Asian Cardiovasc Thorac Ann 2007;15:e43-e45
© 2007 Asia Publishing EXchange Ltd
Safe Treatment of Post Thoracotomy Seroma
Nicolas Durrleman, MD,
Maksim Pryshipov, MD,
Jean-Marie Wihlm, PhD,
Gilbert Massard, PhD
Department of Thoracic Surgery, University Hospital of Strasbourg, France
For reprint information contact: Nicolas Durrleman, MD Tel: 33 664 328 791 Fax: 33 156 093 631 Email: nicodurr{at}hotmail.com, Department of Thoracic Surgery, University Hospital of Strasbourg, 1 Place de l’Hopital, 67000 France.
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ABSTRACT
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Postoperative seroma is a common complication after muscle-sparing lateral thoracotomy. The main cause is considered to be the result of subcutaneous flap mobilization. We present a case of seroma which occurred following a pneumonectomy owing to subcutaneous flooding with pleural fluid, which was successfully treated by subclavian catheter insertion. The technical aspect of the procedure is described.
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INTRODUCTION
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Subcutaneous seroma is quite a common complication after a lateral muscle-sparing thoracotomy. Since description of the muscle-sparing technique in 1991,1 there has been no consensus of its relative advantages or disadvantages compared to the standard postero-lateral approach. The division of latissimus dorsi muscles in postero-lateral thoracotomy was considered to be more painful and to compromise postoperative physical activity. However, trials1,2 comparing the muscle-sparing technique with the classic thoracotomy failed to show any statistically significant difference. Only the incidence of seroma was more common in muscle-sparing thoracotomy, reaching 20% in some series. Lateral thoracotomy leads to anterior extension of the intercostal incision, where the distance between the ribs is larger than in the dorsal part. As a result, closure of the thoracotomy will not be air-tight in some patients with thin chest walls and poor muscle development. This can lead to a communication between the pleural cavity and subcutaneous space. We report the case of a pleuro-subcutaneous fistula complicating a left pneumonectomy for lung cancer.
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CASE REPORT
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A 59-year-old male patient was admitted for surgical treatment of squamous cell lung cancer. Physical examination revealed severe weight loss (height 172 cm and weight 55 kg). The patient underwent uneventful left pneumonectomy with lymph node dissection through a lateral muscle-sparing thoracotomy at the level of the 4th intercostal space. As usual in our practice, the pleural cavity was drained with a 24 Fr silicone-rubber tube connected to a balanced drainage system during the first 2 postoperative days. The subcutaneous space underlying the skin flaps was drained by two 10 Fr drains which were kept on suction. The output of the subcutaneous drains suddenly increased to 200 mL on the 4th postoperative day. The mediastinal shift noted simultaneously could be partially explained by drainage of pleural fluid to the subcutaneous space and drains (Figure 1
). The quantity of the draining fluid decreased to 60 mL on the 9th postoperative day, and the drains were subsequently removed. Three days later, the patient complained of tension along the thoracotomy. Physical examination disclosed a seroma without local signs of inflammation. The absence of respiratory variations excluded a herniation of post pneumonectomy fluid into the wound. There was no fever, and a blood cell count revealed a leukocyte level of 9.7 K.µL–1 and C reactive protein (CRP) level of 56 mg·L–1. A chest X-Ray confirmed enhancement of the chest wall (Figure 2). The seroma was drained by insertion of a subclavian catheter (Cordis, Miami, FL, USA) the same day and a compression dressing was applied (Figure 3). The output decreased from 250 and 150 mL over the first 2 days to 5 mL on the 3rd day. The drainage tubes were withdrawn, and no recurrence of seroma occurred. The patient was discharged on the 16th postoperative day. Physical examination at 1 month follow-up showed no recurrence of seroma.
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Figure 1. On the 4th postoperative day, the mediastinal shift could be partially explained by drainage of pleural fluid to the subcutaneous space and drains.
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Figure 2. Chest X-Ray, enhancement of the chest wall on the 12th postoperative day revealed a seroma along the left thoracotomy.
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Figure 3. Drainage of the seroma by means of a subclavian catheter does not differ from a classic central venous catheterization.
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DISCUSSION
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Muscle-sparing thoracotomy is a commonly used approach in thoracic surgery. Seroma is a procedure-specific complication which is usually explained by dissection of skin flaps. In addition, when dissecting the upper verge towards the axilla, there can be some injury of axillary lymphatic vessels. Less frequently, escape of pleural fluid though a tight intercostal closure could also explain a pseudoseroma corresponding in fact to a herniation of post pneumonectomy fluid.3 In fact, the larger intercostal space in the ventral part of the thoracic cage cannot be approximated tightly, and needs apposition of the pectoralis major and serratus anterior muscles. In the present case report, the patient suffered from a low body mass index (height 172 cm and weight 55 kg) and insufficient muscle volume to cover the intercostal space. In case of lobectomy or lesser resection, this fact may not be very important. In contrast, following pneumonectomy, such a pleuro-subcutaneous communication may lead to maintenance of a pseudoseroma over a prolonged period. A subsequent risk is infection of the seroma, which may further result in empyema.
The classical management of subcutaneous seromas consists of repeated aspiration of the fluid, and application of skin flaps to the underlying muscle by compression dressings. The repeated aspiration of seroma communicating with the post pneumonectomy cavity may lead to dramatic mediastinal shift4 and postpneumonectomy syndrome. Another potential risk with multiple aspirations is infection of the seroma, which in turn can lead to empyema.
The drainage of seroma by means of a subclavian catheter was shown to be an effective treatment with an excellent medium term result. The basis of this technique is to drain the postoperative seroma with a small catheter connected to a drainage device. It can be performed at the patient’s bedside, after local anesthesia and meticulous antisepsis. This procedure avoids repeated perforations of the seroma and the subsequent risks of infection or a surgical revision. Whilst this technique of insertion does not differ from a central venous catheterization, in this indication it is imperative to facilitate extra holes in the catheter to promote homogenous aspiration (Figure 4).
The described technique is a simple, non-invasive and efficient means of treatment for post thoracotomy seroma, but must always be done with concomitant compression dressings. It is an excellent alternative approach allowing the length of hospital stay to be shortened, and avoiding repeated seromal perforations or re-operation.
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REFERENCES
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- Hazelrigg SR, Landreneau RJ, Boley TM, Priesmeyer M, Schmaltz RA, Nawarawong W, et al. The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain. J Thorac Cardiovasc Surg 1991;101:394–401.[Abstract]
- Akcali Y, Demir H, Tezcan H. The effect of standard posterolateral versus muscle-sparing thoracotomy on multiple parameters. Ann Thorac Surg 2003;76:1050–4.[Abstract/Free Full Text]
- Suen HC, Chavez VM, Farmer RT, Rodriguez G Jr, Daily BB. Images in cardiothoracic surgery. Herniation of postpneumonectomy space fluid. Ann Thorac Surg 2005;80:1942.[Free Full Text]
- Cullinane C, Kovitz KL, Hartz RS. Late mediastinal shift after repeated aspiration of postpneumonectomy seroma. Chest 2001;119:975–7.[Medline]
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ABSTRACT
INTRODUCTION
