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.     

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.     

腓肠神经营养血管远端蒂肌皮瓣治疗慢性跟骨骨髓炎

目的探讨应用腓肠神经营养血管远端蒂肌皮瓣治疗慢性跟骨骨髓炎的方法。方法2002年1月-2005年10月治疗7例跟骨骨折所致慢性跟骨骨髓炎,其中男4例,女3例;年龄15-68岁。均为跟骨开放性骨折或跟骨闭合性骨折切开复位内固定或植骨致切口感染、跟骨外露,骨髓炎发生,病程3-12个月。手术彻底清创后采用腓肠神经营养血管远端蒂肌皮瓣移位治疗,肌皮瓣范围为8cm×4cm-12cm×7cm,其中肌瓣范围为4cm×3cm-6cm×5cm。供区直接缝合5例,植皮覆盖2例。结果术后移位肌皮瓣完全成活,切口期愈合。7例均获2-6个月随访,皮瓣质地,外形良好。骨髓炎未见复发,无并发症发生,所有患者均恢复正常行走。结论腓肠神经营养血管远端蒂肌皮瓣治疗慢性跟骨骨髓炎是完全可行的,给跟骨骨髓炎的治疗带来了一种新方法。     

Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis

OBJECTIVE: Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach. METHODS: Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies). RESULTS: Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups. CONCLUSION: We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.     

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。     

Variations in perforators of anterolateral thigh flap

In our study of anterolateral thigh flaps, ten patients had musculocutaneous perforators (58%), four patients had septocutaneous perforators (24%), and three patients had both types of perforators (18%). Average number of perforators found in each flap was 1.9 (range 1–4). The maximum number of perforators in a single case was four. A single perforator was found in seven patients. In patients with both types of perforators, larger flaps could be harvested and there were no complications. The study was carried out over a period of 3 years and included 17 patients treated with free anterolateral thigh flaps in our hospital from April 2004 to August 2007. All age groups and both sexes were included in the study. A cadaveric study was done on ten fresh cadavers in the anatomy department of the same hospital. Although the majority of free anterolateral thigh free flaps are based on musculocutaneous perforators and fewer flaps are based on septocutaneous perforators, our study shows that this versatile free flap can be based on a combination of both septocutaneous and musculocutaneous perforators. Though our cadaveric study did not show any flap to be based on the combination of both types of perforators, our clinical study in which we had three cases of this type definitely shows that the ALT flap can be based on a combination of both septocutaneous and musculocutaneous perforators. Further in these cases with both types of perforators, larger flaps could be harvested and with greater flap success.     

应用中下腹横形腹直肌皮瓣修复胸壁慢性放射性溃疡

目的 探讨乳癌根治术后胸部慢性放射性溃疡的特点及防治特点.方法 对胸部放射溃疡并肋骨、肋软骨或胸骨外露的患者,采用中下腹部横形腹直肌肌皮瓣(TRAM)修复12例,其中单腹直肌蒂6例,单腹直肌蒂附加血管吻合双蒂皮瓣6例.结果 皮瓣全部成活,皮瓣和创缘均一期愈合.随访1～4年,皮瓣色泽、质地、弹性良好.周边瘢痕性组织血运得以改善.结论 TRAM皮瓣是修复胸壁放射性溃疡的理想选择,必要时可附加血管吻合形成双蒂皮瓣.     

手部深层组织严重感染的治疗

目的：探讨手部深层组织严重感染的治疗方法。方法：对378例手部深层组织严重感染患者，术前创面严格抗感染治疗，术中创面彻底清创，在清洁创面上覆盖血运丰富的游离肌皮瓣。术后创面用敏感抗生素溶液冲洗治疗。结果：378块肌皮瓣中，337块全部存活，一次手术治愈率为89．1％；另41例皮瓣远端部分坏死，第2次清创后用局部皮瓣修复。结论：手部深层组织严重感染者，在彻底清创的基础上用吻合血管的肌皮瓣移植，是一种有效的治疗方法。     

