A successfully treated case of empyema with a large tracheal fistula after a radical operation of esophageal cancer by fixation and plombage with major pectoral muscle flap]

We reported a successfully treated case of empyema with a large tracheal fistula which had developed after a radical operation of esophageal cancer (reconstructed with stomach). This 59-year-old male was treated by the method of fixation and plombage with major pectoral muscle flap and thoracoplasty, because we could not use the omentum that were frequently used nowadays for closure of the fistula. The size of the tracheal fistula was a large as the main bronchus bronchoscopically. Postoperative care were the following, the endotracheal tube was inserted from the tracheal stoma to the left main bronchus and 9 days left hemi-ventilation was performed. Continuous suction was performed at the same time from the right main bronchus in order to prevent secretion and blood pour into the left lung. Bronchoscopical examination done 28 postoperative day, the small fistula remained the tip of the muscle flap. But 72 postoperative day, the surface of the fixed muscle flap was replaced by normal bronchial mucomembrane and tracheal fistula was obliterated. Major pectoral muscle could be used as local flap to obliterate empyema cavity associated with tracheal fistula. We believe that utilizing an muscle flap for those who had undergone abdominal operation like our case is a valuable method.     

Bronchial flap closure of the lower membranous trachea

A novel method for closure of the lower membranous trachea after right pneumonectomy using a flap derived from the cartilaginous portion of the right main bronchus is described in this study. This technique was used successfully in patients with tracheal stenosis due to a giant posterior mediastinal tumor known as schwannoma. Because of the severe tracheobronchial stenosis and destroyed right lung, tumor resection combined with resection of the lower membranous trachea and right pneumonectomy was carried out. We closed the defect in the membranous lower trachea with the flap derived from the right main bronchus. The clinical course was uneventful.     

Cranioplasty utilizing a preserved autogenous bone flap coated with acrylic resin

Summary Cranioplasty utilizing a resin-coated preserved autogenous skull flap was devised and used in 36 cases, 14 of them being followed up radiologically. It has been confirmed that this method is advantageous in that it repairs the skull defect satisfactorily both from surgical and cosmetic points of view. Furthermore this method causes no anxiety to the patient because of the autogenous origin of the bone flap. We recommend this method for cranioplasty when an autogenous bone flap is preserved.     

Experimental tracheal reconstruction with a rotated right stem bronchus

Background. To reconstruct a longer tracheal defect, a safe method other than end-to-end anastomosis is necessary.

Methods. Nine mongrel dogs underwent right thoracotomy. The lobes of the right lung other than the apical lobe were resected, keeping the bronchi in place to be manipulated to extend the right stem bronchial conduit. The trachea was resected for a 10-cartilage-ring length. The modified right stem bronchus was then brought into the mediastinum by rotation in the frontal plane. An end-to-end anastomosis was made. The right apical lobe, once separated, was then reanastomosed end-to-side. Ciliary transport was studied.

Results. Eight of the 9 dogs tolerated the surgical procedure well, and the reanastomosed right apical lobe remained well expanded for 1 year or more postoperatively. The inverted segment did not show any cranial ciliary transport movement.

Conclusions. A large tracheal defect more than 10 rings in length can be reconstructed using a rotated right stem bronchus with the right apical lobe reanastomosed. The inverted bronchial segment loses its cranial ciliary transport movement.     

