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Ann Thorac Surg 1996;61:1112-1114
© 1996 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Pericardial Repair After Extensive Resection: Another Use for the Pedicled Diaphragmatic Flap

Department of Thoracic Surgery, Royal Brompton Hospital, London, England

Accepted for publication December 27, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Extended resection for pulmonary malignancy frequently leaves a large pericardial defect, sometimes associated with resection of the phrenic nerve. On the left the defect does not require repair; as long as the defect is sufficiently large to avoid constriction, the heart can herniate freely. On the right such herniation is associated with venous inflow occlusion and death. The pedicled diaphragmatic flap has been used in other situations in thoracic surgery. We have modified this to allow closure of the pericardial defect and concurrent plication of the denervated diaphragm. It may also be used to cover the bronchial stump or a bronchial anastomosis.

Methods. The flap has been used in 13 patients over an 11-year period.

Results. Secure closure of the pericardial defect has been achieved in all patients with satisfactory plication of the diaphragm. Reoperation for bleeding was necessary in 3 patients, but in only 1 was the diaphragm shown to be the site of bleeding. Patients otherwise made an uneventful recovery.

Conclusions. A large pedicled flap of redundant diaphragm provides secure closure for large pericardial defects after extended right pneumonectomy.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Extensive intrapericardial resection for pulmonary malignancy usually leaves a large pericardial defect that is difficult to close without compromise of the pericardial space. On the left, the pericardial defect can be opened widely to allow free movement of the heart without hemodynamic problem. However, on the right, it is necessary to repair the pericardial defect because of the possibility of cardiac herniation with torsion of the great veins and subsequent cardiac arrest [1, 2]. There are several methods of closure, including suturing the cut edges of the pericardium to the epicardium, or patching the defect with parietal pleura or fascia lata [3, 4]. Pericardial substitutes such as strips of bovine pericardium or synthetic materials are also available for this purpose [3, 5, 6]. However, in our practice, we have used a pedicled diaphragm flap with satisfactory results.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
During the last 11 years (1983 to 1993), one of us (P.G.) has used a rotation pedicled diaphragmatic flap in 13 patients who had undergone extensive intrapericardial pulmonary resection in the Thoracic Surgical Department of the Royal Brompton Hospital. There were 9 men and 4 women, ranging in age from 23 to 77 years. Operations were performed for non–small cell lung cancer in 9 cases, small cell lung cancer in 1, non-Hodgkin's disease in 1, liposarcoma in 1, and pulmonary metastasis in 1. The operations included right intrapericardial pneumonectomy in 10 patients, right sleeve pneumonectomy in 1, left pneumonectomy in 1, and right middle and upper lobectomy in 1. During the operation, an extensive resec-tion of the pericardium was undertaken, and although efforts were made to preserve the phrenic nerve, it had to be divided in 12 cases because of the malignant involvement. After the tumor was removed, a pedicled diaphragm flap based medially on the pericardiacophrenic artery or inferior phrenic artery was harvested, with a size matching the pericardial defect. The diaphragmatic defect was closed with continuous suture of braided nonabsorbable material, thus achieving plication as the denervated diaphragm (Fig 1). The diaphragm flap was then reflected superiorly such that the peritoneal surface was outermost, and it was sutured to the margins of the pericardial defect. An adequate sized foramen was left for the superior vena cava to avoid narrowing it. The same flap was also used to cover the bronchial stump in 5 patients after right pneumonectomy and to wrap the tracheobronchial anastomosis in 1 patient after right sleeve pneumonectomy.

View larger version (185K): [in this window] [in a new window]   Fig 1. . Technique for repair of pericardial defect with pedicled diaphragmatic flap (Reproduced with permission from Shields TW, ed. General thoracic surgery, 4th ed. Baltimore: Williams and Wilkins, 1994) .

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Surgeons have been interested in the diaphragm for various uses for a long time. It has been used as a biologic material for repair or reconstruction because of its rich blood supply and simple technique. In 1959, Kantrowitz and McKinnon [7] experimentally used the diaphragm as an auxiliary myocardium. Petrovsky [8] reported very comprehensive experience on the use of diaphragm grafts for plastic operations in thoracic surgery in 1961. Since then, uses of diaphragm flap for various purposes have been reported. It was used to repair or reinforce esophageal perforation or acute esophageal fistulas and injuries [9–11], to treat esophageal achalasia [12], to close chest wall defects [13], and to reinforce anastomosis of the intestines [14]. For lung cancer patients, Vogt-Moykopf and associates [15] use the pedicle diaphragm as one of their methods to secure the tracheobronchial anastomosis after sleeve resection, especially for enveloping carinal anastomoses.