经胸骨正中手术切口感染创面的修复

目的对比观察不同方法修复经胸骨正中手术切口感染创面的治疗效果。方法1997年12月～2006年12月,分别用胸大肌内侧头肌瓣、胸大肌瓣、上蒂腹直肌瓣及大网膜移位修复经胸骨手术切口感染创面13例。男8例,女5例;年龄28～72岁,平均52岁。合并糖尿病8例,肺炎及心力衰竭4例,脓胸3例,慢性肺功能不全4例,恶性肿瘤1例,严重肥胖6例。11例为较新鲜裂开创面,2例为慢性创面。创面范围10cm×5cm～22cm×10cm。结果3例分别于术后3d因血管吻合处破裂大出血、肺炎及癌转移死亡。其余10例伤口期愈合6例,随访6个月～5年,均无复发;2例切口皮肤拉拢缝合处部分皮肤坏死,经再次手术扩创植皮后愈合;2例创口引流处感染,经换药愈合。结论创面较小且位于手术切口上端者适合用胸大肌内侧头肌瓣修复;创面较大且位于切口上端者适合用全胸大肌瓣修复;创面较小且位于切口下端的适合用上蒂腹直肌瓣修复;创面较长可联合应用胸大肌瓣、上蒂腹直肌瓣修复创面;创面巨大合并重要脏器外露时,可用大网膜移位修复创面。残余创面可经植皮及换药愈合。     

轴型皮瓣,肌皮瓣修复四肢复杂性软组织缺损的临床应用

目的：报告轴型皮瓣、肌皮瓣修复四肢复杂性软组织缺损的临床疗效。方法：应用２４种皮瓣、肌皮瓣及骨皮瓣，其中躯干部５种４５块，下肢１０种７０块，上肢９种４３块，通过游离移植或带蒂转位的方法，修复四肢因严重创伤所致的软组织缺损、肌腱及骨质缺损或外露。结果：移植的组织共１５８块，其中成活１５２块，坏死６块，成活率９６．２％。经３个月～４年（平均２０个月）的随访，皮瓣成活良好，所有修复的肢体均保留和恢复了功能。结论：利用轴型皮瓣、肌皮瓣修复四肢复杂性软组织缺损疗程短、疗效好，能取得良好的临床效果。     

应用下腹部横形腹直肌肌皮瓣再造乳房

应用下腹部横形腹直肌肌皮瓣进行４例乳房再造，其中２例为皮瓣带蒂转移，于乳癌根治切除术后即刻完成乳房再造；２例为血管吻合肌皮瓣游离移植，分别于根治术后２个月和５年进行乳房再造。术后游离皮瓣完全成活，带蒂皮瓣分别于术后２￣３周出现脂肪液化，经换药痊愈。４例乳房外形基本满意。随访１０个月￣１８个月，２例游离移植未见异常，１例带蒂转移二术后１年出现腹壁薄弱膨隆，另１例失访。     

Foot and ankle reconstruction: An experience on the use of 14 different flaps in 226 cases

The aim of this report was to present our experience on the use of different flaps for soft tissue reconstruction of the foot and ankle. From 2007 to 2012, the soft tissue defects of traumatic injuries of the foot and ankle were reconstructed using 14 different flaps in 226 cases (162 male and 64 female). There were 62 pedicled flaps and 164 free flaps used in reconstruction. The pedicled flaps included sural flap, saphenous flap, dorsal pedal neurocutaneous flap, pedicled peroneal artery perforator flap, pedicled tibial artery perforator flap, and medial plantar flap. The free flaps were latissimus musculocutaneous flap, anterolateral thigh musculocutaneous flap, groin flap, lateral arm flap, anterolateral thigh perforator flap, peroneal artery perforator flap, thoracdorsal artery perforator flap, medial arm perforator flap. The sensory nerve coaptation was not performed for all of flaps. One hundred and ninety‐four cases were combined with open fractures. One hundred and sixty‐two cases had tendon. Among 164 free flaps, 8 flaps were completely lost, in which the defects were managed by the secondary procedures. Among the 57 flaps for plantar foot coverage (25 pedicled flaps and 32 free flaps), ulcers were developed in 5 pedicled flaps and 6 free flaps after weight bearing, and infection was found in 14 flaps. The donor site complications were seen in 3 cases with the free anterolateral thigh perforator flap transfer. All of limbs were preserved and the patients regained walking and daily activities. All of patients except for one regained protective sensation from 3 to 12 months postoperatively. Our experience showed that the sural flap and saphenous flap could be good options for the coverage of the defects at malleolus, dorsal hindfoot and midfoot. Plantar foot, forefoot and large size defects could be reconstructed with free anterolateral thigh perforator flap. For the infected wounds with dead spce, the free latissimus dorsi musculocutaneous flap remained to be the optimal choice. © 2013 Wiley Periodicals, Inc. Microsurgery 33:600–604, 2013.     

