Extrapleural Pneumonectomy In Atypical Mycobacteriosis: The Modern Use Of "Sarot Procedure"

A case of destroyed lung with fibrothorax after pleura-pulmonary mycobacteriosis, treated by extrapleural pneumonectomy (EPP), is described. Differences between the actual and the historical indications to this procedure are analyzed. An assessment of its current benefits versus disadvantages is done. A 45-year-old, male patient presented with a destroyed left lung and ipsilateral fibrothorax. He had suffered from pulmonary active cavitary disease with caseating empyema, by Mycobacterium Xenopi, recalcitrant to medical therapy and lasting over 5 years. After obtaining sputum conversion, he had continued to suffer from fungal pulmonary superinfections and recurrent bronchopneumonia by Pseudomonas aerugmosa. He was submitted to left EPP with intro-pericardial ligature of pulmonary vessels and transposition, in the pleural cavity, of the latissimus dorsi after pedunculization on its upper end. Histology showed pleuro-pulmonary mycobacteriosis with caseating necrosis and diffuse bronchiectasis. A chest wall hematoma, worsening of a chronic renal disfunction and ischemic necrosis of surgical wound characterized postoperative course. He was assigned to the Infectious Disease Department on the 7th postoperative day. The patient was later submitted to other surgical procedures in general anesthesia, among with orthopedical replacement of hip prosthesis, without any respiratory complications. The 30-month follow up has shown the healing of surgical wound and the full control of pulmonary infections. EPP remains a valid therapeutic option for pulmonary mycobacteriosis. Fortunately, indications for such invasive treatment arc actually very rare. Historically, EPP was performed for active, uncontrolled pulmonary tuberculosis and empyema as an alternative option to thoracoplasty. Actually it is limited to mycobacterial infections carrying severe, irreversible pleuro-pulmonary alterations (sequelae), after sputum negativization. It can also be reserved to active multidrug-resistant tuberculous infections.