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.     

Staged closure of complicated bronchopleural fistulas

Bronchopleural fistulas remain a major complication after thoracic surgery. Despite continued advances in the treatment of this difficult problem, perioperative mortality remains as high as 15%. Multiple treatment strategies have been described with varying degrees of success. Successful treatment of chronic bronchopleural fistulas requires aggressive control of infection, adequate drainage of the chest cavity, closure of the fistula with vascularized tissue, and obliteration of the chest cavity. The authors present their experience with 3 patients who underwent a two-stage closure of their bronchopleural fistulas with pectoralis major muscle flaps followed by omental flap obliteration of the chest cavity. Each patient had previously undergone an Eloesser procedure for chest cavity drainage. The initial muscle flap operation is a small procedure that can be done rapidly with minimal morbidity in chronically ill patients. The intervening period between procedures allows patients to continue aggressive nutritional and physical rehabilitation until they are able to tolerate a second operation for chest cavity obliteration. All bronchopleural fistulas in our series healed, with one minor complication. A staged closure is a safe and effective alternative treatment for chronic and recurrent bronchopleural fistulas.     

The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients

Nineteen patients with bronchopleural fistulas associated with tuberculosis and 2 patients with fistulas following resection for bronchiectasis underwent closure of the fistulas with pedicled flaps of chest wall muscle. The muscle grafting was combined with a limited thoracoplasty in 13 patients. The initial myoplasty produced prompt fistula closure in 15 patients and delayed closure in 2 others. A repeat myoplasty was successful in 2 patients in whom the initial myoplasty failed. Compared with other methods of treating bronchopleural fistulas used during the same period, muscle grafting carried a higher rate of successful fistula closure and a lower mortality rate.     

Pharyngocutaneous fistulas in advanced cancer: closure with musculocutaneous or muscle flaps

Two hundred cases of head and neck cancer were reviewed and 16 pharyngocutaneous fistulas identified, for an incidence of 6 percent. The fistulas were closed with pectoralis major muscle flaps in four patients, pectoralis musculocutaneous flaps in seven patients, sternocleidomastoid muscle flaps in four patients, and latissimus dorsi flaps in two patients. Four types of fistulas were identified, and flap selection was determined by fistula location. Successful closure was obtained in 15 patients (88 percent), although one patient died from recurrence with a persistent fistula.     

Bronchopleural fistula repair using combined breast parenchymal and pectoralis major musculocutaneous flap

A technique is reported for repair of a bronchopleural fistula and obliteration of an empyema cavity using a combined breast parenchymal and expanded, musculocutaneous pectoralis major flap. An empyema after right upper lobectomy and radiation for squamous cell carcinoma developed in a 53-year-old woman. After debridement, a bronchopleural fistula was noted. Her latissimus dorsi muscle was divided during the initial thoracotomy. Local and free flaps were considered. Her breast contained the largest volume of tissue available as she weighed 80 pounds. This report illustrates the use of a tissue-expanded, combined breast and musculocutaneous pectoralis flap in the management of a difficult problem.     

Free deepithelialized anterolateral thigh myocutaneous flaps for chronic intractable empyema with bronchopleural fistula

BACKGROUND: Free deepithelialized anterolateral thigh (DALT) flaps have been used for treatment of chronic intractable empyema with bronchopleural fistula at Chang Gung Memorial Hospital since 1997. METHODS: Twelve patients with chronic empyema were treated at Chang Gung Memorial Hospital from January 1997 to January 2001. Their age ranged from 31 to 70 years (mean age 48.6 years). Left-sided involvement was predominant (left to right ratio = 9:3). All patients had bronchopleural fistula, and all were cured. The average numbers of previous thoracotomy were 5.4. The ipsilateral DALT flaps were harvested with primary closure of donor site. RESULTS: At a mean follow-up of 1 year, no recurrence was noted. All flaps survived well. The average hospital stay was 25.8 days. Complications after reconstruction included chrondritis, partial muscle necrosis, and wound dehiscence (1 patient each). There was no donor site morbidity. CONCLUSIONS: Free DALT flaps can be selected according to different situations during surgery as long as they meet the following requirements: (1) tissue of sufficient volume and good blood supply, and (2) closure of the bronchial leak. Based on this retrospective study, use of free DALT flaps with technical refinement is a reliable method for treatment of chronic intractable empyema combined with bronchopleural fistula.     

