Ann Thorac Surg 1997;63:837-839
© 1997 The Society of Thoracic Surgeons
Case Reports
Treatment of Empyema by Transposition of Contralateral Lower Trapezius Flap
Hideyo Watanabe, MD,
Munehisa Imaizumi, MD,
Seijiro Takeuchi, MD,
Mitsuya Murase, MD,
Takashi Hasegawa, MD
Departments of Thoracic Surgery and Plastic and Reconstructive Surgery, Nagoya University School of Medicine, Nagoya, Japan
Accepted for publication October 10, 1996.
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Abstract
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We report the successful treatment of bronchopleural fistula and empyema using transposition of a contralateral lower trapezius musclocutaneous flap, which provided immediate obliteration of the middle-back empyema cavity. This technique is easy to perform without any intraoperative change of position and with little postoperative impairment of the back and shoulder movement.
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Introduction
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Successful treatment of empyema using an omental pedicle flap or some muscle flaps has been reported. Here we present a case of a bronchopleural fistula and an empyema successfully treated using a contralateral lower trapezius island musclocutaneous flap (LTIMF).
A 59-year-old man underwent right hemicolectomy for ascending colon carcinoma in November 1990. A right lung tumor was found on the chest roentgenograms in April 1993. After transbronchial biopsy, a high-grade fever appeared accompanied by chest pain. The pathologic diagnosis revealed a metastatic colon carcinoma and systemic survey showed no other metastases. He was admitted to the hospital for resection of the tumor.
On admission, his body temperature was 39.0°C and a chest roentgenogram demonstrated a 12 x 8-cm tumor with an abscess cavity in the right lower lobe. On August 4, 1993, through a posterolateral incision, the tumor was found to be adherent to the parietal pleura and purulent discharge from the tumor appeared during operation. Right lower lobectomy and partial resection of the upper lobe were performed.
On August 10, the patient showed an empyema at the posterior thoracic space, and almost all of the wound was opened because of infection. The empyema cavity was drained by the open wound. After irrigation, reoperation was performed on September 10. The patient was placed in the left lateral decubitus position and the full length of the previous operation wound was reopened. We found an abscess formation in the middle posterior thoracic cavity and air leakage in both the suture line of the upper lobe and the right lower bronchial stump. The size of empyema cavity was estimated 10 x 5.5 x 5.0 cm. We removed 8 cm length of the fifth and sixth ribs. We made a vertical fusiform 4 x 25-cm incision between the scapula and midline at the opposite side, and the entire lower portion of trapezius muscle was divided from the level of interface between the rhomboid minor and rhomboid major muscles to the level of the 12th thoracic vertebra. The left LTIMF was placed over the latissimus dorsi and rhomboid muscle (Fig 1
). We deepithelialized the skin of the flap, leaving the subcutaneous tissues on the muscle, and created a subcutaneous tunnel to transfer the LTIMF into the abscess cavity across the midline. The LTIMF was sutured to the opening of the fistula using 4-0 Prolene (Ethicon, Somerville, NJ), the abscess cavity was obliterated, and the chest tube was not left. The donor site was then closed primarily over the closed-suction drainage. The patient was extubated immediately after the operation.
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Fig 1. . The lower trapezius musclocutaneous flap harvested without division of the dorsal scapular artery for contralateral thoracic empyema with no intraoperative position change.
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He was laid on an air-floating bed (Clinisystem; Advanced Medical Technology Inc, Tokyo, Japan) for a week to avoid compression of the flap pedicle at the spinal column. He had an uncomplicated recovery. Computed tomography showed obliteration of the abscess cavity with the LTIMF (Fig 2). He had no shoulder drop or functional impairment. The patient remains alive with intrathoracic recurrence 2
years after the operation.
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Fig 2. . Postoperative chest computed tomogram shows near-complete obliteration of empyema cavity with the lower trapezius musculocutaneous flap ( arrow).
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Comment
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Many muscle flaps and omentum have been used to manage the empyema thoracis. The LTIMF was introduced for head and neck reconstruction [1] and has sometimes been used for the treatment of empyema thoracis after pulmonary resection. As it provides a long arc of flap pedicle, it can be rotated as far as the scalp or the face over the midline in a single stage [2]. Empyema with bronchopulmonary fistula after pulmonary resection may sometimes be located in the middle posterior thoracic cavity near the vertebra. When the ipsilateral trapezius muscle has been transected in the first operation, a contralateral LTIMF can easily reach that area and obliterate the empyema cavity. It is considered an excellent alternative when the latissimus dorsi or the omentum cannot be used. This procedure does not require any intraoperative change of position.
Several technical points must be emphasized. Contralateral LTIMF will cross over the midline, and the spinous process may cause compression of the flap pedicle in a supine position. Therefore, measures must be taken to preserve the vascular supply and the viability of the flap. In this case we used an air-floating bed for a week after the operation. Resection of the spinous process is considered an alternative. However, more studies will be necessary to prove the safety of vascular supply by this technique.
The lower extent of the skin paddle that can be reliably harvested with the trapezius muscle may be important. The lower part of the trapezius muscle is supplied by both the transverse cervical artery and the dorsal scapular artery [3]. If it is harvested based on branches of both of these arteries, the inferior extent may extend 10 to 15 cm caudal to the tip of the scapula [4]. Because the arc of rotation of this flap to the contralateral thoracic cavity is not longer than that used in head and neck reconstruction, it is easy to elevate the LTIMF without dissection of the dorsal scapular artery. To extend the pedicle length, the descending branch of the dorsal scapular artery, which travels deep into the rhomboid major muscle, is divided and the rhomboid minor muscle is either partially or totally divided [3].
However, the disadvantage of the LTIMF is its size limitation for obliteration of a large empyema cavity, which may require thoracoplasty or combined use of other muscle flaps or omentum.
The LTIMF has been used for head and neck reconstruction because the trapezius muscle is a thin, flat muscle, the subcutaneous tissue is sparse, and the skin is hairless. The LTIMF does not cause impairment of the back and shoulder movement [2]. We believe that contralateral LTIMF is useful in thoracic surgery, as in this example for a management of bronchopleural fistula and the empyema or for chest wall reconstruction.
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Footnotes
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Address reprint requests to Dr Watanabe, Department of Thoracic Surgery, Nagoya University School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya, Japan.
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References
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- Baek S, Biller HF, Krespi YP, Lawson W. The lower trapezius island myocutaneous flap. Ann Plast Surg 1980;5:108–14.[Medline]
- Urken ML, Naidu RK, Lawson W, Biller HF. The lower trapezius island myocutaneous flap revisited. Arch Otolaryngol Head Neck Surg 1991;117:502–11.[Abstract/Free Full Text]
- Netterville JL, Wood DE. The lower trapezius flap. Arch Otolaryngol Head Neck Surg 1991;117:73–6.[Abstract/Free Full Text]
- Netterville JL, Panje WR, Maves MD. The trapezius myocutaneous flap. Arch Otolaryngol Head Neck Surg 1987;113:271–81.[Abstract/Free Full Text]
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Abstract
Introduction
