Free rectus abdominis musculocutaneous flap for chronic postoperative empyema

Chronic postoperative empyema remains a challenge for thoracic surgeons. Free musculocutaneous flap transplantation may provide a good alternative option in the treatment of these refractory complications after pulmonary resections. Three patients with chronic postoperative empyemas combined with bronchopleural fistulas underwent obliteration of the empyema tracts with free rectus abdominis musculocutaneous flap transplantations. Surgical treatment was a two-stage procedure that consisted of open-window thoracostomy, followed by obliteration of the pleural cavity using a free transfer of the ipsilateral, full-thickness rectus muscle flap and microanastomoses. No postoperative complications occurred, and the 3 patients resumed normal daily activities. Free rectus abdominis musculocutaneous flap transplantation is safe and effective in the management of chronic postoperative empyema with bronchopleural fistula.     

Reconstruction in the axilla with a pedicled pectoralis minor muscle flap

Covering large defects in the axillary fossa can be challenging because of its complex shape. A variety of local skin, fasciocutaneous and musculocutaneous flaps have been described, with a number of inherent advantages and disadvantages. The use of the pectoralis minor muscle as a pedicled transposition flap has been described for immediate reconstruction of the breast, anterior shoulder reconstruction and the treatment of bronchopleural fistula. We now describe the use of a pedicled pectoralis minor muscle flap for soft tissue coverage of the axillary contents after wide excision of the axilla. This has not been previously described.     

Transposition of modified latissimus dorsi musculocutaneous flap in the treatment of persistent bronchopleural fistula after posterolateral incision

The condition of a 51-year-old man was complicated with empyema and bronchopleural fistula (BPF) after left upper lobectomy and thoracoplasty for pulmonary aspergillosis. On the postoperative day (POD) 12, the opened bronchial stump was directly closed and covered with a pedicled pectoralis major muscle flap. On POD 66, an open-window thoracostomy was done, because of empyema with Pseudomonas aeruginosa. Two years later, we could fill the empyema cavity, and close the multiple BPFs with the transposition of a modified pedicled musculocutaneous (MC) flap and the additional thoracoplasty to gain good quality of life. Although the MC flap was a proximal part of the latissimus dorsi muscle, which was dissected along the posterolateral incision of the first operation, it could be successfully transplanted to cover the BPFs in the open-window. In some patients with a small open-window on the upper anterior chest wall, the pedicled proximal latissimus dorsi MC flap may be very useful for treating persistent BPFs even after a standard posterolateral incision.     

Management of postpneumonectomy bronchopleural-cutaneous fistula with a single free flap.

A variety of local flaps have been described for chest wall and bronchopleural fistula reconstruction. When local options cannot be used because of previous surgery, trauma, radiation, or body habitus, free flaps become an acceptable option. The authors report a case of persistent bronchopleural-cutaneous fistula treated with a free latissimus dorsi musculocutaneous flap that obliterated the right chest cavity, closed the site of empyema drainage, and aided healing of a bronchopleural fistula. Surgical technique including anastomosis to the innominate vein is described.     

Use of Pectoralis Skin Pedicle Flap for Closure of Large Bronchial Fistula Connected with Postpneumonectomy Empyema

In 4 patients, the postpneumonectomy empyema was connected with a large bronchopleural fistula. The empyema was in all cases treated by a permanent open window thoracostoma. The fistulae were closed later with pedicle flaps made of the pectoralis muscle and the adjoining skin. In 2 patients the closing of the bronchial fistula was successful, and the treatment of one patient is not completed. In one patient the open pneural cavity was covered completely by skin using an additional pedicle flap and free skin transplantation. The surgical technique of the pedicle flap operation is described and the cases are reported.     

Clinical experience of omental pedicle flap for bronchopleural fistula

We present two patients who underwent the omental pedicle flap method for bronchopleural fistula. The first case was a 61-year-old man who developed empyema with bronchial fistula due to recurrent tuberculosis resisted to chemotherapy. He underwent complete muscle and omental flap closure of empyema space. The second case was a 63-year-old man who underwent pneumonectomy for adenocarcinoma of the lung. About two weeks after the operation, a bronchopleural fistula developed at the bronchial stump. He underwent complete omental flap closure of fistula. They are doing well 18 and 9 months following operation, respectively. The omental pedicle flap method is clinically useful as a closure method for bronchopleural fistula because of excellent blood supply of the omentum.     