Myoplasty for closure of tracheobronchial fistula

Myoplasty techniques are described in which pedicle or free muscle grafting is used in the closure of either acute or chronic bronchopleural fistula. The pectoralis major muscle, the intercostal muscle pedicles, or the free graft is used according to specific indications.     

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.     

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.     

Vascular occlusion device closure of bronchial stump fistulae: a straightforward approach to manage bronchial stump breakdown

Post lung resection surgery bronchopleural fistula (BPF) continues to be a dangerous complication associated with very high mortality and morbidity. Traditional treatments have included primary closure of the fistula with muscle flaps and thoracic window formation. New techniques for secondary stump closure have included glues, stents and coils. We report another bronchoscopic treatment of BPF using an atrial septal closure/vascular occlusion device combined with bioglue.     

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.     

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 sternal wounds with pectoralis major musculocutaneous advancement flaps in patients with a history of chest wall irradiation

Although debridement and pectoralis major musculocutaneous advancement flap closure has proved to be an effective treatment of sternal wounds in the general population, the purpose of this study was to examine the use of these flaps in patients with previously irradiated chest walls. The authors examined 5 patients with a history of breast cancer and chest wall radiation therapy who developed poststernotomy wound complications that were treated with debridement and pectoralis major musculocutaneous advancement flaps. The average patient age was 76 years. Three patients had previously undergone a radical mastectomy and had only 1 pectoralis major muscle remaining. There were no intraoperative deaths. One patient died during the 30-day postoperative period. There were no hematomas, seromas, or dehiscences. One woman developed a postoperative wound infection. Functional and aesthetic results were excellent. This study demonstrates that early, aggressive sternal debridement and closure with pectoralis major musculocutaneous advancement flaps is effective in patients with a history of chest wall irradiation, including those who have had 1 pectoralis major muscle previously resected.     

Two Cases of Single-Stage Closure of a Bronchopleural Fistula Using Latissimus Dorsi Musculocutaneous Flaps after Lung Surgery

Two cases of successful primary closure of a bronchopleural fistula with favorable infection control using latissimus dorsi musculocutaneous flaps are reported. Case 1 was a 70-year-old man who underwent resection of the right lower pulmonary lobe due to right lung metastasis of sigmoid colon cancer. A bronchopleural fistula was found on day 28 after surgery. Infection was controlled by antibiotic administration and tube drainage. Closure of the bronchopleural stump, thoracoplasty and plombage of latissimus dorsi muscles were performed for single-stage closure without open treatment, based on a negative pleural effusion culture. Case 2 was a 64-year-old man who underwent right lower pulmonary lobe resection due to right lung cancer. A bronchopleural fistula was found on day 14 after surgery. In single-stage closure, thoracoplasty and plombage of latissimus dorsi muscles were performed due to infection control and a negative pleural effusion culture. Both cases had a good postoperative course.     

Reconstruction of the infected median sternotomy wound

Infection of a median sternotomy incision may result in a large, unsightly, unstable, and potentially fatal wound. We report on a series of 18 patients who were treated during the past six years with muscle flap closure for this difficult wound problem. We describe the evolution of our current preferred techniques and the results we have achieved with them. Patient risk factors and hospital course are discussed. Before definitive flap closure, all patients were treated with aggressive debridement of the bone and cartilage involved. Our first 4 patients were treated with pectoralis major myocutaneous rotation flaps. Since 1982, our procedure of choice has been to use a rectus abdominis muscle flap covered with either chest skin advancement flaps or, for deeper wounds, bilateral pectoralis major myocutaneous advancement flaps. The current technique makes possible an excellent cosmetic result with no functional deficit, and it lends good stability to the chest wall. We continue to use pectoralis flaps if there is reason to believe the blood supply to the rectus has been compromised.     

