Case Study
Use of previously divided latissimus dorsi muscle for bronchopleural fistula
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 582–584 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314546356 aan.sagepub.com
Tevfik Kaplan1, Basar Kaya2, Baturay Kansu Kazbek3, Bulent Kocer4, Serdar Han1 and Erdem Yormuk2
Abstract Management of postpneumonectomy bronchopleural fistula remains a major challenge for thoracic surgeons. Successful closure of a postpneumonectomy bronchopleural fistula was performed in a 60-year-old man, using a flap made by a combination of serratus anterior and latissimus dorsi muscle which had been divided during the pneumonectomy operation. The flap was prepared on the presence of a dependable collateral serratus anterior branch to the lateral thoracic artery, which provides retrograde flow to the latissimus dorsi muscle.
Keywords Empyema, fistula, pneumonectomy, postoperative complications, reconstructive surgical procedures, thoracic surgical procedures
Introduction The incidence of postoperative bronchopleural fistula (BPF) has been reported to be 1.5% to 28% in pneumonectomy cases. It can lead to life-threatening conditions such as postpneumonectomy empyema.1 The mortality of a BPF is reported to be 15% to 75%.2 Intrathoracic muscle flap transposition has been shown to be useful in controlling postpneumonectomy BPF.3
Case report A 60-year-old man was admitted to our hospital with cough and sputum and was diagnosed with stage IIIA (T2N2M0) squamous cell carcinoma of the right upper lobe and intermediate bronchus. He had 3 cycles of neoadjuvant chemotherapy (gemcitabine, cisplatin) before undergoing a right pneumonectomy. No complication was observed during the immediate postoperative period, however, at the 1-year follow-up, a BPF was detected (Figure 1). Several attempts were made to treat the BPF with intrabronchial glue, but they were unsuccessful. At the 2-year follow-up, we noted empyema in the right hemithorax. We inserted a chest tube and irrigated the right intrathoracic space with antibiotic solution for 30 days. After confirming by
culture that there was no infection in the thoracic cavity, we recommended treatment options to the patient, including chronic open drainage, direct stump closure with muscle reinforcement, or thoracoplasty, but the patient decided on closure of the BPF by transferring an intrathoracic muscle flap. The operative plan involved the segmental perforators of latissimus dorsi muscle as a reverse flap. In the operating room, the patient underwent double-lumen left-sided intubation, and the thoracotomy incision was reopened to the bronchial stump site at the 4th intercostal space. The bronchial stump was debrided and closed in a 1 Department of Thoracic Surgery, Ufuk University School of Medicine, Ankara, Turkey 2 Department of Plastic and Reconstructive Surgery, Ufuk Univeristy School of Medicine, Ankara, Turkey 3 Department of Anesthesiology and Reanimation, Ufuk University School of Medicine, Ankara, Turkey 4 Department of Thoracic Surgery, Ankara Numune Teaching and Research Hospital, Ankara, Turkey
Corresponding author: Tevfik Kaplan, Department of Thoracic Surgery, Ufuk University School of Medicine, Dr. Rıdvan Ege Teaching and Research Hospital, Mevlana Bulvarı No: 86-88 (Konya Yolu) B Blok 6. kat, Balgat, Ankara, C ¸ ankaya 06520, Turkey. Email: [email protected]
Downloaded from aan.sagepub.com by guest on November 15, 2015
Kaplan et al.
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double-layer fashion with interrupted polypropylene sutures. We confirmed the presence of a dependable collateral serratus anterior branch to the lateral thoracic artery, which provides retrograde flow to the latissimus dorsi muscle. Cautious dissection was applied, the flap was elevated properly (Figure 2A, 2B), and inset to the fistula with a partial serratus anterior muscle flap without any problem (Figure 2C). We did not do any rib resection for this procedure, and ended the operation by placing a chest tube in the thoracic cavity. The patient was discharged on the 15 th postoperative day and he was well without any evidence of infection or BPF at the 6-months follow-up.
Figure 1. Bronchoscopic view of the bronchopleural fistula.
Discussion Bronchopleural fistula remains the most frightening complication following pneumonectomy. The major factors contributing to the development of BPF after pneumonectomy are induction chemo/radiotherapy, a right pneumonectomy, and postoperative mechanical ventilation.1 The factors in our patient were induction chemotherapy and a right pneumonectomy. If empyema and BPF are detected after pneumonectomy, the first step is to put a chest tube into the thoracic cavity for drainage and irrigation with antibiotic solution. Surgical approaches include chronic open drainage, direct stump closure with muscle reinforcement, an omental flap, transsternal bronchial closure, and thoracoplasty with or without extrathoracic chest wall muscle transposition.2,3 In this case, the BPF was small and we tried to manage it with endobronchial glue several times before surgery, but obtained inadequate results, so we recommended chronic open drainage first, but the patient opted for BPF closure with muscle reinforcement. A standard posterolateral thoracotomy generally divides the latissimus dorsi muscle and rarely divides the serratus anterior muscle, so after a previous posterolateral thoracotomy, a serratus anterior muscle flap is frequently the choice for BPF closure.3 Transposition of the serratus anterior muscle results in some degree of scapular winging. Segmental use of the serratus anterior muscle for intrathoracic transposition has been used to overcome this situation.3 Nevertheless, the serratus muscle flap is thin, short, and has 3 separate parts, which sometimes limits its use for closure of a BPF.
