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J Thorac Cardiovasc Surg 1994;107:1251-1254
© 1994 Mosby, Inc.

GENERAL THORACIC SURGERY

Protection and revascularization of bronchial anastomoses by the intercostal pedicle flap

Rome, Italy

Received for publication May 19, 1993. Accepted for publication Aug. 19, 1993. Address for reprints: E. A. Rendina, MD, Cattedra di Chirurgia Toracica, Universitá di Roma "La Sapienza," Policlinico Umberto I, 00161 Roma, Italy.

Abstract

We used an improved method for preparation of the intercostal pedicle flap for encircling bronchial anastomoses, and we studied its vascular supply after the operation. The flap was used in 56 patients undergoing various types of sleeve resection and in three patients undergoing single lung transplantation. The technique is simple, fast, and causes neither extra surgical trauma nor complications. It allows satisfactory isolation and sealing of the bronchial anastomosis. Even if complete anastomotic dehiscence occurs (one case), the flap preserves the continuity of the airway, thus avoiding bronchopleural fistulas or other complications. The postoperative arteriographic study of the intercostal artery supplying the flap (performed in 14 patients) demonstrated the full patency of the vessel in all cases. It also showed that a fine vascular network develops around the anastomosis early in the postoperative period. (J THORAC CARDIOVASC SURG 1994;107:1251-4)

Protection of the bronchial anastomosis is important after bronchoplastic procedures such as sleeve lobectomy ^1,2 or sleeve pneumonectomy with carinalresection. ^3,4 The risk of erosion of the adjacent pulmonary artery may be minimized by encircling the anastomosis with well vascularized tissue, and bronchopleural fistulas caused by dehiscence may be avoided. In addition, the revascularization of the distal bronchus avoids problems related to ischemia.

We hereby report our experience with an improved method for preparation of the intercostal pedicle flap as a means of protection and revascularization of bronchial anastomoses.

PATIENTS AND METHODS

The intercostal pedicle flap was used in 59 patients between May 1989 and May 1992. Three patients underwent right pneumonectomy with carinal resection, and 53 underwent various types of sleeve resection. Three additional patients underwent single lung transplantation with no anastomotic problems. Excluding patients who underwent transplantation, the indications included lung cancer (n = 45), bronchial carcinoid (n = 9), and other benign lesions (n = 2).

Technique
With the patient in the lateral decubitus position, a standard posterolateral thoracotomy incision is made. The dorsalis major and serratus anterior muscles are divided, and the costal plane is exposed. The preparation of the flap is performed before opening the chest, and the rib retractor is not inserted until the procedure is completed to avoid crushing the intercostal vessels. The periosteum of the fifth rib is incised and then separated from the bone in continuity with the underlying intercostal muscle (Fig. 1). The periosteum is not treated with silver nitrate. Care must be taken to preserve the muscular insertion to the periosteum to avoid injuring the intercostal neurovascular bundle. The fifth rib is then gently retracted upward, and the parietal pleura is separated by finger dissection from the chest wall to create a wide pleural flap in continuity with the intercostal muscle (Fig. 1). The preparation of the cranial aspect of the pedicle is thus completed.

View larger version (43K): [in this window] [in a new window]   Fig. 1. Preparation of the cranial aspect of the intercostal flap. Periosteum is harvested in continuity with the muscle to preserve the intercostal vessels.

View larger version (42K): [in this window] [in a new window]   Fig. 2. Preparation of the inferior aspect of the intercostal flap. Part of the muscular insertion on the sixth rib and the periosteum are left in place.

View larger version (46K): [in this window] [in a new window]   Fig. 3. Appearance of the pedicle after the preparation is completed. The muscle is in continuity with a wide bilateral flap of parietal pleura.

View larger version (53K): [in this window] [in a new window]   Fig. 4. The flap is positioned around the bronchial anastomosis. See text for description.

View larger version (65K): [in this window] [in a new window]   Fig. 5. The flap is secured to the bronchus. The muscular bulk guarantees retraction and protection of the pulmonary artery from the bronchial suture. The wide pleural flap ensures ideal isolation of the anastomosis.