The use of omental pedicle flap for tracheobronchial reconstruction in infants and children

For the surgical repair of long-segment tracheal stenosis, costal cartilage graft or extensive resection with end-to-end anastomosis has often been used. Both procedures have a risk of developing anastomotic leakage, which is potentially a lethal complication, or stenosis resulting from compromised blood supply to the tissue at the anastomosis. We have used omental pedicle flap (OPF) to seal the anastomotic line and to restore the vascularity of the graft and the trachea in an attempt to avoid fatal complications. During the period between 1986 and 1990, OPF technique was used in tracheobronchial reconstruction in six patients aged 4 months to 3 years; cartilage graft for extensive tracheal stenosis (4), tracheal resection and anastomosis (1), and bronchial resection and anastomosis (1). The omentum was separated from the colon to form an OPF with the right gastroepiploic vessels preserved. The OPF was brought to the upper trachea in the mediastinum through the retrosternal space. There was no immediate postoperative death due to anastomotic leak. Endotrachial tubes were removed in all patients. Four of the six are totally free of airway problems. One patient showed persistent stridor because of remaining stenosis at the cervical trachea. The remaining one patient who underwent bronchial resection developed anastomotic stenosis probably due to the compression of the floppy left main bronchus by adjacent aorta. The OPF seems to be an important surgical adjunct in order to eliminate fatal complications in tracheobronchial reconstruction.     

Bronchial carcinoid of an accessory tracheal bronchus

We present a rare case of bronchial carcinoid tumor arising in an accessory right tracheal bronchus and involving the associated tracheal lobe in a 48-year-old man, who presented with a history of recurrent respiratory infections and recent onset of hemoptysis. Diagnosis was established on preoperative bronchoscopy and biopsy. The tumor was completely removed by right upper lobectomy with the tracheal bronchus resected flush to its origin from the right lower tracheal wall. Final histology revealed a typical carcinoid tumor.     

Muscle plombage for extensive bronchial necrosis after right lower lobectomy

Bronchial stump necrosis is a lethal complication after pulmonary resection. We report a patient who had extensive necrosis of the intermediate bronchus after right lower lobectomy. The large bronchial defect was successfully fixed with latissimus dorsi muscle and replaced by bronchial epithelialization.     

Airway anomalies in patients with congenital diaphragmatic hernia

PURPOSE: Congenital diaphragmatic hernias (CDH) sometimes are associated with airway anomalies such as congenital stenosis, abnormal branching of the bronchi, and pulmonary hypoplasia. The incidence of these associated airway anomalies has not been reported previously. METHODS: Bronchoscopy was performed in all neonates with CDH from 1987 to 1999. In addition to anatomic anomalies, bronchial hypoplasia was defined as narrowing and shortening of the bronchi at bronchoscopy. RESULTS: Anatomic anomalies were identified in 7 of 39 patients with CDH: 1 had congenital tracheal stenosis with pulmonary artery sling, 1 had a defect of the right upper lobe bronchus, 2 had a tracheal bronchus, and 3 had a trifurcated trachea. Bronchial hypoplasia on the affected side was identified in 15 patients and was seen in all patients with anatomic anomalies of the tracheobronchial tree except the 2 with tracheal bronchus. After excluding 5 patients with severe associated anomalies, 6 of 14 patients with an abnormal tracheobronchial tree died, whereas 1 of 20 patients without airway abnormalities died. CONCLUSIONS: Anatomic anomalies of the tracheobronchial tree and bronchial hypoplasia on the affected side were identified in 17.9% and 38.4% of patients with CDH, respectively. CDH patients who exhibited these abnormalities showed a poor outcome.     

Selective right bronchial intubation using tracheal tubes under fibroscopic guidance]

