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Ann Thorac Surg 2002;73:349
© 2002 The Society of Thoracic Surgeons
a Section of General Thoracic Surgery, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St, 4th Floor Silverstein, Philadelphia, PA 19104-4283, USA
To the Editor
We welcome the opportunity to reply to Dr Demos’ letter regarding our report of a bronchial anastomostic stricture after ossification of a wrapped intercostal muscle. We will also take this opportunity to respond briefly to the thoughtful comments from Drs Rendina and Fell in the Discussion section after our article. We are surprised this case report has stirred up so much interest.
We agree with all three commenting surgeons that stricture resulting from ossification of an intercostal muscle flap is an uncommon occurrence. We have also used wrapped intercostal muscle pedicles in many cases, and this is the only one in which we have seen this complication, thus the report. Unlike Dr Demos, however, we have no trouble imagining how an ossifying pedicle can stricture the tracheobronchial tree as it contracts. We took pains in the wording of our initial article to clarify that there was likely some role of the small caliber of this patient’s ill-conceived middle lobe to bronchus intermedius anastomosis in the development of the stricture. Although we feel it is likely that ossification of the muscle flap wrapped circumferentially around an already small anastomosis is what led to further narrowing and thus clinical deterioration, there is no way to be certain that this is the case. Surely, a small amount of narrowing due to contraction of an ossifying muscle flap around a wider anastomosis, such as that created after a sleeve right upper lobectomy, would not usually lead to clinical problems. Nevertheless, this does occasionally occur, as evidenced by Drs Rendina and Fell’s mention of one patient with such a narrowing due to an ossified flap in a patient late after a sleeve left upper lobectomy, and by the report from Prommegger and Salzer referenced in our article.
To our knowledge there is no evidence that silver nitrate actually reduces this uncommon complication in patients, or that it may not have other unwanted side effects. Furthermore, in our view, applying the wrap exceedingly loosely around the anastomosis may not allow it to serve the intended purpose of buttressing against leaks and bringing in an outside vascular supply.
Given that we feel that there is some, albeit low, risk of stenosis at anastomoses circumferentially wrapped by intercostal muscle flaps, and given that there are other vascularized pedicled flaps available that have never been proven to be any less effective than intercostal muscle and have zero risk of ossification (ie, pericardial fat wraps), we still favor the use of these alternative buttresses in settings requiring a circumferential wrap. However, if the pericardial fat is of insufficient bulk, as it sometimes is, we do not hesitate to use intercostal muscle including the periosteum of only one rib in the harvested flap.
Related Article
Ann. Thorac. Surg. 2002 73: 349.
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