Surgical treatment of chronic empyema

Empyema remains challenging for thoracic surgeons. This review covers diverse aspects of acute empyema and chronic empyema and its surgical treatment. The triphasic nature of thoracic empyema (stages I, II, and III) is also addressed. The principles of empyema treatment are early diagnosis and early treatment. For acute empyema (empyema in stages I and II), early surgical intervention, such as video-assisted thoracoscopic débridement, is recommended when conventional chest tube drainage has failed. Radical treatments of chronic empyema (empyema in stage III) include (1) removal of the empyema space (decortication with or without lung resection) and (2) obliteration of the pleural space with muscle flaps or omentum flaps, or by thoracoplasty. Decortication is the procedure of choice for patients with reexpandable underlying lung. When bronchopleural fistula exists in the underlying lung, the fistula should be securely closed. For those patients whose underlying lung cannot be expected to reexpand, the procedure of choice is either concomitant removal of the affected lung with the empyema space or obliteration of the pleural space. For patients who are not eligible for the above-mentioned radical treatment, open-window thoracostomy can be considered. This procedure is not only performed as a definitive treatment of empyema but also as a preparatory treatment for radical procedures. Radical procedures are performed when patients recuperate. Choosing the most suitable operation based on the stages of empyema, the conditions of the underlying lung, and the conditions of a patient holds the key to success.     

Anatomic study and clinical application of distally-based neuro-myocutaneous compound flaps in the leg

OBJECTIVE: Anatomical study on the anastomosis between the neurovascular axis and the musculocutaneous perforators in leg. The distally-based neuron-myocutaneous flap was used for repairing special patients with soft tissue defect in foot and ankle. METHODS: Systematical observation was carried out on 30 injected lower legs about the anastomosis between the neurovascular axis and the musculocutaneous perforators, and we summarized the clinical experiences from February 2004 on 12 cases using distally-based neuron-myocutaneous flap for repairing special patients with soft tissue defect in foot and ankle. RESULTS: The neuron-vessels of sural nerve anastomosed permanently with the musculocutaneous perforators of medial and lateral head of gastrocnemius. There were two to three anastomoses found, respectively. The medial anastomotic branches were found larger in caliber than the lateral ones. The spatium intermuscular branches of the posterior tibial artery gave off their junior branches and anastomosed with the vessels in or out of the soleus muscle. There were two to three muscular branches perforated out of the soleus muscle, with mean caliber 0.5 +/- 0.2 mm and accompanying with one to two veins. The neuron-vessels of the superficial fibular nerve gave off alone its course two to three muscular branches to the long extensor muscle digits and the long fibular muscle, and one to two fasciocutaneous to the skin. The diameter of the muscular branches was 0.4 +/- 0.2 mm in average. Accounting for the operating models in the 12 cases, we had distally-based sural neuron-myocutaneous flap in 7 cases, saphenous neuron-myocutaneous flap in 4 cases, and superficial fibular neuron-myocutaneous flap in 1 case. All these cases were followed up at least for 2-6 months and had the significant results of nice limb's shape and cured osteomyelitis. CONCLUSION: Distally-based neuro-myocutaneous flap in leg can live with reliable blood circulation. These flaps offer excellent donor sites for repairing special the soft tissue defect in foot and ankle.     

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.     

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.     

