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Ann Thorac Surg 2001;71:2081-2082
© 2001 The Society of Thoracic Surgeons

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Correspondence

Diaphragm flap for routine prophylactic reinforcement of bronchial stump after pneumonectomy

^a Section of Cardiothoracic Surgery, Yale University School of Medicine, 121 FMB, 333 Cedar St, New Haven, CT 06510, USA

e-mail: john.elefteriades{at}yale.edu

To the Editor

Our recent literature review disclosed an article by Mineo and Ambrogi [1] on therapeutic use of a diaphragm flap for treatment of postpneumonectomy bronchopleural fistula. We had independently utilized a similar technique for prevention of postpneumonectomy bronchopleural fistula. We believe that prophylactic application of this technique deserves consideration as one alternative for reinforcing the bronchial stump after pneumonectomy.

Many surgeons believe that prophylactic reinforcement of the bronchial stump following pneumonectomy confers added security against bronchial stump leak and associated complications. Pleura, intercostal muscle, pericardium, azygous vein, and pericardial fat pads are employed for stump reinforcement. In fact, a more robust flap—thicker, larger, better vascularized, more versatile—is easily available in the operative field: the diaphragm itself. Surgeons do not consider the diaphragm disposable, having been trained to preserve the phrenic nerve and diaphragm because of their importance to respiration. However, the ipsilateral diaphragm is generally inconsequential following pneumonectomy. Some surgeons deliberately crush the phrenic nerve, allowing the diaphragm to rise up to minimize the postpneumonectomy space.

In our technique, a rectangular, medially based flap of diaphragm is taken by two parallel, radially directed incisions extending outward from the central mediastinum (Fig 1). The parallel incisions are carried out to the costal margin. A large, bulky, well-vascularized flap results which can reach throughout the thorax. The flap is hinged at its medial base and advanced to the previously closed bronchial stump. The thoracic surface of the diaphragm pedicle faces inward toward the mediastinum. The pedicle is attached to the mediastinal tissues around the bronchial stump by interrupted sutures, creating a roof over the stump. The resulting defect in the diaphragm is closed with a running suture begun at each end of the harvest site and carried toward the middle. This suture accomplishes hemostasis of the vascular diaphragm as well as closing the defect. The entire process is simple, efficient, and definitive. We have used this technique routinely after pneumonectomy, following an initial application in a patient previously heavily radiated for unrelated lymphoma. In each case, this technique has proven feasible, easy to implement, and effective in preventing bronchial stump leak.

View larger version (63K): [in this window] [in a new window]   Fig 1. Technique of prophylactic diaphragm flap reinforcement for prevention of bronchopleural fistula following pneumonectomy. (A) Mobilization of medially based transmural diaphragm flap. (B) Closure of diaphragm. (C) Close-up of flap over bronchus.

Petrovsky [3] used the diaphragm as a flap during the 1950s, especially for esophageal defects. The diaphragm has been used to close established bronchopleural fistulas presenting late after operation, as empyema or space infection, as in the article by Mineo and Ambrogi [1]. Yet, despite the severity of bronchopleural fistula, surgeons do not commonly employ the diaphragm prophylactically to reinforce the bronchial stump after pneumonectomy. We recommend this technique specifically for routine prophylactic application for the prevention of the serious complication of postpneumonectomy bronchial stump breakdown and its accompanying sequellae. It is possible that routine application of this technique may decrease the incidence of this dreaded problem.

References

1. Mineo T.C., Ambrogi V. Early closure of the postpneumonectomy bronchopleural fistula by pedicled diaphragmatic flaps. Ann Thorac Surg 1995;60:714-715.[Abstract/Free Full Text]
2. Puskas J.D., Mathisen D.J., Grillo H.C., et al. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg 1995;109:989-996.[Abstract]
3. Petrovsky B.V. The use of diaphragm grafts for plastic operations in thoracic surgery. J Thorac Cardiovasc Surg 1961;41:348-355.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sayeed-Shah, U. Articles by Elefteriades, J. A. Search for Related Content PubMed PubMed Citation Articles by Sayeed-Shah, U. Articles by Elefteriades, J. A. Related Collections Lung - other Related Article