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.     

Closure of a large bronchial fistula with a latissimus dorsi myocutaneous flap

We describe a case of a large bronchial fistula and empyema after right upper lobectomy that was treated successfully with open window thoracostomy followed by a latissimus dorsi myocutaneous flap and limited thoracoplasty. A latissimus dorsi myocutaneous flap can provide immediate airtight closure of a large bronchial fistula, allowing lavage and curettage of the empyema cavity to reduce the chance of postoperative infection. An important aspect of this technique is that the deepithelialized skin side rather than muscle is sutured to an opening of the bronchus. As compared with other techniques, a latissimus dorsi myocutaneous flap is superior in that it requires a single incision and does not require an intraop-erative change of position. In addition, the technique causes little dysfunction of the chest and shoulder and preserves the vascular supply to ensure the viability of the flap even if it was divided in a previous operation.     

Intrathoracic Transposition of a Pectoralis Major and Pectoralis Minor Muscle Flap for Empyema in Patients Previously Subjected to Posterolateral Thoracotomy

The latissimus dorsi muscle flap cannot be used to eliminate an empyema cavity in patients who have previously undergone posterolateral thoracotomy, because of the division of this muscle. Moreover, thoracoplasty alone cannot sufficiently eliminate an empyema cavity that includes the thoracic apex, where space remains between the clavicle and the first rib. Therefore, we constructed a flap from the pectoralis major (P.Ma) and pectoralis minor (P.Mi) muscles to eliminate empyema cavities in five patients who had undergone lobectomy (n = 3) or pneumonectomy (n = 2) via posterolateral thoracotomy from 3 months to 40 years previously. All five patients had bronchopleural fistulae, and because of the previous upper lobectomy or pneumonectomy, they had large empyema cavities including the thoracic apex. Open-drainage thoracotomy was performed due to severe infection, and intrathoracic transposition of the P.Ma and P.Mi muscle flap with simultaneous thoracoplasty was carried out 7–124 weeks (mean 38 weeks) later. The P.Ma and P.Mi muscle flap easily reached the apex space with sufficient obliteration of the empyema cavity. All of the patients remained free of empyema 12–85 months after thoracic closure. The P.Ma and P.Mi muscle flap is useful for eliminating empyema cavities including the thoracic apex in patients who have previously undergone a posterolateral thoracotomy. Received: December 28, 1999 / Accepted: November 20, 2000     

Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy.

OBJECTIVE: Besides other factors, the choice of reconstructive method for full thickness thoracic wall defects depends on the morbidity of preceding surgical procedures. The pedicled latissimus dorsi flap is a reliable and safe option for reconstruction of the thorax. A posterolateral thoracotomy, however, results in division of the muscle. Both parts of the muscle can be employed to close full thickness defects of the chest wall. The proximal part can be pedicled on the thoracodorsal vessels or the serratus branch; the distal part can be pedicled on paravertebral or intercostal perforators. This retrospective study was undertaken to evaluate the reconstructive potential of both parts of the latissimus dorsi in thoracic wall reconstruction after posterolateral thoracotomy. METHODS: Between 1987 and 1999, 36 consecutive patients underwent reconstruction of full-thickness thoracic wall defects with latissimus dorsi-flaps after posterolateral thoracotomies. The defects resulted from infection and open window thoracostomy (n=31), trauma (n=3) and resection of tumours (n=2). The patients' average age was 57 years (range 22-76 years). Twenty-five patients were male, 11 were female. In 31 cases the split latissimus dorsi alone was employed; in five cases additional flaps had to be used due to the size of the defects, additional intrathoracic problems or neighbouring defects. RESULTS: In 34 cases defect closure could be achieved without major complications. Empyema recurred in the pleural cavity in one case and one patient died of septicaemia. The 15 patients who had required a respirator in the preoperative phase could be extubated 4.8 days (average) after thoracic wall reconstruction. Postoperative hospital stay averaged 16 days. CONCLUSIONS: Different methods are available for reconstruction of full thickness defects of the thoracic wall. After posterolateral thoracotomy in the surgical treatment of empyema, oncologic surgery and traumatology, the latissimus dorsi muscle still retains some reconstructive potential. Advantages are low additional donor site morbidity and anatomical reliability. As it is located near the site of the defect, there is no need for additional surgical sites or intraoperative repositioning. In our service, the split latissimus dorsi muscle flap has proven to be a valuable and reliable option in thoracic wall reconstruction.     