We have evaluated the technique of right bronchial intubation for selective right pulmonary ventilation using one lumen tracheal tubes as an alternative to double lumen tubes. We studied 20 patients ASA II-III with a relatively preserved pulmonary function who were programmed for left thoracotomy. We used Shiley nr. 9 or Mallinckrodt nr. 11 tubes. After endotracheal intubation the tube was blindly advanced to the main right bronchus. The position of the tube was assessed by auscultation and it was verified and modified, if necessary, by fibroscopic visualization. The tube was advanced in such a way that Murphy's hole of the endotracheal tube remained in front of the exit of the right superior lobar bronchus. In three patients (15%) blinded placement of the tube was appropriate and in 4 patients (20%) fibroscopic replacement of the tube was required. In the remaining 13 patients (65%) placement of the tracheal tube was considered incorrect: tube rotation in 7 cases, upper placement of the Murphy's hole with respect to the origin of the superior lobar bronchus in 4 cases, and excessive distal placement of Murphy's hole with respect to the superior lobar bronchus in 2 patients. Complications related with the incorrect position of the tube were: leaking of gas into the left bronchium in 5 patients (25%), displacement of the tracheal tube into the main left bronchus requiring withdrawal of the tube to the trachea in one case (5%), hypoxemia (saturation of O2 lower than 90%) in spite of ventilation with FiO2 = 1 in two patients, moderate hypercapnia in three cases, and atelectasis of the right superior lobe during the postoperative phase in three patients (15%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Right lower lobectomy with flap bronchoplasty for primary lung cancer

A 59-year-old man was referred to our hospital for further investigation of an abnormal chest shadow. A chest computed tomography( CT) revealed a tumor shadow originating in the superior segment( S6)of the right lower lobe. Bronchoscopy showed no visible tumor, but adenocarcinoma cells were detected in brush cytology samples. We diagnosed primary lung cancer, classified as cT2aN0M0, and planned a radical operation. Intraoperatively, since the tumor had invaded the outer wall of intermediate bronchus, we considered a flap bronchoplasty to preserve the middle lobe. The right lower lobectomy and partial resection of intermediate bronchus were made with preserving unaffected ventral wall of lower bronchus. The lower bronchus remnant was used as a flap to cover the defect in the intermediate bronchus. The postoperative course was uneventful, and bronchoscopic findings revealed good healing of the suture line and sufficient airway patency.     

游离肋骨-前锯肌-皮肤复合组织瓣修复大面积颅骨缺损

目的:探讨吻合血管的游离肋骨-前锯肌-皮肤复合组织瓣修复大面积颅骨缺损的临床应用价值。方法:设计以胸背血管为营养血供的游离肋骨-前锯肌-皮肤复合组织瓣,用以修复大面积颅骨缺损10例。结果:10例患者,组织瓣完全成活9例,坏死1例。随访1～10年,患者术后外观满意,无感染、皮下积液等并发症发生。结论:游离肋骨-前锯肌-皮肤复合组织瓣可以很好地完成大面积颅骨缺损的修复,是一种理想的自体修复材料。     

Median thoracic flap with cartilage for repair of large tracheal defect]

Large defect of the tracheal wall is very difficult to repair without support of cartilage. Two patients with large defect of the tracheal anterior wall (2.5-3.0 x 6.0 cm) were treated successfully. For the patients with much scar in neck a median thoracic flap (3.5 x 4.0 x 7.0 cm) was designed as follow: The flap was elevated, and 3 autocartilage bows (0.5 x 0.4 x 0.4 cm) were implanted into the separated tunnels just beneath the subdermal vascular plexus of the flap. The flap was sutured at the border of tracheal wall defect. The cartilage bows were fixed and covered with a combined cervico-thoracic and cervico-acromial bilobate flap. 13 cadavers showed that 1-2 stem vessels (n = 9) or 4-5 vascular branches (n = 4) developed in the flap.     

