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www.e-arms.org Bronchopleural fistula (BPF) is a communication in the
form of a sinus tract between the pleural space and the bronchial tree.1 Mortality rates varies between 18% to 67%.
The most common cause of death isaspiration pneumonia and subsequent acuterespiratory distress syndrome or development oftension pneumothorax.2,3 Closure of bronchial stump with various muscular flaps has been reported.4,5 In addition, the use of afibrin sealant and omentalpedicled flap has been reported for closure of BPF. But there has been few reports about the treatment of large defect with BPF accompanied by surrounding muscle injury including serratus anterior muscle, intercostals muscle. We report our experience in two patients suffering from large defect with BPF, who were treated with free flaps.
CASE REPORT
Case 1
A 65-year-old male patient with repeated hemoptysis of tuberculosis had got right lung resection 49 years
ago. He was diagnosed as BPF with bronchoscopy 1 year 6 months ago so drainage using modified Eloesser procedure was done. But BPF was recurred, application of fibrin sealant via bronchoscopy was tried. After the broncholeural fistula recurred again, closure of BPF with latissimusdorsimyocutaneous free flap was planned.
After the patient intubated with double lumen endotracheal tube, being laid in a left lateral decubitus position. The cardiothoracic surgery team made an incision at the posterolateral chest wall and resected partially 6th to 9th ribs, then resected all the fibrotic tissue, contaminated tissue in the thoracic cavity. During the procedure, the head of the rib and transverse process of the spine were preserved and washed with antiseptic solution several times. Then, BPF with soft tissue defect sized about 20 cm by 7 cm was on the right chest wall. Plastic surgery team designed latissimusdorsimusculocutaneous free flap sized 24 cm by 7 cm in a prone position and elevated the flap using thoracodorsal artery as a pedicle. After primary closure of the donor site, microanastomosis was performed in a left
Use of the Free Flap for Large Defect with Bronchopleural Fistula: Case Report
Joo Seok Park, Se Hoon Choi*, Eun Key Kim
Departments of Plastic Surgery, *Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea pISSN 1226-2706 eISSN 2288-6184 Arch Reconstr Microsurg 2014;23(1):21-24
CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2014 by the Korean Society for Microsurgery. All Rights Reserved.
Received March 12, 2014 Revised March 13, 2014 Accepted April 21, 2014
Correspondence to: Eun Key Kim Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea
Tel: +82-2-3010-3600 Fax: +82-2-476-7471 E-mail: [email protected]
Bronchopleural fistula is an unnatural communication between the bronchial tree and pleural space. Closure of the bronchial stump using various muscular flaps has been previously reported. There have been few reports on treatment of large defects with bronchopleural fistula accompanied by surrounding muscle injury. We report on our experience with two patients suffering from large defect with bronchopleural fistula, who were treated with free flaps. No recurrence of bronchopleural fistula was observed during follow-up.
Key Words: Bronchial fistula, Free tissue flaps
ARMS
Case ReportArchieves of Reconstructive Microsurgery
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lateral decubitus position (Fig. 1). After the deepithelization of the flap, cardiothoracic surgery team closed the BPF with the flap and sutured the incision on the posterolateral chest wall. Because of the absence of monitoring flap, duplex ultrasonography was used to evaluated the flow of anastomosis site (Fig. 2). Three months after flap surgery, BPF was not recurred on computed tomography.
Case 2
A 65-year-old male patient was diagnosed with small cell lung cancer in a health examination. Right upper lobectomy and segmentectomy of right lower lobe were performed 1 year 2 months ago. At the time of surgery, pathology findings from the tissue biopsy showed aspergillosis.
But chest computed tomography and clinical findings were not consistent with aspergillosis so the patient was observed without antifungal agents. Then, chest computed tomography and bronchoscopy were done due to repeated pneumonia, the patient were diagnosed as BPF. Thoracic surgery team closed the BPF with several interrupted 3-0 prolene sutures and reinforced the fistula with parietal pleura. At this surgery, tissue culture showed aspergillosis so antifugal agents had been used. There were infection sign Fig. 1. (A) The thoracic surgery team incised at the poterolateral
chest wall and resected partially 6th~9th ribs, then resected all the fi brotic tissue, contaminated tissue in the thoracic cavity. (B) Plastic surgery team designed latissimus dorsi musculocutaneous free fl ap sized 24 cm by 7 cm in a prone position and elevated the fl ap using thoracodorsal artery as a pedicle.
