVIDH. WATERMAN (Knoxville, Tenn.): We have been interested in diaphragmatic surgery since the 1940’s, and in the early 1950’s we re orted some cases of transplantation of the diaphragm that we operated on in an e ort to solve this same problem that Dr. Brewer has discussed. Bjork also described the operation about the same time. Although we reported seven cases in 1954, as I recall, we have operated on very few since then. It is just too much trouble; furthermore, the excursion of the diaphragm is not as good as before transplantation. We have had more success, actually, in restoring function to apparently paralyzed high diaphragms which we have plicated and brought down to a lower level. Restoration of partial excursion usually results, and the patient reports marked clinical improvement. I was much impressed today that the function of these operated diaphragms of Dr. Brewer’s remains good. This in itself is the most important point we should bear in mind.
DR. EMILA. NACLERIO (New York, N.Y.): After a right-sided pneumonectomy, most of us perform a phrenicotomy before closing the chest to decrease the size of the pleural space. On the other hand, for a left-sided pneumonectomy, we do not cut the phrenic nerve because the resultant rise of the diaphragm predisposes to the development of three potentially deleterious effects: (1) acute gastric dilatation, (2) significant shifting of the heart to the contralateral side, and (3) a 20% or more diminished ventilatory function of the remaining lung. Dr. Brewer, would you please comment on the effects of a right-sided versus a left-sided phrenoplasty? DR. JAMES E. DAILEY(Houston, Tex.): I agree with Dr. Brewer that rapid obliteration of the dead space following resection is imperative. Distention of residual lung as well as distortion which causes kinking of the bronchi and vessels following resection are as dangerous to the patient as is the immediate prospect of air leaks or bronchial fistulas. Preoperative, postoperative, and concomitant thoracoplasty, pneumoperitoneum, and the use of a foreign material to obliterate space are all excellent procedures, each having a place in selected cases. Dr. Brewer has ably demonstrated another unique procedure that will surely find its place with the others. I take issue with him on two points: (1) It is not necessarily true that use of a foreign substance, as he says “for plombage,” increases risk of infection. (2) The term plombage should not be used as all-inclusive. Plombage describes a procedure or a substance used to fill a cavity produced by a collapsed lung. Prosthesis, the replacement of an absent part by an artificial one, better describes a substance used as a space filler following resection. Since 1953, at the East Texas Tuberculosis Hospital in Tyler, Texas, and in Houston, we have had experience with a total of 325 Ivalon sponges. Eighteen became infected-an incidence of 5.5%. Sponges were used as a plombage in 49 cases, with 2 (4.0%) infected; as a prosthesis they were used concomitant with pneumonectomy in 173 cases, of which 13 (7.5%) became infected, concomitant with lobectomy in 94 cases, of which 3 (3.1%)became infected, and were inserted postpneumonectomy in 9 cases, with no infections. DR. BREWER:I should like to thank the discussants for their pertinent comments. VOL.
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BREWER AND GAZZANIGA The respirator does aid in expanding the remaining lung. When the dead space is small, no space problem exists. However, the respirator will not expand a fibrotic lung in an older person with a large dead space. I thank Dr. Waterman for his remarks. We have tried transplanting the diaphragm in dogs. It is a difficult operation and has serious drawbacks from the functional standpoint, as he pointed out. Dr. Naclerio, we have not observed the diaphragm on the left side to rise high enough following lobectomy to cause any trouble. I quite agree with you that following left-sided pneumonectomy gastric problems do occur. I might say parenthetically that we are not sure about the value of phrenoplasty following pneumonectomy. This is under study now. Dr. Dailey, you have presented an excellent series of cases with plombage and few infections. Other people, including ourselves, have had infection following plombage and are therefore wary about this procedure.
NOTICES FROM THE SOCIETY OF THORACIC SURGEONS Abstracts for papers to be presented at the 1969 Annual Meeting of The Society of Thoracic Surgeons are now being accepted. The meeting is to be held in San Diego, California, on January 27-29, 1969. The deadline for receipt of abstracts is September 15, 1968. An original and 8 copies should be submitted to Kenneth L. Hardy, M.D., Chairman, Program Committee, T h e Society of Thoracic Surgeons, 3115 Webster St., Oakland, Calif. 94609. Abstracts must summarize an original contribution not presented or submitted elsewhere. It must not exceed 200 words in length. Abstracts received after the deadline or exceeding 200 words will not be considered. T h e program committee reserves the right to select papers for either regular or forum-type presentations. Essayists are reminded that the complete manuscript must be submitted in duplicate either to the Editor of The Annals of Thoracic Surgery before the meeting or to the secretary of the Society at the meeting, immediately prior to presentation. 126
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