应用背阔肌与胸大肌联合肌瓣及假体置入即刻乳房再造

目的探讨经乳房外侧弧形切口皮下乳腺切除术后,带蒂转移背阔肌肌瓣,与胸大肌肌瓣形成联合肌瓣覆盖乳房假体,进行即刻乳房再造术的治疗效果。方法选择临床分期为Ⅰ期或Ⅱ期．肿瘤未侵及皮肤和胸肌的乳腺癌患者共30例,经乳房外侧弧形切口皮下切除乳腺腺体并清扫腋窝淋巴结,利用同一切口,切取背阔肌肌瓣带蒂转移,分离胸大肌下间隙,切断胸大肌下缘与胸壁附着处直至胸骨边缘,将转移的背阔肌肌瓣与胸大肌断缘缝合,组成联合肌瓣,形成宽大的包裹假体的腔隙．置入假体。结果30例再造乳房外形及手感良好,其中优22例（73．3％）,良8例（26．7％）。术后所有患者均随访半年以上,均无瘤生存。结论再造乳房形态美观,能够置入较大的假体,不增加背部的切口,适合于无淋巴结转移、对侧乳房无明显下垂的早期青年乳腺癌患者的即刻乳房再造。     

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.     

Chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae treated by open window thoracostomy followed by thoracoplasty and latissimus dorsi muscle transposition

We describe a case of chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae successfully treated by open window thoracostomy followed by thoracoplasty and transposition of the latissimus dorsi muscle. A 69-year old man with a history of artificial pneumothorax for pulmonary tuberculosis was referred to our hospital with fever and purulent bloody sputum. He was diagnosed as having right chronic tuberculous empyema with bronchopleural fistulae. Immediate tube thoracostomy markedly relieved symptoms except for low-grade fever. Sputum and empyema cavity cultures were repeatedly positive for MRSA. Open window thoracostomy (5th to 7th ribs resection) was performed to control the infection. The empyema cavity was cleaned with no residual calcified pleura. His condition gradually improved and he underwent thoracoplasty and transposition of the latissimus dorsi muscle 22 months after the initial surgery. He was discharged 25 days postoperatively in good condition. Seventeen months after the curative surgery, he remains well with no evidence of recurrence. A two-stage operation, open window thoracostomy to control infection followed by thoracoplasty and transposition of the latissimus dorsi muscle, is useful in cases of chronic tuberculous MRSA empyema with bronchopleural fistulae.     

Muscular flaps and reconstructive surgery of empyema: about 12 cases

SUBJECT: The chronic empyema is a dreadfull outcome of pulmonary resection. Its management is difficult: a thoracostomy or a thoracoplasty by resection of rib segments are rarely efficient. A large debridement associated with a muscular flap is helpfull in the treatment of these cavities. These flaps allow the filling of these pleural spaces and the treatment of the bronchopleural fistulae which are constant and responsible of the perenniality of such infection. PATIENTS AND METHODS: From June 1997 to December 2006, 12 patients, aged from 25 to 45 years old, were treated for chronic empyema following total pulmonary resection by using muscular flaps. The causes were: post-tuberculosis pulmonary deterioration in 8 cases, bronchic cancer in 3 cases, post-traumatic tracheobronchic breaking in 1 case. An open window thoracostomy was performed for all the patients and with a follow-up of 2 years, there was no healing of this infection. In our procedure, the patients underwent in the same time a large thoracoplasty that involved 3 to 5 rib segments (10 cm in length) to reduce the pleural space and a myoplasty. The muscular flaps used were pedicled in 8 cases: a latissimus dorsi in 6 cases, a latissimus dorsi with an anterior serratus in 2 case, and were free in 4 cases: a latissimus dorsi in 3 cases, a latissimus dorsi with an anterior serratus in 1 case. These flaps were sufficient to fill the cavities and were applied and stitched around the fistulae. RESULTS: There was no complication during or after the operations with a mean follow-up of 3 years. These chronic empyema were completely healed in all cases without recurrence of the suppuration or the bronchopleural fistulae. CONCLUSION: The one-stage thoracomyoplasty including the resection of rib segments and local or regional muscular flaps is a very efficient treatment of the chronic pleural empyemas. It is very important, for an easy treatment of such cavities, to teach the thoracic surgeons the great interest of preserving the local muscular flap during the initial thoracotomy.     

