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J Thorac Cardiovasc Surg 1995;110:1139-1141
© 1995 Mosby, Inc.

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BRONCHOPLEURAL FISTULA AFTER PNEUMONECTOMY: REPAIR AND PREVENTION WITH A DEEPITHELIALIZED LATISSIMUS DORSI MYOCUTANEOUS ISLAND FLAP

Amsterdam, The Netherlands

Breakdown of the suture line on the main bronchus after pneumonectomy is an infrequent but life-threatening condition. After management of the acute situation with drainage and antibiotics, surgical closure can be attempted. ¹ The local and general conditions, however, are far from ideal for the healing of a new bronchus suture line. There is now ample evidence that successful healing is promoted by reinforcing the new suture line with well vascularized tissue. ^2-5 We recently obtained favorable results with a deepithelialized latissimus dorsi (LD) myocutaneous island flap, which has the advantage of adding the tensile strength of the dermis to the vascularization of the LD muscle.

Case report

A 74-year-old man underwent a right pneumonectomy because of squamous cell carcinoma of the upper lobe extending into the main bronchus (T2 N0 M0). The main bronchus was closed with staples (Auto Suture; United States Surgical Corp., Norwalk, Conn.). Postoperative recovery was uneventful, and the patient left the hospital in good condition after 12 days. At postoperative day 24, however, he returned because of high fever and massively productive cough. Bronchoscopy revealed a large defect in a short right main bronchus. Acute management consisted of tube drainage of the right pleural cavity and antibiotic therapy. After 5 days, an open-window thoracostomy was performed. The pleural cavity was packed with gauzes, which were changed daily. Under this regimen, the infection subsided quickly and the general condition of the patient improved. The pulmonary reserve remained marginal, however, because of preexisting emphysema. For closure of the fistula omentum, transposition was considered but rejected because we were worried about the effect of a combined thoracotomy and laparotomy on the function of the remaining lung. Instead, we decided to use the deepithelialized LD myocutaneous flap to reinforce the planned new suture line. The operation was carried out 28 days after the open-window thoracostomy.

Operative technique

The operation was carried out with the patient under general anesthesia in the left lateral position, with selective intubation of the left main bronchus. Before operation, the LD muscle had been outlined on the skin and a skin island of 8 x12 cm had been marked, taking into account the transection of the muscle during the previous thoracotomy and the length needed to reach the bronchus stump without tension. The thoracotomy was placed on the lower margin of this projected skin island. The sixth intercostal space was used to enter the thorax; the already-present thoracostomy was used as part of the approach. On inspection, the parietal pleura was greatly thickened and the pleural cavity was greatly reduced in volume. The bronchial leak was easily recognizable by the remaining metal staples in the edge of the fistula. The bronchus was embedded in dense, fibrotic tissue. An effort to close the open stump by direct suturing failed because of the tension needed to close the lumen and the fragility of the bronchus wall. The deepithelialized LD flap was mobilized. The epidermis was removed from the skin island. The island was cut free, with care taken to preserve the perforating vessels from the underlying muscle. The LD was mobilized as far as the axilla. To fascilitate dissection, an additional incision was made on the lower margin of the axilla. This allowed easy identification and preservation of the thoracodorsal vascular pedicle. The LD tendon was cut to gain more mobility. The lateral part of the third rib was resected to create an easy and direct access to the pleural cavity. The flap could easily be positioned to allow the dermal surface to cover the open bronchus without any tension. The bronchus was now closed with U-shaped sutures (Vicryl 1-0; Ethicon, Inc., Somerville, N.J.), taking the dermis on one side, passing through the opposing sides of the bronchus, and taking the dermis on the other side and back again (Fig. 1). With this technique, three sutures effectively closed the bronchus. The dermal flap was then spread out over the surrounding mediastinum and fixed with sutures. The thoracotomy was closed, with the window thoracostomy left open to ensure adequate drainage in the postoperative period.

View larger version (25K): [in this window] [in a new window]   Fig. 1. Artist's impression of the suturing technique used to reinforce the bronchus suture line with the deepithelialized myocutaneous LD flap.

View larger version (0K): [in this window] [in a new window]   Fig. 2. Computed tomographic scan of the thorax showing the deep ithelialized LD flap nicely covering the bronchus suture line.

Advantages of the deepithelialized myocutaneous LD flap over other flaps ^2-4 are the proximity of the donor site, the reliable blood supply, and the tensile strength of the flap's skin. The LD flap provides a useful tool in the repair of bronchopleural fistulas after pneumonectomy and for prevention of such fistulas in patients at high risk.

Footnotes

From the Departments of Surgery^a and Pulmonology,^b Netherlands Cancer Institute, Amsterdam, The Netherlands.

J THORAC CARDIOVASC SURG 1995;110:1139-41

References

1. Smolle-Juttner F, Beuster W, Pinter H, Pierer G, Pongratz M, Friehs G. Open window thoracostomy in pleural empyema. Eur J Cardiothorac Surg 1992;6:635-8.[Abstract/Free Full Text]
   
2. Muller LC, Abendstein B, Salzer GM. Use of the greater omentum for treatment and prophylaxis of anastomotic and stump dehiscence in major airway surgery. Thorac Cardiovasc Surg 1992;40:323-5.[Medline]
   
3. Kamei Y, Moriura S, Ikeda S, et al. Combination gastric seromuscular patch and omental pedicle flap for bronchial fistula. Ann Thorac Surg 1993;56:366-8.[Abstract/Free Full Text]
   
4. Zimmerman T, Muhrer KH, Padberg W, Schremmle K. Closure of acute bronchial stump insufficiency with a musculus latissimus dorsi flap. Thorac Cardiovasc Surg 1993;41:196-8.[Medline]
   
5. Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulae associated with lung cancer operations: univariate and multivariate analysis of risk factors, management, and outcome. J THORAC CARDIOVASC SURG 1992;104:1456-64.[Abstract]
   

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