Management of empyema cavity with the vacuum-assisted closure device

Management of empyema after pulmonary resection remains a challenging problem. Along with mandatory drainage of the thoracic cavity and investigations to rule out bronchopleural fistula, a reliable method of thoracic cavity closure is needed. The open thoracic window and Eloesser flap techniques rarely represent definitive therapy. Muscle flap and thoracoplasty procedures may provide well-vascularized tissue to close bronchopleural fistula and obliterate the empyema cavity, but they are quite complex and involve significant patient morbidity. We report a case of empyema without bronchopleural fistula after lobectomy in which the vacuum-assisted closure device was used to achieve complete wound healing after open drainage.     

支气管胸膜瘘合并难治性脓胸个体化综合治疗分析

目的总结和分析支气管胸膜瘘合并难治性脓胸个体化综合治疗的方法和疗效。 方法2015年7月—2019年11月共收治支气管胸膜瘘合并难治性脓胸患者12例,其中男性10例,女性2例;年龄23～78岁,平均(60.75±15.05)岁。初始手术为非小细胞肺癌4例,肺部良性疾病4例,包裹性胸腔积液3例,恶性胸腺瘤肺转移1例。胸膜瘘发生后,采取经脓胸引流控制感染和介入封堵瘘口治疗;病情基本稳定后,行肌瓣移植术填塞脓腔等综合措施,并根据病情进行个体化治疗。 结果全组无围手术期死亡病例;在平均17.45个月的随访中,1例患者因肿瘤转移死亡;1例复发小脓腔;其余10例无支气管胸膜瘘和脓胸复发,肌瓣存活,复查胸部CT/MRI显示脓腔被彻底填塞。 结论对支气管胸膜瘘合并难治性脓胸患者采取个体化综合治疗措施,能达到彻底根治的目的,成功率高,疗效显著,值得推广。     

自体腹直肌皮瓣移植治疗慢性难治性脓胸(附4例报告)

目的介绍自体腹直肌皮瓣移植治疗慢性难治性脓胸的新方法。方法2004年11月至2007年3月4例上肺叶切除术后并发支气管胸膜瘘的慢性脓胸病人实行自体皮瓣移植。血供为营养腹直肌皮瓣的腹壁下血管与胸背血管相连。结果术后均无呼吸道并发症，5d内顺利拔管，术后3～6周顺利出院，平均随访10个月，均未发生脓腔复发和皮瓣坏死。结论应用自体腹直肌皮瓣移植可以成功治疗较大胸部残腔的慢性难治性脓胸伴支气管胸膜瘘的病例。     

Closure method of bronchopleural fistula with omental pedicle flap in three cases following pneumonectomy

This report presents that successful closure of bronchopleural fistula was performed by using omental pedicle flap for three postpneumonectomy patients. In our department, these cases were experienced among 142 pneumonectomies from January 1984 to July 1989. The initial operations were a pleuropneumonectomy for empyema, a pneumonectomy and a sleeve pneumonectomy for lung cancer. Our technique was direct closure of bronchopleural fistula with omental pedicle flap without thoracoplasty. Although none of them had recurrence of bronchopleural fistula nor other complications in postoperative course, two patients died of cancer.     

The use of a Dumon stent for the treatment of a bronchopleural fistula

We report the successful management of a bronchopleural fistula with bronchial stent placement combined with irrigation of the empyema cavity. A bronchopleural fistula occurred in a 67-year-old man after a right upper lobectomy for lung cancer. Resuturing of the bronchial stump plus omental wrapping and subsequent closure of the open stump with a pedicled flap of intercostal muscle were not effective. Consequently, we placed a Dumon stent in the right main bronchus to close the stump.     

