Ann Thorac Surg 2001;71:1702
© 2001 The Society of Thoracic Surgeons
Case report: invited commentary
Invited commentary
Erino A Rendina, MDa,
Stanley C Fell, MDb
a Department of Thoracic Surgery, Universita’ di Roma "La Sapienza", II Clinica Chirurgica, Policlinico Umberto I, Rome 00161, Italy
b Cabin Ridge, Campfire Rd, Chappaqua, NY 10514, USA
(Email: erinoangelo.rendina{at}tin.it).
As the interest in bronchial sleeve resection increases, a number of technical issues arise that pertain specifically to this operation. The use of steroids in the early postoperative period, the possibility of reimplanting segmental bronchi, and the association with the reconstruction of the pulmonary artery are all currently being investigated. In this regard, the case report by Deeb and coworkers is a timely presentation on the main and perhaps the only complication of the use of the intercostal muscle flap. However, although reossification of the intercostal muscle flap can occur, it does not necessarily cause problems. In a series of 145 patients undergoing sleeve resection for lung cancer, we observed this phenomenon occasionally, but it did not have any impact on the bronchial caliber (Fig 1). The ossified intercostal muscle flap caused mild stenosis at the anastomotic site and at the origin of the segmental bronchi in only 1 patient 6 years after left upper sleeve resection. Two years later, bronchoscopy showed stable findings, and no obstruction, atelectasis, or other complications have developed.
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Fig 1. Reossification of the intercostal pedicle flap occurring three months after right upper sleeve lobectomy. The residual lobes are acceptably ventilated and the airway at the level of the anastomosis shows a normal caliber.
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The case report by Deeb and associates prompts a few considerations: - 1. The authors brilliantly solved a difficult technical problem, but the accuracy of the harvesting and wrapping of the intercostal muscle flap cannot be ascertained because the original operation was performed at another institution.
- 2. Although some authors use two intercostal muscles, one muscle en bloc with a wide pleural flap is enough to encircle any bronchial anastomosis. This minimizes the amount of periosteum around the airway.
- 3. The use of silver nitrate is an easy and efficient solution to avoid ossification.
- 4. If the intercostal muscle flap is applied loosely around the bronchus, even if some retraction occurs, there is no reason why the hardening caused by ossification should produce stenosis.
- 5. Retraction can be limited by carefully preserving the vascular supply to the flap.
It is our opinion that the advantages of the use of the intercostal muscle flap largely outweigh its shortcomings: its versatility, ease of use, and efficacy in the protection and revascularization of the airway make it a precious ally in bronchial reconstructive surgical procedures.