双腔支气管导管插管深度对患者侧卧位后导管错位发生率的影响

目的 比较左双腔支气管导管不同的插管深度对患者侧卧位后导管错位发生率的影响.方法 选择全麻胸科手术患者60例,在纤维支气管镜(fibroptic bronchoscopy,FOB)引导下将Robertshaw双腔支气管导管(double-lumen tube,DLT)插入左主支气管,采用随机数字表法调整双腔管的位置将其分为3组:Ⅰ组:患者仰卧,从气管腔侧插入FOB,隆突在正前方清晰可见,调整导管使蓝色支气管套囊上缘正好在隆突下可见(充气后);从左支气管腔插入FOB,可清晰看到左肺上叶支气管开口.Ⅱ组:从气管腔侧插入FOB,将蓝色支气管套囊上缘调整在隆突下恰不可见,即从DLT的左支气管腔插入FOB,使隆突正好位于蓝色支气管套囊上缘与左支气管腔壁上不透光黑线的正中央,可清晰看到左上叶支气管开口;Ⅲ组:从气管腔侧插入FOB,左支气管腔壁上不透光黑线正好在隆突下可见,从左支气管腔插入FOB,可清晰看到左肺上叶支气管开口.结果 仰卧位到侧卧位后,DLT头侧移位Ⅰ、Ⅱ、Ⅲ组各11例、4例、2例,Ⅱ、Ⅲ组明显低于Ⅰ组(P＜0.05),Ⅱ、Ⅲ组间比较差异无统计学意义;DLT尾侧移位的发生组间比较差异无统计学意义;DLT重新调整Ⅰ、Ⅱ、Ⅲ组各11例、5例、4例,Ⅱ、Ⅲ组明显低于Ⅰ组(P＜0.05),Ⅱ、Ⅲ组差异无统计学意义(P＞0.05).结论 隆突正好位于蓝色支气管套囊上缘与左支气管腔壁上不透光黑线的正中央或左支气管腔壁上不透光黑线正好在隆突下可见明显降低患者侧卧位后错位发生率.     

单纯肺组织瓣修补气管缺损的临床应用

目的探讨单纯应用自体肺组织瓣修补气管缺损的临床应用效果。 方法对确诊的6例气管肿瘤患者,其中4例为主气管肿瘤,2例为左主支气管肿瘤,均采用自体肺组织瓣修补气管缺损方法行胸段气管重建术。 结果6例患者呼吸困难均明显缓解,气管缺损处肺组织瓣重建愈合良好,重建气管无明显狭窄及肉芽组织形成。术后随访显示所有患者疗效稳定,其中5例随访至今均健在,最长存活时间达10年;1例患者术后1年失访。 结论自体肺组织瓣修补气管缺损是一种可行的气管重建新方法。     

Single lung ventilation in children using a new paediatric bronchial blocker

As video-assisted thoracoscopic surgery has become more common in paediatric patients, the use of single lung ventilation in children has also increased. Single lung ventilation in young children is performed by either advancing a tracheal tube into the mainstem bronchus opposite the side of surgery or by positioning a bronchial blocker into the mainstem bronchus on the operative side. Techniques for placing a variety of bronchial blockers outside the tracheal tube have been described. We describe a technique for placement of a new bronchial blocker through an indwelling tracheal tube using a multiport adaptor and a fibreoptic bronchoscope.     

The relationship among bronchial blocker cuff inflation volume, proximal airway pressure, and seal of the bronchial blocker cuff.

The resting volume and diameter of the bronchial blocker cuff (defined as inflation of the cuff to just its natural shape) of the Univent (Fuji Systems Corp, Tokyo, Japan) tube are 2 mL and 5 mm. However, much larger inflation volumes may be required to seal an adult mainstem bronchus and the surface area of contact between the resultant spherical or ellipsoid-shaped cuff and the wall of the mainstem bronchus may be small and susceptible to leak with the application of high proximal airway pressures. This experiment determined the relationship among airway diameter, proximal airway pressure, inflation volume of the bronchial blocker cuff, and leakage of air around the bronchial blocker cuff in an in vitro model. The experimental model consisted of silicon tubing of 12.8-, 16.0-, and 19.2-mm ID as the mainstem bronchus. The main tracheal cuff sealed the Univent tube into the proximal end of the mainstem bronchus and the bronchial blocker cuff was inflated with various volumes near the distal end of the mainstem bronchus. The space between the tracheal cuff and the bronchial blocker cuff was then progressively pressurized in either a static or pulsed manner. The very distal end of the bronchus was functionally submerged under a beaker of water so that a bronchial blocker cuff leak would be indicated by bubbling. It was found that the Univent bronchial blocker cuff sealed the 12.8- and 16.0-mm ID mainstem bronchi against airway pressures as great as 100 cmH2O, with inflation volumes that were within the manufacturer's recommendation of 6 to 7 mL.(ABSTRACT TRUNCATED AT 250 WORDS)     