Figure 2. (A) The latissimus dorsi muscle flap. (B) The combined latissimus dorsi and partial serratus anterior muscle flap. (C) The bronchopleural fistula was closed with the latissimus dorsi and serratus anterior muscle flap.
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584
Asian Cardiovascular & Thoracic Annals 23(5)
Latissimus dorsi muscle is a type V muscle according to its blood supply, thoracodorsal vessels, or intercostals or lumbar perforators. The proximal part of the muscle can be pedicled on the thoracodorsal vessels or the serratus branch. The thoracodorsal artery gives off 1– 2 branches to the serratus muscle prior to entering the latissimus dorsi muscle.3,4 It can be elevated at full length and has a bulky tissue that provides reliable closure of a BPF. This procedure should have a multidisciplinary approach involving plastic surgeons because it needs advanced skills in the preparation of the pedicled latissimus dorsi flap on the segmental perforators and branch vessels.4 In this case, the operation was performed by a team of thoracic and plastic surgeons. The procedure ended successfully, and the healing period was uneventful without scapular winging. We concluded that the use of a latissimus dorsi muscle flap pedicled on the collateral serratus branch of the thoracodorsal artery is a safe and valuable option for closing a BPF, even after a previous posterolateral thoracotomy.
Conflict of interest statement None declared.
References 1. Deschamps C, Bernard A, Nichols FC 3rd, et al. Empyema and bronchopleural fistula after pneumonectomy factors affecting incidence. Ann Thorac Surg 2001; 72: 243–247. 2. Kahn JH, Rahman SB, McElhinney DB, et al. Management strategies for complex bronchopleural fistula. Asian Cardiovasc Thorac Ann 2000;8:78–84. Available at: http://aan.sagepub.com/content/8/1/78.full. Accessed July 14, 2014. 3. Arnold PG and Pairolero PV. Inthrathoracic muscle flaps: a 10-year experience in the management of life-threatening infections. Plast Reconstr Surg 1989; 84: 92–98. 4. Koch H, Tomaselli F, Pierer G, et al. Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy. Eur J Cardiothorac Surg 2002; 21: 874–878.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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Use of previously divided latissimus dorsi muscle for bronchopleural fistula
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 582–584 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314546356 aan.sagepub.com
Tevfik Kaplan1, Basar Kaya2, Baturay Kansu Kazbek3, Bulent Kocer4, Serdar Han1 and Erdem Yormuk2
Abstract Management of postpneumonectomy bronchopleural fistula remains a major challenge for thoracic surgeons. Successful closure of a postpneumonectomy bronchopleural fistula was performed in a 60-year-old man, using a flap made by a combination of serratus anterior and latissimus dorsi muscle which had been divided during the pneumonectomy operation. The flap was prepared on the presence of a dependable collateral serratus anterior branch to the lateral thoracic artery, which provides retrograde flow to the latissimus dorsi muscle.
Keywords Empyema, fistula, pneumonectomy, postoperative complications, reconstructive surgical procedures, thoracic surgical procedures
Introduction The incidence of postoperative bronchopleural fistula (BPF) has been reported to be 1.5% to 28% in pneumonectomy cases. It can lead to life-threatening conditions such as postpneumonectomy empyema.1 The mortality of a BPF is reported to be 15% to 75%.2 Intrathoracic muscle flap transposition has been shown to be useful in controlling postpneumonectomy BPF.3
Case report A 60-year-old man was admitted to our hospital with cough and sputum and was diagnosed with stage IIIA (T2N2M0) squamous cell carcinoma of the right upper lobe and intermediate bronchus. He had 3 cycles of neoadjuvant chemotherapy (gemcitabine, cisplatin) before undergoing a right pneumonectomy. No complication was observed during the immediate postoperative period, however, at the 1-year follow-up, a BPF was detected (Figure 1). Several attempts were made to treat the BPF with intrabronchial glue, but they were unsuccessful. At the 2-year follow-up, we noted empyema in the right hemithorax. We inserted a chest tube and irrigated the right intrathoracic space with antibiotic solution for 30 days. After confirming by
culture that there was no infection in the thoracic cavity, we recommended treatment options to the patient, including chronic open drainage, direct stump closure with muscle reinforcement, or thoracoplasty, but the patient decided on closure of the BPF by transferring an intrathoracic muscle flap. The operative plan involved the segmental perforators of latissimus dorsi muscle as a reverse flap. In the operating room, the patient underwent double-lumen left-sided intubation, and the thoracotomy incision was reopened to the bronchial stump site at the 4th intercostal space. The bronchial stump was debrided and closed in a 1 Department of Thoracic Surgery, Ufuk University School of Medicine, Ankara, Turkey 2 Department of Plastic and Reconstructive Surgery, Ufuk Univeristy School of Medicine, Ankara, Turkey 3 Department of Anesthesiology and Reanimation, Ufuk University School of Medicine, Ankara, Turkey 4 Department of Thoracic Surgery, Ankara Numune Teaching and Research Hospital, Ankara, Turkey
Corresponding author: Tevfik Kaplan, Department of Thoracic Surgery, Ufuk University School of Medicine, Dr. Rıdvan Ege Teaching and Research Hospital, Mevlana Bulvarı No: 86-88 (Konya Yolu) B Blok 6. kat, Balgat, Ankara, C ¸ ankaya 06520, Turkey. Email: [email protected]
Downloaded from aan.sagepub.com by guest on November 15, 2015
Kaplan et al.
