Overview
Definition:
The Eloesser flap, also known as a thoracoplasty with skin flap, is a surgical technique primarily used for managing chronic empyema, particularly when lung re-expansion is difficult or impossible after other treatments like decortication or prolonged chest tube drainage
It involves creating a fenestration in the chest wall by removing a segment of ribs and then turning a pedicled skin flap into the pleural space to obliterate the cavity.
Epidemiology:
Empyema is a common complication of pneumonia, accounting for significant morbidity
Chronic empyema, requiring complex procedures like the Eloesser flap, is less common but presents a significant challenge
Incidence varies with geographic location, healthcare access, and prevalence of underlying lung diseases or risk factors such as tuberculosis, thoracic trauma, and post-operative complications.
Clinical Significance:
The Eloesser flap is crucial for patients with refractory chronic empyema who have non-expandable lungs and persistent, purulent pleural collections
It aims to obliterate the pleural space, thereby preventing further infection, improving patient comfort, and facilitating wound healing
Successful management is vital to prevent sepsis, respiratory compromise, and chronic illness
It is a key surgical option for DNB and NEET SS candidates to understand in the context of complex thoracic infections.
Indications
Absolute Indications:
Persistent, loculated, or multiloculated chronic empyema that fails to resolve with conservative measures
Bronchopleural fistula with contiguous empyema
Significant thoracic deformity or pain related to a large, unresolvable empyema cavity
Failed prior decortication or rib resection surgery.
Relative Indications:
Patients with poor general health or comorbidities that preclude more extensive surgery
As a salvage procedure after failure of other thoracic interventions
To control persistent sepsis from a non-draining empyema.
Contraindications:
Active uncontrolled sepsis without source control
Severe, irreversible respiratory failure
Extensive pleural symphysis that makes obliteration impossible
Inability to tolerate major surgery
Very small, easily manageable empyema cavities.
Preoperative Preparation
Assessment:
Thorough history and physical examination focusing on respiratory status, nutritional status, and presence of sepsis
Detailed review of prior treatments and imaging studies (CT chest, MRI)
Evaluation of pulmonary function tests (PFTs) to assess respiratory reserve.
Imaging:
CT scan of the thorax is essential to delineate the size and location of the empyema cavity, identify any loculations, assess the thickness of the visceral and parietal pleura, and evaluate for associated lung pathology or bronchopleural fistulas
MRI may be useful in selected cases to assess for empyema necessitatis or involvement of adjacent structures.
Antibiotic Therapy:
Broad-spectrum intravenous antibiotics are initiated covering aerobic and anaerobic organisms, adjusted based on culture and sensitivity results from pleural fluid aspiration
Duration of therapy is guided by clinical response and resolution of infection.
Nutritional Support:
Malnutrition is common in patients with chronic empyema
Preoperative nutritional assessment and aggressive supplementation (oral or parenteral) are critical to optimize healing and surgical outcomes.
Pulmonary Toilet:
Chest physiotherapy, incentive spirometry, and, if necessary, bronchoscopy to clear secretions and improve lung aeration are vital preoperatively.
Procedure Steps
Anesthesia And Positioning:
General anesthesia with double-lumen endotracheal tube for lung isolation is preferred
Patient is positioned in the lateral decubitus position.
Thoracostomy And Rib Resection:
A curvilinear incision is made over the affected chest wall, typically encompassing several ribs (e.g., 4th to 8th)
A segment of one or two ribs is resected (e.g., 5-8 cm) to create the fenestration into the empyema cavity
The intercostal muscles and pleura are then incised.
Debridement And Lavage:
The empyema cavity is thoroughly debrided of all necrotic tissue, pus, and thick fibrinopurulent material
Copious irrigation with saline or antiseptic solutions is performed to cleanse the cavity.
Skin Flap Creation:
A pedicled skin and subcutaneous tissue flap is raised from the chest wall, based superiorly or inferiorly depending on the location of the empyema
The flap is designed to be large enough to fill the entire debrided pleural space.
Flap Inversion And Closure:
The skin flap is inverted and sutured into the debrided pleural cavity, obliterating the space
The intercostal muscles and skin are then closed over the flap, often with drains placed in the subcutaneous space if necessary.
Chest Tube Insertion:
A chest tube may be placed in the residual pleural space (if any) or the subcutaneous tissue to allow for drainage and gradual collapse of the space.
Postoperative Care
Pain Management:
Aggressive multimodal pain management including epidural analgesia, patient-controlled analgesia (PCA), and non-opioid analgesics is crucial for patient comfort and facilitates early ambulation and pulmonary physiotherapy.
Chest Drain Management:
Chest tubes, if inserted, are managed according to standard protocols, typically with suction
Their removal is based on output and absence of air leak.
Wound Care:
Regular dressing changes and meticulous wound care are essential to prevent surgical site infections and ensure proper flap healing
The skin flap requires monitoring for viability and signs of ischemia.
Pulmonary Physiotherapy:
Aggressive pulmonary physiotherapy, including incentive spirometry, deep breathing exercises, and early ambulation, is critical to prevent atelectasis and pneumonia, and to promote lung expansion as much as possible.
Antibiotic Therapy Continuation:
Intravenous antibiotics are continued based on intraoperative findings and sensitivity data, with a transition to oral agents when the patient is stable and able to tolerate oral intake.
Complications
Early Complications:
Hemorrhage from the chest wall or pleural vessels
Surgical site infection
Skin flap necrosis or dehiscence
Persistent air leak
Empyema recurrence
Sepsis
Respiratory failure.
Late Complications:
Chronic pain syndrome
Chest wall deformity
Chronic drainage from the skin flap (fistula)
Granulation tissue formation
Bronchopleural fistula recurrence
Chronic lung disease progression.
Prevention Strategies:
Meticulous surgical technique, careful debridement, adequate blood supply to the skin flap, judicious use of drains, aggressive pain control, proactive pulmonary physiotherapy, and appropriate antibiotic therapy are key
Early recognition and management of any signs of infection or flap compromise are vital.
Prognosis
Factors Affecting Prognosis:
The underlying cause of empyema, the extent of pleural fibrosis, the patient's overall health status and nutritional status, the presence of comorbidities (e.g., diabetes, COPD), and the success of surgical obliteration of the cavity are major prognostic factors.
Outcomes:
When successful, the Eloesser flap can lead to obliteration of the empyema cavity, resolution of infection, relief of symptoms, and improved quality of life
However, recurrence and chronic drainage can occur, requiring further intervention
Long-term outcomes are variable, with some patients experiencing chronic pain or residual deformity.
Follow Up:
Regular follow-up appointments are necessary, especially in the early postoperative period, to monitor wound healing, assess for signs of infection or recurrence, and evaluate respiratory status
Long-term follow-up may include periodic chest imaging and clinical assessment.
Key Points
Exam Focus:
The Eloesser flap is a historical but still relevant technique for chronic, non-resolving empyema with non-expandable lungs
It involves creating a fenestration and obliterating the cavity with a pedicled skin flap
Understand the indications, contraindications, and stepwise procedure, along with potential complications.
Clinical Pearls:
Adequate debridement of the empyema cavity is paramount for success
Ensure robust blood supply to the skin flap
Aggressive pain control is essential for effective postoperative physiotherapy and lung expansion
Consider nutritional support as a critical component of preoperative management.
Common Mistakes:
Underestimating the extent of debridement required
Inadequate flap design leading to necrosis or insufficient obliteration
Insufficient pain management leading to poor mobilization and respiratory complications
Failing to consider nutritional status
Not adequately investigating for underlying bronchopleural fistulas.