Thorakoplastik

Thoracoplasty is a surgical procedure that was originally designed to permanently collapse the cavities of pulmonary tuberculosis by removing the ribs from the chest wall  . It involved resection of multiple ribs, allowed the apposition of parietal to the visceral or mediastinal pleura. Until supplanted by effective chemotherapy, it was one of several methods used to put the lung to rest, with the hope of inactivating the disease .

Indications

• cavitary tuberculosis (of apical and posterior segments of upper lobe*)
• empyema
• bronchopleural fistula
• persistent spaces following pulmonary resections

* Thoracoplasty is never used to treat basal spaces because:

• lower spaces are better managed by open window drainage or muscle flap transfer
• it is very difficult to obtain complete collapse of the chest wall at the base

Procedure

Overview

Most thoracoplasties are performed through a standard posterolateral thoracotomy, which can be extended upward, if necessary. The 2^nd to the 8^th ribs are usually resected in an extra-musculo-periosteal fashion (should extend one rib inferior to the extent of the disease). The 1^st rib is preserved (to maintain the integrity of the neck and shoulder girdle).

Procedure types

• intrapleural thoracoplasty
  • involves multiple rib excisions as well as resection of the parietal pleura, periosteum, intercostal muscles, and intercostal neurovascular with preservation of intercostal muscles which is allowed to fall into the cavity
• extrapleural thoracoplasty
  • the rib periosteum, intercostal muscle and parietal pleura are preserved and allowed to drop into cavity
• plombage thoracoplasty
  • a space is created between the rib cage, periosteum and endothoracic fascia (with out resecting the ribs) 
  • in this extrapleural space is inserted the plombe (methymethacrylate spheres, lead bullets, tissue expanders, sponge, lucite balls and oil) 
• tailoring (limited) thoracoplasty
  • a limited operation
  • only a few ribs are removed

Clinical features

Many are asymptomatic. Complete unilateral thoracoplasty may be associated with dyspnea or chest discomfort .

Results and complications

• late results show successful collapse and obliteration of the space in 80 to 90% of patients with a intra operative mortality ranged from 0% to 10% 
• postoperative complications
  • failure to heal
  • failure to obliterate the space
  • failure to control infection
  • failure to close the bronchopleural fistula
  • respiratory failure
• late complications of plombage thoracoplasty
  • leakage of plombage material
  • fistulae formation
  • late infection

Radiographic features

Chest radiograph

• plombage
  • radiopaque or radiolucent well-circumscribed densities within the affected lung, usually the lung apex
  • the appearance often looks like ‘ping pong balls’
  • other inert substances may be used
  • this may be associated with adjacent rib anomalies or absent ribs
• unilateral thoracoplasty
  • associated with more extensive rib anomalies / rib excision
  • the whole hemithorax is small with no significant aerated lung present
  • the right upper chest is deformed and the pleural space is calcified

Differential diagnosis

In some situations, congenital anomalies such as neurofibromatosis type I can rarely resemble the appearances of a thoracoplasty.

History and etymology

It was originally described by de Cerenvile in 1885 to treat cavitary tuberculosis.

Siehe auch:

• Tuberkulose
• thorakale Plombage
• Pneumolyse
• Brustwanddeformitäten

und weiter:

• Plombage