Ann Thorac Surg 1998;66:586-587
© 1998 The Society of Thoracic Surgeons
How to Do It
Pericardial closure using fascia lata in patients undergoing pneumonectomy with pericardiectomy
Yoshihiko Kageyama, MDa,
Kazuya Suzuki, MDa,
Kozo Matsushita, MDa,
Hiroshi Nogimura, MDa,
Teruhisa Kazui, MDa
a First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
Accepted for publication April 17, 1998.
Address reprint requests to Dr Kageyama, First Department of Surgery, Hamamatsu University School of Medicine, 3600 Handa-cho, Hamamatsu, Shizuoka 431-3192, Japan
e-mail: (kageka{at}hama-med.ac.jp)
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Abstract
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In patients undergoing pneumonectomy with concomitant pericardiectomy, patch closure of the defect in the pericardium is required to prevent postoperative cardiac herniation. We used harvested autologous fascia lata as a pericardial patch in such operations on 6 patients with progressive lung cancer after induction chemoradiotherapy.
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Introduction
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In recent years, there have been reports from several centers of bronchial stump fistula and empyema as fatal postoperative complications of pneumonectomy after induction chemoradiotherapy for progressive lung cancer [1, 2]. In patients undergoing concomitant pericardiectomy, the pericardial defect should be closed to prevent cardiac herniation [3], but artificial materials such as expanded polytetrafluoroethylene are liable to become a focus for infection [4]. We used harvested autologous fascia lata as a pericardial patch and covered the bronchial stump with pedunculated mural pleura.
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Technique
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Before the operation, both the chest and the trunk as far as the thigh were disinfected. When procedures in the chest cavity were almost complete, or in parallel with the intrathoracic procedures except the pericardial closure, a transverse incision of about 10 cm was made in the thigh region without a change in patient position (Fig 1). After blunt dissection of the subcutaneous tissue and the fascia lata, sufficient fascia lata to serve as a pericardial patch was harvested with electrocautery. After harvesting, the incision was closed without insertion of a drain. The harvested fascia lata was trimmed to match the size and shape of the pericardial defect, the fascia lata was attached to the pericardiectomy site by mattress sutures of 2-0 Ti-cron (Sherwood Davis & Geck, St. Louis, MO), and the defect was closed. We used pedunculated mural pleura to wrap the bronchial stump and attached it with fibrin glue.
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Fig 1. Autologous fascia lata was harvested with electrocautery through a transverse incision high on the lateral thigh.
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Comment
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In patients undergoing pneumonectomy with concomitant pericardiectomy, patch closure of the pericardial defect is necessary to prevent postoperative cardiac herniation. In recent years, induction chemotherapy and radiotherapy have been used for patients with progressive lung cancer, and pneumonectomy associated with concomitant pericardiectomy is also performed in some cases after such treatment. Sheets of artificial materials such as expanded polytetrafluoroethylene are generally used for pericardial patches, but these materials have very weak resistance to infection, and complete cure is often impossible unless the patch is removed once infection occurs. We have experienced 3 patients with empyema after pneumonectomy with pericardiectomy and patch closure using expanded polytetrafluoroethylene pericardial sheets after induction chemotherapy, and 1 of these patients died. Although absorbable mesh (polyglycolic acid mesh) may be promising compared with other artificial materials, such mesh has not been applied clinically in patients undergoing pneumonectomy. There may still be some problems to be solved, especially in terms of strength [5].
We have used fascia lata as a pericardial patch in patients undergoing pneumonectomy with pericardiectomy after induction chemoradiotherapy for progressive lung cancer since August 1996. This procedure has been employed for 6 patients to date, and none of them has had any complications related to the use of fascia lata.
Fascia lata is widely used in plastic surgical operations in various fields, and there are reports of its use for pericardial patches after open heart operations [6]. Its value has been widely confirmed. This tissue is easy to harvest and can be obtained in only about 10 minutes by our method. Strength is no problem, but it has the disadvantage of creating a wound in another area besides the chest.
In the future, with the increase in the number of patients undergoing induction chemoradiotherapy, it will become impossible to overlook problems such as susceptibility to infection and tissue fragility after induction therapy. It is therefore possible that the use of fascia lata grafts will increase further.
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Acknowledgments
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We gratefully acknowledge Yoshio Ueda, MD, PhD, Department of Oral and Maxillofacial Surgery, for his technical assistance and Satoru Ban, MD, First Department of Surgery, Hamamatsu University School of Medicine, for his kind assistance.
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References
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- Puskas J.D., Mathisen D.J., Grillo H.C., Wain J.C., Wright C.D., Moncure A.C. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg 1995;109:989-995.[Abstract]
- Chella A., Lucchi M., Ribechini A., et al. Pre-operative chemotherapy for stage IIIa (N2) non–small cell lung cancer. Eur J Surg Oncol 1995;21:393-397.[Medline]
- Papsin B.C., Gorenstein L.A., Goldberg M. Delayed myocardial laceration after intrapericardial pneumonectomy. Ann Thorac Surg 1993;55:756-757.[Abstract]
- Koskas F., Goeau-Brissonniere O., Nicolas M.H., Bacourt F., Kieffer E. Arteries from human beings are less infectible by Staphylococcus aureus than polytetrafluoroethylene in an aortic dog model. J Vasc Surg 1996;23:472-476.[Medline]
- Bunton R.W., Xabregas A.A., Miller A.P. Pericardial closure after cardiac operations. An animal study to assess currently available materials with particular reference to their suitability for use after coronary artery bypass grafting. J Thorac Cardiovasc Surg 1990;100:99-107.[Abstract]
- Kohanna F.H., Adams P.X., Cunningham J.N., Jr, Spencer F.C. Use of autologous fascia lata as a pericardial substitute following open-heart surgery. J Thorac Cardiovasc Surg 1977;74:14-19.[Abstract]
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Abstract
Introduction