胸脐皮瓣移植修复下肢大面积软组织缺损并骨外露15例

【摘要】〓目的〓介绍胸脐皮瓣游离移植修复小腿软组织缺损的方法和体会。方法〓本组共15例患者,男12例,女3例;年龄20~57岁,平均35岁。受伤原因:交通意外伤10例,压砸伤3例,机器绞伤2例。损伤部位:单纯小腿损伤的11例,合并足部(包括内、外踝)4例。所有的创面均伴有肌腱的损伤、外露或骨缺损、骨外露。皮肤组织缺损面积18 cm×13 cm~28 cm×16 cm。急诊手术3例,择期手术12例。采用游离胸脐皮瓣修复缺损。结果〓术后带蒂胸脐皮瓣全部成活;1例远端皮缘坏死,经换药处理后痊愈。其中创面一期愈合有12例,二期愈合3例。结论〓胸脐皮瓣质好,供皮面积大,有利于治疗大面积缺损的下肢创面。     

Preoperative evaluation of a tracheal bronchus by three-dimensional 64-row multidetector-row computed tomography (MDCT) bronchography and angiography: Report of a case

We performed successful surgery for lung cancer after confirming the anatomical abnormality of a tracheal bronchus by three-dimensional multidetector-row computed tomography (3D-MDCT) bronchography and angiography. Tracheal bronchus is unusual, and right upper lobectomy for lung cancer would rarely be performed in a patient with a tracheal bronchus. Most clinicians are unfamiliar with the anatomy of a right upper lobe that includes a tracheal bronchus. Preoperative 3D imaging of the tracheal bronchus and its related vessels familiarized us with the anatomy of this patient before the operation. Thus, we recommend preoperative 3DMDCT bronchography and angiography, especially for patients with a possible bronchial anomaly.     

Reconsideration of the anatomy of sling left pulmonary artery: the association of one form with bridging bronchus and imperforate anus. Anatomic and diagnostic aspects

In sling (retrotracheal) left pulmonary artery (SLPA), the tracheobronchial pattern is generally considered basically normal. Analysis of dissected specimens and/or bronchograms and other preparations from five studied and 32 reported patients suggests that there are two different forms of SLPA: (1) types 1A and B, with normal TB pattern [with (A) or without (B) a right pre-eparterial (tracheal bronchus)], and the aberrant left pulmonary artery causing TB compression. The tracheal bifurcation in type 1 SLPA is usually demonstrable at the fourth to fifth thoracic vertebral level; (2A) SLPA type 2A, with bridging bronchus (BB), in which condition the right main bronchus supplies the right upper lobe, but the bronchus supplying the right middle and lower lobes (the bridging bronchus) arises from the left main bronchus (LMB), posterior to which the SLPA courses; (2B) SLPA type 2B, with absence of the right bronchial tree, and the right lung (usually hypoplastic) supplied by a BB from the LMB, posterior to which the SLPA courses. SLPA types 2A and B have in common varying degrees of tracheal stenosis with abnormal cartilage rings and absent tracheal pars membranacea, abnormally low tracheal "bifurcation" (pseudocarina) at average level T6, increased bronchial angles with "inverted T" pattern, and lower level of anterior esophageal indentation by the SLPA than SLPA type 1. Imperforate anus occurred in 8/58 (14%) of patients with SLPA types 2A or B, but possibly in none with SLPA type 1. SLPA type 2 is the predominant form of SLPA, with the incidence of type 2B being twice that of type 2A.(ABSTRACT TRUNCATED AT 250 WORDS)