A treatment protocol for chronic post-pneumonectomy empyema associated with bronchopleural fistula: A single-centre retrospective study

Chronic post-pneumonectomy empyema (CPPE) associated with bronchopleural fistula (BPF) is a potentially fatal complication and remains a surgical challenge. This study aims to propose a treatment protocol for managing this severe disease. From July 2009 to June 2021, 47 CPPE with BPF patients were treated in our department. CT scan with 3D reconstruction was used to detect BPF and to evaluate the location and volume of empyema cavity. Different surgical techniques were used to close BPFs according to they sizes. Multiple pedicled muscle flaps were chosen to fill the empyema cavity, and among them, latissimus dorsi (LD) was the mostly used flap. For cases that regional flaps were not suitable, free flaps were used. Patients were followed-up from 7.9 to 102.8 months. Forty-four patients (93.6%) healed after the operation. Closure of BPFs failed in three patients (6.4%), leading to regional infection. These patients were treated by bronchoscopic application of sealants, continuous drainage and antibiotics, and they eventually healed. Total or partial flap loss was not seen in any of the cases. Treatment protocol was proposed based on these results. CT scan with 3D reconstruction is an effective examination to evaluate pleural cavity defect and BPF. Proper technique to close the BPF and right choice of flap to fulfil the empyema cavity are the two most important key points to treat CPPE associated with BPF patients.     

Intrathoracic transplantation of musculocutaneous flap for chronic empyema

We have used the musculocutaneous (MC) flap to treat 4 patients with chronic empyema secondary to pulmonary tuberculosis. Subjects were 4 male patients aged 72.8 in average. The period of illness was 10 months at the shortest and 15 years at the longest. All of the patients had been introduced to our department after open drainage thoracostomy. Two patients had been performed intrathoracic transplantation of the pedicled omentum flaps, however infection had been recurred and one patient had been carried out abdominal surgery, thus in whom the omentum flap couldn't be used. Intrathoracic transplantation of two latissimus dorsi musculocutaneous flaps and two rectus abdominis musculocutaneous flaps were carried out. After the radical operations, their refractory infected empyemas were completely healed. The MC flap was shown to be useful as a radical operation for severe chronic empyema, especially for the case in which the omentum flap can't be used.     

Harvest technique for pedicled transposition of latissimus dorsi muscle: an old trade revisited

Transposition of extrathoracic muscle flaps has been the cornerstone of treatment of a number of complex intrathoracic pathologies such as bronchopleural fistulas and residual infected pleural spaces. We present a simple step-wise technique for preservation and harvesting of the most common muscle flap employed by thoracic surgeons, namely latissimus dorsi, just prior to performing a standard posterolateral thoracotomy. Since 2004, we have successfully utilized pedicled latissimus muscle as our preferred prophylactic flap against development of postoperative bronchopleural fistulas or recurrent empyemas. This technique should be part of every thoracic surgeon's surgical armamentarium.     