Treatment of bronchopleural fistula after pneumonectomy

Breakdown of the closure of the main-stem bronchus after pneumonectomy is a dreaded complication, and empyema and bronchopleural fistula frequently develop in patients who survive. Management of these fistulas remains a formidable therapeutic challenge, which has been approached with a variety of surgical techniques. We report our experience with anterior transpericardial closure, emphasizing the ability to expose either main-stem bronchus by this approach. The case histories of three patients who had bronchopleural fistula after pneumonectomy are presented. The first patient had left pneumonectomy for complicated tuberculosis; the second had right pneumonectomy for neoplasm; and the third had right pneumonectomy for trauma. All fistulas were treated surgically via a median sternotomy and transpericardial approach to the distal trachea. The posterior pericardium was divided between the superior vena cava and aorta. In-continuity staple closure (with two lines of staples) of the proximal main-stem bronchus was employed in all cases. Two patients remain clinically well 21 and 17 months after the operation. The third patients did well initially but developed a recurrent bronchopleural fistula 2 1/2 months after the operation and has required repeat closure with pedicled muscle flaps. In postpneumonectomy bronchopleural fistula, the anterior, transpericardial approach to bronchial closure has several advantages: the relatively well-tolerated median sternotomy, the avoidance of dealing directly with areas of postoperative scarring and the devascularized bronchial stump, the avoidance of areas of chronic sepsis, and the avoidance of thoracoplastic surgical deformity of the chest wall, with possible associated compromise in pulmonary function. Our experience also indicates that either main-stem bronchus is accessible through an approach between the superior vena cava and aorta, without division of either pulmonary artery.     

Pedicled myocutaneous and muscle flaps in the management of complicated cardiothoracic problems.

The purpose of this study was to review our experience with the management of patients with complicated cardiothoracic problems by the use of pedicled myocutaneous or muscle flaps, and discuss the various methods of reconstruction. Over the last 11 years, we have treated 54 patients with complicated cardiothoracic problems by reconstruction with pedicled myocutaneous or muscle flaps. The underlying causes were chest wall tumours (n = 13), radionecrosis of the chest wall (n = 12), deep or chronic sternal infections (n = 25), and bronchopleural fistulas (n = 4). The most commonly used muscles for reconstruction were pectoralis major and the rectus abdominis. Our results compare favourably with those reported elsewhere. We conclude that although the use of pedicled myocutaneous or muscle flaps is not free of complications, it is an effective and reliable method for the management of patients with complicated cardiothoracic problems.     

Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication

The management of postpneumonectomy empyema remains a disturbing and controversial area in the field of thoracic surgery. Many methods have been described and have had varying degrees of success. We present a series of 5 consecutive patients who underwent single-stage complete muscle flap closure of the pneumonectomy space with extrathoracic muscle flaps and omental grafts between October, 1981, and April, 1983. Two men and three women ranging from 37 years to 64 years old underwent such a closure from 3 to 13 months after original resection. Two patients had associated bronchopleural fistula. Prior to closure, 3 patients were managed with chest tubes and 2 with a modified Eloesser procedure. All operations were single-stage procedures, and all wounds closed primarily, with no permanent tubes or chest wall openings. There was no morbidity or mortality, and no subsequent operation has been required. Single-stage complete muscle flap closure of the postpneumonectomy empyema space has not been described previously, and we think it offers a possible solution to this potentially fatal complication.     

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.     

经心包纵隔内关闭支气管残端治疗难治性支气管胸膜瘘

目的总结经心包纵隔内关闭支气管残端治疗难治性支气管胸膜瘘的经验。方法3例难治性支气管胸膜瘘的病人，采用胸骨正中切口经心包纵隔内关闭支气管残端加胸壁开窗引流治疗。结果3例支气管残端均闭合良好，随访至少5个月，无复发。结论该手术方法安全、疗效肯定，操作简单，复发率低，可在临床推广。