Utility of the free deep inferior epigastric perforator flap in chest wall reconstruction

Breast cancer chest wall recurrence is often treated with chemotherapy, radical surgery, and radiation. Extensive chest wall resection requires soft-tissue reconstruction with tissue that provides chest wall stability and durability for additional radiation. Local and regional muscle and musculocutaneous flaps are often used for reconstruction. Free flaps, such as the transverse rectus abdominis musculocutaneous flap, are used for large defects, although donor site morbidity can result. The free deep inferior epigastric perforator (DIEP) flap provides coverage for large defects and may have less donor site morbidity. We describe the use of the free DIEP flap to reconstruct large chest wall defects (mean, 501 cm2 defects) after the resection of recurrent breast cancer in two patients. One patient had 2% flap loss. No donor site morbidity occurred. The free DIEP flap is a durable and reliable flap that provided immediate and complete coverage of these large chest wall defects with no donor site morbidity and did not delay the administration of adjuvant therapy.     

One-stage pedicled omentum majus transplantation into thoracic cavity for treatment of chronic persistent empyema with or without bronchopleural fistula

Objective: Assessment of the present results of surgical treatment for chronic persistent empyema with or without bronchopleural fistula (BPF) using one-stage pedicled omentum majus transplantation into the thoracic cavity. Methods: From November 1979 to December 1996, 50 patients with chronic persistent empyema were treated by pedicled omentum majus transplanted into the thoracic cavity. There were 35 men and 15 women, and the age range was 15–58 years. Empyema had been present for 0.5–18 years. Twenty-six of 35 cases with chronic tuberculous empyema and six of 15 cases with chronic bacterial empyema suffered from concomitant BPF (n=32). In the latter, the most common organisms were Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli. Results: There were no perioperative deaths. Two cases had a significant air leak on the first postoperative day. One of them underwent rethoractomy 30 h after the initial operation to stop the fistula using intrathoracic omentum. Thoracic dead space disappeared in most of the operated cases and a sterilized dry cavity remained in some cases. Conclusions: One-stage pedicled omentum majus transposition is a safe and easy procedure for chronic persistent empyema and BPF, it breaks down residual or recurrent inflammatory foci mechanically and closes the BPF effectively with minimal deformity of the chest wall.     

应用腹直肌前鞘-腹外斜肌腱膜瓣修复先天性膀胱外翻

目的总结先天性膀胱外翻的修复,探讨腹直肌前鞘—腹外斜肌腱膜瓣及肌蒂阔筋膜张肌肌皮瓣在修复膀胱外翻中的应用。方法应用腹直肌前鞘—腹外斜肌腱膜形成的前鞘—腱膜瓣加局部皮瓣或同侧肌蒂阔筋膜张肌肌皮瓣修复先天性膀胱外翻及腹壁缺损,局部皮瓣修复尿道上裂,肌皮瓣的应用面积最大为10cm×8cm。结果临床应用12例,膀胱外翻及腹壁的修复均达到了良好效果,膀胱括约肌功能基本恢复,二次尿道紧缩后12例均能控制排尿。肌蒂阔筋膜张肌肌皮瓣部分坏死2例,游离植皮后痊愈。结论选择性地应用腹直肌前鞘及腹外斜肌腱膜形成前鞘—腱膜瓣加强腹壁,局部皮瓣转移或应用同侧肌蒂阔筋膜张肌肌皮瓣转移修复腹壁缺损能有效地修复先天性膀胱外翻,恢复膀胱颈部括约肌的连续性及尿道紧缩,能达到自主控制排尿的目的。     

The use of omental pedicle flap for treatment in the field of thoracic surgery

We present a series of 16 consecutive patients who underwent the omental pedicle flap method in the field of thoracic surgery. Fourteen of 16 patients were chronic empyema with bronchopleural fistulae and/or thoracic fistulae. A pedicle of omentum containing the right gastroepiploic artery was passed through a tunnel in the anterior diaphragm into the empyema cavity. It was fixed by mono-filament sutures on the bronchopleural fistulae. All but two patients were cured successfully by single-stage procedures. We also used a omental pedicle flap for mediastinal infection and reconstruction of the chest wall. We conclude that the use of omental pedicle flap is a promising method for treatment of serious infection in the field of thoracic surgery.