Reconstruction of upper extremity large soft-tissue defects using pedicled latissimus dorsi muscle flaps--technique illustration and clinical outcomes

SUMMARY: Reconstruction of large soft-tissue defects of an upper extremity is very challenging due to the unavailability of expendable local muscle. Appropriate soft-tissue restoration is an essential component of such reconstruction treatment protocols, and often requires a vascularised flap to protect the exposed neurovascular and musculotendinous structures. The latissimus dorsi muscle makes an ideal pedicled flap because of its long neurovascular pedicle, large size, ease of mobilisation and expendability. Moreover, the flap provides well-vascularised tissue from a region far from the area of injury. This paper describes the technique for pedicle latissimus dorsi flap transfer and also reports the authors' experience of its application for the acute treatment of massive upper-extremity soft-tissue injuries. 20 patients with large soft-tissue defects over the upper extremity caused by trauma and infection underwent aggressive debridements and immediate soft-tissue reconstruction using a pedicled latissimus dorsi muscle flap. Successful reconstructions were achieved and primary healing of wounds occurred in all patients, with minor complications. The donor site morbidity was minimal. At a mean of 3.6 years' follow-up (range: 1.5-6 years), all functional results were good and the patients were satisfied with their outcomes.     

Transaxillary latissimus dorsi flap reconstruction in head and neck cancer. Limitations and refinements in 56 cases

The transaxillary latissimus dorsi musculocutaneous flap is suitable whenever a large volume of tissue is required for head and neck reconstruction. Fifty-six transaxillary latissimus dorsi musculocutaneous flap reconstructions were performed in 55 patients. There were two cases of complete flap necrosis and eight cases of partial flap necrosis. The latissimus dorsi vascular pedicle is separate from the irradiated field. The pedicled latissimus dorsi flap provides coverage of the orbitocranium, including the supraorbital region and central portion of the upper face. In the event that the pedicled latissimus dorsi flap does not reach far enough cephalad, the nutrient vessels may be separated from the axillary artery and anastomosed to vessels in the neck. Combined defects of the esophagus, mandibulofacial region, and neck may be reconstructed with a single large latissimus dorsi flap. Hairless skin particularly suitable for oral cavity reconstruction is usually available. Aesthetic and functional deficits are minimal after latissimus dorsi reconstruction. Disadvantages of this technique include repositioning of the patient, increased blood loss, and longer operating time. Permanent brachial plexus injury may occur. The latissimus dorsi musculocutaneous flap should not be used when defects can be reconstructed by simpler methods.     

Conjoint muscle free flap for obliteration of an upper thoracic empyema cavity

Successful obliteration of an empyema cavity with vascularized flaps can, on occasion, best be accomplished using a free tissue transfer. A conjoint free muscle flap captures the immunological attributes of muscle necessary in the infectious milieu of these defects, augments the potential flap volume required to fill these often large defects, yet relies on only a single recipient site for the requisite microanastomoses. These advantages are demonstrated by a case using a combined latissimus dorsi/serratus anterior conjoint muscle free flap to obliterate a chronic upper thoracic empyema cavity. The internal mammary vessels were the most readily accessible recipient site, and should be considered an important alternative when managing these challenging wounds of the upper chest.     

Latissimus dorsi pedicled flap for upper extremity soft-tissue reconstruction

The latissimus dorsi often is used as a functional muscle transfer to restore elbow and shoulder motion. Although less common, its use as a pedicled muscle flap with a split-thickness skin graft provides excellent soft-tissue coverage of large upper extremity wounds. Seven male patients ranging in age from 6-71 years were treated with a pedicled latissimus dorsi muscle flap and split-thickness skin graft for coverage of open wounds of the shoulder, arm, or elbow with exposed vital structures (mean wound size: 15x10 cm). The flap also was used as a functional muscle transfer in one patient to replace destroyed anterior and middle portions of the deltoid. Wounds resulted from trauma in three patients, infection following trauma in two, and sarcoma excision in two. All flaps healed well, and donor site morbidity was minimal. At mean 16-month follow-up (range: 3-41 months), all muscle flaps had contoured well, producing satisfactory cosmesis. Functional results were good, and all patients were satisfied with their outcome. The tendinous insertion is left intact to guard against excessive traction on the pedicle when the flap is used for soft-tissue coverage only.     

