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Ann Thorac Surg 2001;71:1700-1702
© 2001 The Society of Thoracic Surgeons
a Section of General Thoracic Surgery, Department of Surgery, Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
b Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
Accepted for publication May 2, 2000.
Address reprint requests to Dr Kaiser, Section of General Thoracic Surgery, University of Pennsylvania Medical Center, 3400 Spruce St, 6th Floor, Silverstein Building, Philadelphia, PA 19104
e-mail: kaiser{at}mail.med.upenn.edu
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Introduction |
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A 63-year-old man was diagnosed with squamous cell carcinoma of the right lower lobe in 1996. He subsequently underwent right lower sleeve lobectomy with reanastomosis of the right middle lobe bronchus to the proximal bronchus intermedius by an outside surgeon. An intercostal muscle flap was harvested in a subperiosteal fashion from both above and below the ribs and wrapped circumferentially around the anastomosis. Bronchoscopy performed immediately after operation showed the anastomosis to be patient.
Six months later, the patient began to experience recurrent right middle lobe pneumonias resulting in repeated hospitalizations for intravenous antibiotics. Repeat bronchoscopy demonstrated severe stenosis of the bronchial anastomosis. A 10-mm silicone Hood stent was inserted by way of a rigid bronchoscope across the stenotic right bronchus intermedius anastomosis. The patient demonstrated definite clinical improvement for 2 months after stent insertion, but he then had recurrence of pneumonia and progressive dyspnea. Repeat bronchoscopy was performed again, and the stent was found to be dislodged from the bronchus intermedius and obstructing the right upper lobe bronchial orifice. The stent was removed from the airway. An attempt was made to insert an expandable wire stent into the stenotic anastomosis, but by then the lumen was too small to accommodate even the guidewire.
Subsequently the patient was seen with methicillin sodium–resistant staphylococcal pneumonia. Flexible bronchoscopy again showed nearly complete obstruction of the bronchus intermedius by dense, fibrotic tissue. Preoperative chest computed tomographic scan demonstrated narrowing of the right middle lobe bronchus with dense calcification along the course of the intercostal muscle flap (Fig 1). Despite the fact that severe underlying chronic obstructive pulmonary disease (forced vital capacity of 1.01 L [27%] and forced expiratory volume in 1 second of 0.89 L [33%]) placed him at a high risk for perioperative complications, surgical resection was considered the patient’s only therapeutic option.
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Heterotopic ossification of the intercostal muscle pedicle is a well-known phenomenon [2, 5, 6] with uncertain clinical implications. Rendina and colleagues [2] reported excellent clinical results with the use of intercostal muscle flaps in 56 patients undergoing sleeve resection or lung transplantation; anastomotic dehiscence occurred in 3 patients (5%), all of whom had undergone preoperative irradiation, but none of the dehiscences resulted in broncopleural fistula. Some of the patients had ossification of the pedicles, but this was not of clinical significance in any patient. This fact might be attributed to the harvesting technique: a sub-periosteal dissection was done on the upper rib only, which meant that the intercostal muscle flap had periosteum on only one side of the pedicles.
Prommegger and Salzer [5] reported the case of a patient similar to ours in whom bronchial stenosis developed postoperatively as the results of flap calcification after sleeve resection. This patient was treated with excision of the ossified parts of the muscle flap. In an experimental study, Fell and associates [6] showed that cauterization of the periosteum with 30% silver nitrate reduced the amount of calcification of the pedicle, and later Fell [7] suggested loose wrapping around the bronchial anastomosis or esophagaeal repair.
Stenting a lumen in this setting is problematic because of the high and fixed extrinsic pressure developed by the calcifications, and surgical intervention is likely to be unavoidable. It is our opinion that even techniques such as partially avoiding subperiosteal resection and cauterizing with silver nitrate cannot completely avert the risk of subsequent calcification. Complete removal of periosteum, including that portion along the upper rib, jeopardizes the blood supply to the flap. Therefore, we prefer to wrap sleeve anastomoses preferentially with pericardial fat or, if this is insufficient, with pleura. Omentum should also be strongly considered in the highest-risk situations, such as in patients who have had preoperative radiation therapy.
Although sleeve resection with reattachment of the middle lobe is rarely indicated (in the case of our patient, this decision was made by an outside surgeon), this report of stenosis of a sleeve anastomosis caused by muscle flap ossification after such a reconstruction is nevertheless instructive. Our experience and our review of the literature suggests that perhaps any circumferential wrapping with an intercostal muscle flap is unwise, as the potential for circumferential stenosis resulting from heterotopic calcification is always present. We recommend the use of the pedicled intercostal muscle flap only in clinical circumstances where an onlay wrap rather than a circumferential wrap, will suffice.
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