Bronchoscopy was performed in all patients before extubation and on the first postoperative day. The anastomosis appeared satisfactory in all patients. Routinely, bronchoscopy was also performed 1, 3, 6, 12, and 24 months after the operation in uncomplicated cases. Osteoneogenesis of the periosteum, whenever it may have occurred, did not cause stenosis or other problems. Anastomotic complications occurred after 6 to 12 days in three patients: one patient had a complete dehiscence and two patients had partial dehiscences associated with granuloma formation on the bronchial edges. The complication rate was 5%. The continuity of the airway, however, was maintained by the flap, and no bronchopleural or bronchovascular fistulas occurred. In the patient with complete dehiscence, the pleural surface of the flap was visible bronchoscopically, bulging in the bronchial lumen. The bronchus was fully recanalized by yttrium-aluminum-garnet laser, and the patency of the airway was assured by the insertion of a silicone rubber endobronchial prosthesis, which was removed after 6 to 12 months with no further complications.

In 14 patients, after informed consent was obtained, selective angiograms of the intercostal artery were obtained in the seventh (n = 6) and fourteenth (n = 8) (Fig. 6) postoperative days. In all cases the patency of the artery could be demonstrated, and at only 7 days after the operation a fine vascular network surrounding the anastomosis was visible.

View larger version (137K): [in this window] [in a new window]   Fig. 6. Selective angiography of the intercostal artery supplying the flap (small arrows) taken in the fourteenth postoperative day. The arterial loop around the bronchial anastomosis and a fine vascular network are evident (medium arrow). A fine vascular network is also evident in the area of the reimplanted bronchus (large arrow).

Many techniques have been proposed for encircling the bronchial anastomosis after either bronchoplastic procedures ^1-5 or lung transplantation. ^6-8 Omentopexy has the disadvantage of requiring abdominal exploration, and pleural, pericardial, thymic, or mediastinal tissue flaps are often insufficient in length, width, consistency, or vascularization.

Intrathoracic transposition of an intercostal pedicle flap is not new in thoracic surgery ^9-13; however, we have demonstrated that, with the technique that we have used, the sealing of the anastomosis is satisfactory even in cases of complete dehiscence. In comparison with omentopexy, the intercostal flap technique is faster and simpler, and it neither requires extra surgical trauma nor exposes the patient to the risk of abdominal complications. It also has advantages over the pericardium, pleura, thymus, or mediastinal fat: the muscular-pleural flap can always be wrapped completely around the bronchus with a continuous layer of tissue, which is well vascularized and thin, notwithstanding its good consistency. The flap can therefore be easily tailored and sutured to the bronchus to ensure positive isolation and protection of the anastomosis. It may be prepared simply and quickly before opening the chest and may be replaced between the ribs at chest closure if not needed.

We used this technique successfully in 56 sleeve resections and three single lung transplantations; three patients with bronchogenic carcinoma who had preoperative irradiation had an anastomotic dehiscence (one complete and two partial). In none of the patients did a bronchopleural fistula or further complication occur, and the patients fully recovered after 6 to 12 months.

Revascularization of the donor bronchus distal to the anastomosis is a major issue in bronchoplastic surgery and especially in lung transplantation. Fell ⁷ and Morgan ⁶ and their associates demonstrated early revascularization of the bronchial mucosa in canine models by using the intercostal muscle and the omentum; the latter method has gained popularity also in human lung transplantation. However, the viability of bronchial revascularization with the intercostal muscle has not been confirmed in human beings. The arteriographic images that we have obtained demonstrate that a properly prepared, well vascularized intercostal flap may facilitate bronchial revascularization after a sleeve resection early in the postoperative period. This finding requires specific investigation before being applyed to transplantation because of the many physiopathologic differences involved.

Acknowledgments

We thank M. Seminara and M. Passacantilli for preparing the illustrations.

Footnotes

From the Departments of Thoracic Surgery and Radiology,^a University of Rome "La Sapienza," Rome, Italy

References

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8. Noirclerc MJ, Metras D, Vaillant A, et al. Bilateral bronchial anastomosis in double lung and heart-lung transplantation. Eur J Cardiothorac Surg 1990;4:314-7.[Abstract]
   
9. Blair E. Study of the viable intercostal pedicle graft in tracheobronchial surgery. J THORAC CARDIOVASC SURG 1958;36:869-78.
   
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Erino A. Rendina Federico Venuta Diego A. Bognolo Costante Ricci Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rendina, E. A. Articles by Rossi, P. Search for Related Content PubMed PubMed Citation Articles by Rendina, E. A. Articles by Rossi, P.