Fig. 2. In case 1 patient, because of the absence of monitoring flap, duplex ultrasonography was used to evaluated the flow of anastomosis site. (A) The patient laid in a left decubitus position. (B) Probe of duplex ultrasonography was placed to the anastomosis site. (C) Flows of artery and vein at the anastomosis site were shown.
Joo Seok Park, et al. Free Flap for Bronchopleural Fistula
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www.e-arms.org on the right pleura, thoracic wall on the subsequent chest
computed tomography, so debridement and vertical rectus abdominis myocutaneous free flap were planned. After the patient intubated with double lumen endotracheal tube, being laid in a left lateral decubitus position. The thoracic surgery team incised at the poterolateral chest wall and resected partially 5th to 6th ribs,then resected all the fibrotic tissue, contaminated tissue in the thoracic cavity. Then, BPF with soft tissue defect sized about 12 cm by 5 cm was on the right chest wall. Plastic surgery team designed vertical rectus abdominis musculocutaneous free flap sized 15 cm by 5 cm in a prone position and elevated the flap using deep inferior epigastric artery as a pedicle. Microanastomosis between the inferior epigastric artery and thoracodorsal artery was done.
After the deepithelization except the monitoring flap sized 2
cm by 2 cm, thoracic surgery team closed the BPF with the flap and sutured the incision on the posterolateral chest wall with exposure of the monitoring flap (Fig. 3). Oral antifungal agents have been taken currently 1 year after flap surgery, BPF was not recurred on computed tomography.
DISCUSSION
Risk factors for BPF can be divided into local factors and systemic factors. Systemic factors include diabetes, malnutrition, low preoperative hemoglobin level, neoadjuvant chemotherapy, steriod treatment, chronic obstructive pulmonary disease (forced expired volume 1 <60%, pulmonary diffusion capacity of carbon monoxide <50%).
Local factors include neoadjuvant radiotherapy, existing Fig. 3. (A) Thoracic surgery team incised at the poterolateral chest wall and resected partially 5th~6th ribs, then resected all the fibrotic tissue, contaminated tissue in the thoracic cavity. (B) Design for vertical rectus abdominis musculocutaneous free flap sized 12 cm by 6 cm in a prone position. (C) Suture of the incision on the posterolateral chest wall with exposure of the monitoring flap (arrow). (D) Front view photo of immediate postoperation.
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empyema, right pneumonectomy, 2 cm or more bronchi cut, lack of blood supply to the bronchial, tumor of bronchial side, postoperative mechanical ventilation therapy, chest tube mounted in a long time.6,7
When the size of BPF is not wide, pedicled serratus muscle flap can be the choice. After the epithelium is removed from the skin, dermal layer, solid portion of skin, can be used to close the fistula. The serratus muscle, unlike the latissimus dorsi muscle, is preserved when performing the thoracotomy.
When massive empyema or candidasis appear along with BPF, using the serratus muscle is not a good choice.8 Hollaus et al.5 reported that intercostal muscle flap can be used for BPF and showed 12% of mortality. It may be difficult for the flap to be dissected when the fistula exist on the upper portion of thorax or the massive fibrosis already progressed.
It can be better choice to use the free flaps than pedicled flap when the BPF is combined with massive empyema, surrounding necrosis or fibrosis. When wide chest wall defect is involved with BPF, free flap could be useful for the reconstruction of soft tissue defect. Although the injury to latissimus dorsi muscle is inevitable when performing the thoracotomy, the pedicle of latissimusdorsi muscle, thoracoabdominal artery, was not injured in two cases above. So they can be used as recipient vessels. In the both cases, BPF was accompanied by soft tissue defect sized over than 60 cm2. So we can consider about musculocutaneous free flap including large muscle. There are some large musculocutaneous flaps, for examples, the latissimus dorsi musculocutaneous flap, rectus abdominis musculocutaneous flap and anterolateral thigh flap including vastus lateralis.
When selecting musculocutaneous flap, surgeon should consider about the patient’s operation history, thickness of the flap, size of BPF, soft tissue defect. When using the rectus abdominis musculocutaneous flap or anterolateral thigh flap, it
has advantage to operate in a lateral decubitus position where thoracic surgery team could operate. If the two mentioned flaps are not available regarding patient’s operation history or thickness of the flap, latissimus dorsi musculocutaneous flap can be choosen. Latissimus dorsi musculocutaneous flap has advantages of large muscle and skin paddle, reliable anatomy as well as disadvantage of need to change position during operation.
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