A new technique for muscle flap closure of the empyema space in complicated chronic bronchopleural fistula

OBJECTIVES: It is difficult to close the empyema space once it is opened, especially in cases complicated with a chronic bronchopleural fistula. A muscle flap closure is generally employed to prevent this situation. However, this operation occasionally fails because the space newly recurs around the fistula due to atrophic change occurring in these translocated muscles. The aim of the present new technique was to prevent inspiratory pressure from the inside of the bronchus by bronchial emboli, and help the adhesion between the fistula stump and the muscle flap, even if they have become atrophic and no longer have sufficient volume to fill the entire empyema space. METHODS: We carried out fiberscopic embolism of causative bronchioles followed by muscle flap closure in 4 patients in whom open drainage had already been performed against parapneumonic empyema within the bronchial fistula. The bronchial fistula was plugged from the inside of the bronchus by silicon material, and stainless steel wire was used to connect this plug tightly to the muscle flaps, so that the fistula was sandwiched between them. In all cases, we succeeded in complete closure of the bronchial fistula and empyema space without using the omentum, and there has been no recurrence. CONCLUSION: The presented new technique was beneficial for achieving muscle flap closure of the empyema space with a chronic bronchopleural fistula.     

Surgical management of children with pyopneumothorax: serratus anterior digitation flap

Spontaneous bronchopleural fistula after childhood empyema remains a surgically challenging condition to treat and is associated with a high morbidity. Four children with pyopneumothorax and associated spontaneous infective bronchopleural fistula are reported. Drainage of the empyema by thoracotomy was performed together with limited decortication and the suturing of a raised digitation of serratus anterior around the fistula to achieve a successful outcome. The surgical technique of raising a serratus anterior digitation flap is described.     

Postpneumonectomy empyema. The role of intrathoracic muscle transposition

Forty-five patients (36 male and nine female) were treated for postpneumonectomy empyema. All were initially managed with the first stage of the Clagett procedure (open pleural drainage). In 28 patients with associated bronchopleural fistula the fistula was closed and reinforced with muscle transposition at the time of open drainage. Seven patients had multiple flaps. The serratus anterior muscle was transposed in 28 patients, latissimus dorsi in 11, pectoralis major in four, pectoralis minor in one, and rectus abdominis in one patient. After the fistula was closed and the pleural cavity was clean, the second stage of the Clagett procedure (obliteration of the pleural cavity with antibiotic solution and closure of the open pleural window) was done. The number of operative procedures ranged from 1 to 19 (median 5.0). Length of hospitalization ranged from 4 to 137 days (median 34.0 days). There were six operative deaths (mortality rate 13.3%), none in the patients who had both stages of the Clagett procedure. Follow-up of the 39 operative survivors ranged from 2.1 to 90.2 months (median 21.8 months). Eighty-four percent of patients in whom the Clagett procedure was completed (26/31) had a healed chest wall with no evidence of recurrent infection. The bronchopleural fistula remained closed in 85.7% of patients (24/28). There were 19 late deaths, none related to postpneumonectomy empyema. We conclude that the Clagett procedure remains safe and effective in the management of postpneumonectomy empyema in the absence of bronchopleural fistula and that intrathoracic muscle transposition to reinforce the bronchial stump is an effective procedure in the control of postpneumonectomy-associated bronchopleural fistula.     

Decortication in chronic thoracic empyemas —A report of three cases—

Three cases of chronic thoracic empyema treated by decortication are reported with special reference to the indications for surgery. The first patient was a 68-year-old man who had right chronic thoracic empyema with a bronchopleural fistula. He underwent open thoracostomy, and decortication was performed after 8 months. The second patient was a 74-year-old man who had right chronic empyema without bronchopleural fistula. Open thoracostomy was also performed and decortication was done after 2 months. Postoperative pulmonary function was significantly improved in both patients. The third patient was a 66-year-old man who had left chronic empyema with a bronchopleural fistula. He underwent open thoracostomy and left lower lobectomy, and then decortication and the omental pedicle flap method were performed after 4 months. All three patients are still doing well currently. It is concluded that decortication significantly improves pulmonary function in properly selected patients, and that computed tomography is helpful for assessing the re-expansion ability of the collapsed lung.     