583
double-layer fashion with interrupted polypropylene sutures. We confirmed the presence of a dependable collateral serratus anterior branch to the lateral thoracic artery, which provides retrograde flow to the latissimus dorsi muscle. Cautious dissection was applied, the flap was elevated properly (Figure 2A, 2B), and inset to the fistula with a partial serratus anterior muscle flap without any problem (Figure 2C). We did not do any rib resection for this procedure, and ended the operation by placing a chest tube in the thoracic cavity. The patient was discharged on the 15 th postoperative day and he was well without any evidence of infection or BPF at the 6-months follow-up.
Figure 1. Bronchoscopic view of the bronchopleural fistula.
Discussion Bronchopleural fistula remains the most frightening complication following pneumonectomy. The major factors contributing to the development of BPF after pneumonectomy are induction chemo/radiotherapy, a right pneumonectomy, and postoperative mechanical ventilation.1 The factors in our patient were induction chemotherapy and a right pneumonectomy. If empyema and BPF are detected after pneumonectomy, the first step is to put a chest tube into the thoracic cavity for drainage and irrigation with antibiotic solution. Surgical approaches include chronic open drainage, direct stump closure with muscle reinforcement, an omental flap, transsternal bronchial closure, and thoracoplasty with or without extrathoracic chest wall muscle transposition.2,3 In this case, the BPF was small and we tried to manage it with endobronchial glue several times before surgery, but obtained inadequate results, so we recommended chronic open drainage first, but the patient opted for BPF closure with muscle reinforcement. A standard posterolateral thoracotomy generally divides the latissimus dorsi muscle and rarely divides the serratus anterior muscle, so after a previous posterolateral thoracotomy, a serratus anterior muscle flap is frequently the choice for BPF closure.3 Transposition of the serratus anterior muscle results in some degree of scapular winging. Segmental use of the serratus anterior muscle for intrathoracic transposition has been used to overcome this situation.3 Nevertheless, the serratus muscle flap is thin, short, and has 3 separate parts, which sometimes limits its use for closure of a BPF.
Figure 2. (A) The latissimus dorsi muscle flap. (B) The combined latissimus dorsi and partial serratus anterior muscle flap. (C) The bronchopleural fistula was closed with the latissimus dorsi and serratus anterior muscle flap.
Downloaded from aan.sagepub.com by guest on November 15, 2015
584
Asian Cardiovascular & Thoracic Annals 23(5)
Latissimus dorsi muscle is a type V muscle according to its blood supply, thoracodorsal vessels, or intercostals or lumbar perforators. The proximal part of the muscle can be pedicled on the thoracodorsal vessels or the serratus branch. The thoracodorsal artery gives off 1– 2 branches to the serratus muscle prior to entering the latissimus dorsi muscle.3,4 It can be elevated at full length and has a bulky tissue that provides reliable closure of a BPF. This procedure should have a multidisciplinary approach involving plastic surgeons because it needs advanced skills in the preparation of the pedicled latissimus dorsi flap on the segmental perforators and branch vessels.4 In this case, the operation was performed by a team of thoracic and plastic surgeons. The procedure ended successfully, and the healing period was uneventful without scapular winging. We concluded that the use of a latissimus dorsi muscle flap pedicled on the collateral serratus branch of the thoracodorsal artery is a safe and valuable option for closing a BPF, even after a previous posterolateral thoracotomy.
Conflict of interest statement None declared.
References 1. Deschamps C, Bernard A, Nichols FC 3rd, et al. Empyema and bronchopleural fistula after pneumonectomy factors affecting incidence. Ann Thorac Surg 2001; 72: 243–247. 2. Kahn JH, Rahman SB, McElhinney DB, et al. Management strategies for complex bronchopleural fistula. Asian Cardiovasc Thorac Ann 2000;8:78–84. Available at: http://aan.sagepub.com/content/8/1/78.full. Accessed July 14, 2014. 3. Arnold PG and Pairolero PV. Inthrathoracic muscle flaps: a 10-year experience in the management of life-threatening infections. Plast Reconstr Surg 1989; 84: 92–98. 4. Koch H, Tomaselli F, Pierer G, et al. Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy. Eur J Cardiothorac Surg 2002; 21: 874–878.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from aan.sagepub.com by guest on November 15, 2015