In our practice, we find that a pedicled diaphragmatic flap is an ideal biologic material for repairing the pericardial defect after extensive resection of a pulmonary malignancy. It is strong, elastic, and well vascularized. In addition, the parietal pleural cover on the diaphragmatic flap provides a smooth inner surface, which is similar to that of the pericardium. The method is simple, practical, and also economical. With the use of diaphragm flap, we can not only repair the pericardial defect to prevent herniation of the heart, but also cover the bronchial stump or wrap the tracheobronchial anastomosis with the same flap when necessary. Plication of the hemidiaphragm to repair the diaphragmatic defect after harvesting the diaphragmatic flap can effectively prevent postoperative paradox movement for patients whose phrenic nerve had to be divided because of malignant involvement.

A large variety of prosthetic materials have been used to repair pericardial defects. Although for the cardiac surgeon, the choice is predominantly based on a concern to avoid adhesions at reoperation [16], the thoracic surgeon is predominantly concerned with the dangers of infection and a desire to avoid cardiac herniation. Pneumonectomy will be complicated by the development of empyema in 2% to 26% of cases [17]. Although infection around a prosthesis inserted to fill a chest wall defect is uncommon [18, 19], it is a troublesome problem and usually requires the removal of the prosthetic material. One might expect this to prove much more difficult in the deep location of a prosthesis used to fill a pericardial defect. Newer materials such as Marlex or polytetrafluoroethylene are more resistant to infection, but their removal would prove hazardous and difficult in this situation. Autologous materials are readily available, free of cost, and resistant to infection. We have found pleura to be too thin and tenuous to function as a pericardial substitute, and it seemed sensible to us to make use of redundant tissue available when the diaphragm has been denervated by extended resection of the pericardium and phrenic transection.

We have used this technique on one occasion on the left side, but found it less satisfactory, because the flap had to extend across the apex of the heart, so it is difficult to reach the stump. Usually, pericardial defects on the left are widely opened down to the diaphragm to allow the free movement of the heart without strangulation.

Reoperation for bleeding was necessary in 3 of our cases (23%). Although the source of bleeding was located on the pericardial flap in only 1 case, we must consider that the flap may have been incriminated in more cases. Bleeding is not uncommon after such extended resections. In our review of transfusion practices [20], blood transfusion was required in 54% of pneumonectomy patients and in all those having completion pneumonectomy. In another of our studies [21], reoperation for bleeding was necessary in 8% of our cases undergoing completion pneumonectomy, an operation with many of the technical difficulties attendant upon extended resection. Other authors reporting the morbidity of extended resection found bleeding to be troublesome in 13% of such cases [22]. The incidence of bleeding in this small series having pericardial substitution is not, therefore, alarming, and we believe the other advantages of this technique outweigh this possible hazard. Care must, however, be exercised when inspecting the flap before using it to close the pericardial defect.

In our series of 13 cases, the immediate postoperative effect was satisfactory. No serious cardiac or respiratory complications such as cardiac herniation, cardiac tamponade, infection, paradox movement, or bronchial fistula were found. The pedicled diaphragmatic flap is a good material for repair of the pericardial defect after extensive resection of pulmonary malignancy on the right. It can also be used to cover the bronchial stump or to wrap the tracheobronchial anastomosis when necessary. Repair of the resultant diaphragmatic defect provides plication, thus preventing paradox movement when the phrenic nerve had to be divided. Our experience showed that this method is effective to prevent serious postoperative cardiac and respiratory complications.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Doctor X. Jiao is a Chinese visiting scholar supported by the World Health Organization Fellowship.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Goldstraw, Department of Thoracic Surgery, Royal Brompton Hospital, Sydney St, London, SW3 6NP England.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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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): Peter Goldstraw Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Goldstraw, P. Articles by Jiao, X. Search for Related Content PubMed PubMed Citation Articles by Goldstraw, P. Articles by Jiao, X.