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J Thorac Cardiovasc Surg 2006;131:1422-1423
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Intercostal muscle flap without increase of pain and blood loss after lung surgery

Tomohiro Maniwa, MD, Yukihito Saito, MD, Hiroyuki Kaneda, MD

Department of Thoracic and Cardiovascular Surgery, Kansai Medical University Hospital, Fumizonocho 10-15, Moriguchi, Osaka 570-8506, Japan

To the Editor:

We read with interest the article by Cerfolio and colleagues. 1 Go This report demonstrated that harvesting the intercostal muscle flap (ICM) reduces the pain of thoracotomy. We also have some data about the pain in comparison of cases with ICM harvesting and other cases without ICM harvesting (non-ICM), as in the study performed in our institution. ICM is very mobile and vascular rich. Therefore the ICM was used in the reinforcement of perforated esophagus or bronchopleural fistula. 2 Go In our series of patients, performing lobectomy with reinforcement of ICM to bronchial stump never resulted in bronchopleural fistula over the decade.

We had 35 patients who had ICM flap with lobectomy (ICM group) and 51 patients who did not (non-ICM group) in the last 2 years in our institution. We compared the pain of patients between the groups using a 6-point scale pain score for 4 hours after lung surgery (Figure 1). There was no statistically significant difference between the groups (P = .47).


Figure 1
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  		Figure 1. Statistical analysis. All statistical analyses were performed on a personal computer with the statistical package JMP version 5.0 for Windows (SAS Institute). The incidence and significance of pain scores was compared with harvesting ICM factors by using the {chi}2 test as appropriate. Analysis of variance was used for the analysis comparing 2 groups. Analysis of variance was also used for the intercostal muscle (ICM) flap for drainage. All tests were 2 tailed. Left, Six-point scale pain score for 4 hours after lung surgery. No statistically significant difference could be observed between the groups (P = .47); however, on the whole, the pain score is lower than for the non-ICM group. Right, Volume of chest tube at day 1 after the operation. No statistical difference could be observed between the groups (P = .62); however, the median is also lower than for the non-ICM group.

 
Because we wondered whether harvesting the ICM might lead to an increase of blood loss from the muscle after the operation, we also examined the blood loss after the operation observed from the chest tube. The drainage volume from the chest tube at day 1 after the operation was 215 mL in median (range, 30-480 mL) in the ICM group and 272 mL (range, 10-530 mL) in the non-ICM group (Figure 1). There was no statistically significant difference between the groups (P = .62). We believe that harvesting with cautery causes no increase of bleeding. When harvesting, maintaining a good blood supply is very important in this technique. It was reported that ICM sometimes results in calcification in the flap itself, 3 Go resulting in various complications in the short and long term after the operation. We believe that enough blood supply in the ICM does not lead to calcification of the ICM because use of ICM in our institution never resulted in calcification of the ICM. In addition, there was no complication caused by harvesting the ICM in our series of patients, such as subcutaneous seroma or abscess.

Again, in our series of patients, there was no difference in terms of pain. We suspect that there might be 2 reasons why our results were different from your results. One possibility is that not cutting the rib in the author's procedure of non-ICM surgery might strongly press the nonharvested intercostal nerve and increase the pain, resulting in the difference of pain between the ICM group and the non-ICM group. When we open the chest with standard thoracotomy, we usually cut the rib, and we joint the rib at the end of the operation. We believe that cutting the rib releases the tension of the rib in the operation to some extent and reduces the patients' pain. The other possibility is that the different procedure of the wideness of the chest opening might cause the difference in pain. When opening the chest, we take care to hardly retract the rib and not to damage the intercostal nerve. We would like to hear your opinion.


   References
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 References
 

  1. Cerfolio RJ, Price TN, Bryant AS. Intercostal muscle flap reduces the pain of thoracotomy. a prospective randomized trial. J Thorac Cardiovasc Surg 2005;130:987-993.[Abstract/Free Full Text]
  2. Hollaus PH, Huber M, Lax F, et al. Closure of bronchopleural fistula after pneumonectomy with a pedicled intercostal muscle flap. Eur J Cardiothorac Surg 1999;16:181-186.[Abstract/Free Full Text]
  3. Kwek BH, Wain JC, Aquino SL, et al. The radiologic appearance of intercostal muscle flap. Ann Thorac Surg 2004;78:432-435.[Abstract/Free Full Text]



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