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Ann Thorac Surg 1996;62:630-631
© 1996 The Society of Thoracic Surgeons
Department of Thoracic Surgery, II Clinica Chirurgica, University "La Sapienza" of Rome, Policlinico Umberto 1, 00161, Roma, Italy
To the Editor:
We read with interest the article by Anderson and Miller [1], which most timely emphasizes the importance of protection of tracheobronchial anastomoses either after bronchoplastic procedures or in patients who had preoperative chemotherapy or radiotherapy. Such a comprehensive review, for its quality and high influence potential, however, should not lack in completeness. We were therefore surprised to note that among the many techniques available for this purpose, Anderson and Miller failed to emphasize the use of the intercostal pedicle flap, which we [2] have reported to be an effective and easy procedure. Based on our experience, we proposed it as the procedure of choice to protect and revascularize bronchial anastomoses. The intercostal muscle is prepared en bloc with a wide pleural flap before the rib retractor is inserted to avoid jeopardizing the muscle's vascular supply [2]. The flap is then divided anteriorly at the costochondral junction and a pedicle based posteriorly on the intercostal artery is obtained. This muscular-pleural flap is long enough to reach any site within the pleural cavity and wide enough to easily encircle and seal any kind of tracheobronchial anastomosis. Its efficacy in protecting and sealing the suture line has been proved in 59 patients undergoing various types of tracheobronchial reconstructive procedures. In particular, it is noteworthy how effective the intercostal pedicle flap was in preventing the occurrence of a bronchopleural fistula in 3 patients previously treated by radiotherapy who had a complete (1) or partial (2) dehiscence of the anastomosis. Bronchoscopically, the pleural surface of the flap was visible bulging into the bronchial lumen, but no bronchopleural or bronchovascular fistula developed, and the patients fully recovered after 6 to 12 months of airway stenting by a silicone prosthesis.
In our article [2] we also addressed the issue of revascularization of the airway stumps, and we demonstrated arteriographically that a properly prepared intercostal pedicle flap may indeed generate a fine vascular network around the anastomosis early in the postoperative period. To the best of our knowledge this has not yet been proved for any other intrathoracic flap (eg, pleura alone, pericardium, mediastinal fat).
Our experience has now increased to 96 patients undergoing bronchial sleeve resection, 24 of whom had had preoperative neoadjuvant chemotherapy for stages IIIA and IIIB lung cancer. The intercostal pedicle flap was used in all of them to encircle the anastomosis. Patients undergoing neoadjuvant chemotherapy, as Anderson and Miller [1] point out most correctly, are particularly at risk for bronchial complications after lobectomy and pneumonectomy, and even more so after sleeve resection. Interestingly, in our group of 24 such patients we did not experience any bronchial complication. We are strongly persuaded that much of the credit for this good result goes to the excellent protection and early revascularization yielded by the intercostal flap technique.
To obtain an ideal flap, the latter has to be taken down before the pleural cavity is opened; this has been regarded as a disadvantage, because one could not be sure whether a sleeve should be performed or not. However, when neoadjuvant therapy patients are concerned, some kind of bronchial protection is recommendable anyhow as pointed out by Anderson and Miller [1], and the intercostal pedicle flap may well be prepared in advance.
Anderson and Miller [1] should be commended for bringing up the issue of flap protection of tracheobronchial sutures, but their fine overview on such an intriguing subject is not complete unless the effectiveness and ease of the intercostal pedicle flap is pointed out. In our experience this proved to be by far the best technique to seal and revascularize bronchial anastomoses.
References
Department of Cardiothoracic Surgery, Emory University School of Medicine, 25 Prescott St, NE, Atlanta, GA 30308
To the Editor:
I agree that the intercostal muscle flap is an excellent means of coverage of the bronchial stump. It was not mentioned in our article because articles on its advantages have been published numerous times in The Annals in the last 10 years.
Our article covered other means available for coverage of the bronchial stump.
This article has been cited by other articles:
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  A. D'Andrilli, M. Ibrahim, C. Andreetti, A. M. Ciccone, F. Venuta, and E. A. Rendina Transdiaphragmatic Harvesting of the Omentum Through Thoracotomy for Bronchial Stump Reinforcement Ann. Thorac. Surg., July 1, 2009; 88(1): 212 - 215. [Abstract] [Full Text] [PDF]
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B. H. Kwek, J. C. Wain, and S. L. Aquino The radiologic appearance of intercostal muscle flap Ann. Thorac. Surg., August 1, 2004; 78(2): 432 - 435. [Abstract] [Full Text] [PDF]
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