Management of postpneumonectomy Aspergillus empyema extending into the thoracic wall: a plea for radical surgery and caution when using liposomal amphotericin B

Semi-invasive aspergillosis is a rare disease leading to severe complications even in fully immunocompetent patients. The therapeutic role of systemic and intrapleural antifungal agents remains not well known. We report herein the case of a 54-year-old woman who developed Aspergillus empyema invading the thoracic wall and subcutaneous tissues after completion pneumonectomy for aspergilloma. She initially was treated conservatively with systemic and intrapleural amphotericin B without any success and developed a severe anaphylactic reaction to intravenous liposomal amphotericin B (Ambisome). She then underwent an open-window thoracotomy with intrathoracic transposition of a latissimus dorsi muscle flap and was started on itraconazole therapy. The thoracostomy was closed after 6 months and the patient is doing well without any signs of recurrent infection after 3 years.     

Paraffin Plombage of the Chest Revisited

Complications related to previous thoracic plombage procedures are not uncommon. The management of these complications can be challenging. We present a patient who had a partial resection of the left upper lobe, a seven-rib thoracoplasty, and paraffin wax plombage 38 years previously, in whom a chest wall mass and a discharging sinus developed. She underwent excision and debridement of the paraffin wax mass followed by serratus anterior and latissimus dorsi pedicled muscle intrathoracic transposition. Follow-up at 2 years revealed excellent cosmetic and functional results.     

机器人和腔镜背阔肌乳房重建关键技术

机器人和腔镜背阔肌乳房重建是目前乳房重建的重要手术方式,包括背部供区“无痕化”背阔肌乳房重建、“皮岛式”背阔肌乳房重建。其特点为：腋窝无切口,仅做3个trocar孔,在微创视野下通过皮下隧道完成背阔肌皮瓣切取或转移,随后3个trocar孔可用于术后引流,不增加额外切口;背部供区不遗留瘢痕;微创视野下获取背阔肌肌瓣整个过程不需要拉钩。机器人和腔镜辅助背阔肌乳房重建优势为切口隐蔽、创伤小,美容效果好,是一种安全、可行的手术。     

背阔肌双极移位重建产瘫儿童屈肘肌功能

目的：介绍和评价背阔肌双极移位重建臂丛神经产伤后屈肘肌功能障碍的手术方法和结果。方法：从1992年6月-2002年6月，本科共收治分娩性臂丛神经损伤病人36例，其中采取背阔肌双极移位治疗臂丛神经产伤后屈肘肌功能障碍10例，男4例，女6例，手术时平均年龄为7(5—12)岁，2例息儿在术后1年因肩关节连枷而行肩关节固定术。结果：本组10例病人术后平均随访3(1．5—6)年，肘关节屈曲肌力达到4级以上，手触嘴的功能均恢复，无神经血管束损伤等手术并发症。结论：臂丛神经产伤引起的屈肘肌功能障碍严重影响患儿的生活和学习能力，需要手术治疗。本组选择的背阔肌双极移位，具有操作相对简便、符合生物力学、并发症少和结果确实的优点，因此是一种值得推荐的手术方法。     

Reconstruction of the upper extremity with a compound rib-latissimus dorsi osteomusculocutaneous flap.

The reliability and versatility of the pedicled latissimus dorsi muscle or osteomusculocutaneous flap make it our first choice in the management of upper arm injuries and we have treated three such patients in this way. They had severe skeletonising, crushing injuries of an upper extremity with humeral defects that were treated with latissimus dorsi musculocutaneous flaps and segments taken from the ribs. All the flaps survived completely with no injury of the pleura at the donor site. The reconstructed humerus was strong enough for the patients to participate in all activities of daily living. We think that this technique is suitable for the upper arm defects with humeral loss because of its simplicity and minimal morbidity.