Treatment of postpneumonectomy empyema and associated bronchopleural fistula. Experience of 100 consecutive postpneumonectomy patients

Experience in the management of 100 consecutive patients with postpneumonectomy empyema is presented. Open-window thoracostomy was used for treatment of the empyema in all cases. The patients were grouped according to surgical procedure after this treatment. In group 1 the thoracostomy window was left permanently open. In group 2 it was closed, and in group 3 the open pleural cavity was covered with skin, using a pedicle of muscle and skin and free skin transplants. The pectoralis skin pedicle was used to close large bronchopleural fistulas. The results in each group are presented and a staged method, which can be used in all cases of postpneumonectomy empyema, with or without bronchopleural fistula, is described.     

A case of post-upper lobectomy empyema treated by serratus anterior muscle and pedicled latissimus dorsi musculocutaneous flaps plombage via open-window thoracostomy.

A 62-year-old male was admitted to our hospital for operation for Aspergillus empyema with a fungus ball in the right upper lobe. We performed a right upper lobectomy and decortication of the middle and lower lobes through a standard posterolateral thoracotomy with dissection of the latissimus dorsi and serratus anterior muscles, in October 2000. Twenty-one days postoperatively (POD), he developed an empyema and a bronchopleural fistula. We performed open-window thoracostomy through the axilla with removal of the third and fourth ribs at 41 POD, and sterilized the open drainage cavity in the out-patient clinic 11 months after discharge. Although the condition of the bronchopleural fistulas was not improved, and methicillin-resistant Staphylococcus aureus (MRSA) was found in the purulent discharge, the discharge decreased. Finally, a pedicled latissimus dorsi musculocutaneous and serratus anterior muscle flap plombage was performed 11 months after initial operation. The patient is now well and works as a driver 21 months after discharge. We conclude that muscle flaps of the pedicled latissimus dorsi and serratus anterior muscles can be useful for plombage of the cavity in cases of post-standard thoracotomy.     

The Association of Vacuum-Assisted Closure Therapy with Dynamic Volume Change of a Muscle Flap Transposed in an Empyema Cavity for Chronic Empyema: A Case Report

A 62-year-old woman with a history of lung resection for lung cancer was admitted to our hospital due to cough, which became progressively more severe. She was diagnosed with chronic empyema with bronchopleural fistula (BPF) of the right upper bronchial stump. Although a pedicled muscle flap was transposed to the empyema cavity, the fistula remained. We used a vacuum-assisted closure system after open-window thoracotomy and observed the cavity reduction with expansion of the transposed muscle flap. We quantitatively evaluated the dynamics of the cavity change using a three-dimensional image analysis system. A reduction of the volume of the muscle flap by prolonged empyema and expansion of the muscle flap was observed immediately after vacuum-assisted management. However, expansion of the right residual lung was not recognized. Pedicled muscle flap transposition followed by vacuum-assisted management after open-window thoracotomy may be effective for treating chronic empyema caused by BPF.     

Transsternal transpericardial closure of a postpneumonectomy bronchial fistula in a patient who underwent pneumonectomy because of a war injury

Most common causes of intrathoracic empyema include pulmonary infections and postoperative bronchopleural fistulas complicating a lung surgical resection, mainly pneumonectomy, as a result of the failure of the bronchial stump to heal. A 22-year-old Serbian patient presented with chronic posttraumatic empyema. Two years before during a war, he experienced chest injury due to a firearm wound, with massive intrathoracic bleeding and need for emergency left pneumonectomy. Empyema with a bronchopleural fistula occurred during the postoperative course. The patient underwent left open window thoracostomy with a daily bandage change. Here we report the treatment of the bronchopleural fistula using sequential surgical approach including transsternal transpericardial closure of the fistula followed by reconstruction of the chest wall with a regional muscle flap. Our case report highlights the feasibility and efficacy of the transsternal surgical approach to treat postpneumonectomy bronchopleural fistula, thereby avoiding the direct approach to the bronchial stump through the infected pneumonectomy cavity.     

A modified pectoralis muscle flap for closure of postpneumonectomy esophagopleural fistula: technique and results

In surgical treatment of late postpneumonectomy esophagopleural fistula, closure of the empyema space is of prime importance. A wide thoracoplasty and ample decapitation of the empyema cavity allow sufficient room for a modified pectoralis muscle flap, which provides sufficient mass to obliterate the entire empyema cavity. We present the cases of 2 patients in whom an esophagopleural fistula occurring 3 and 16 years after pneumonectomy was successfully closed by this method.