Ann Thorac Surg 2002;74:1231-1233
© 2002 The Society of Thoracic Surgeons
Case report
Intrathoracic myoplasty for prosthesis infection after superior vena cava replacement for lung cancer
Lorenzo Spaggiari, MD, PhD*a,
Piergiorgio Solli, MDa,
Giulia Veronesi, MDa,
Ugo Pastorino, MDa
a Department of Thoracic Surgery, European Institute of Oncology, Milan, Italy
Accepted for publication May 19, 2002.
* Address reprint requests to Dr Spaggiari, Department of Thoracic Surgery, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
e-mail: lorenzo.spaggiari{at}ieo.it
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Abstract
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Prosthesis infection after lung and superior vena cava system resection for non-small cell lung cancer is a life-threatening complication. We report a case in which an intrathoracic muscle flap transposition was used to cure tracheal fistula associated with prosthesis infection without the explant of the vascular graft.
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Introduction
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Superior vena cava (SVC) system resection for non-small cell lung cancer (NSCLC) is rarely performed, and oncological results are still the object of debate [1]. Prosthetic SVC replacement for lung cancer may pose a risk of life-threatening complications, and prosthesis infection represents a catastrophic event that requires prompt surgical treatment [1, 2]. We report a case in which a prosthetic infection secondary to tracheal fistula was treated by an intrathoracic muscle flap transposition without the explant of the vascular graft.
A 54-year-old man underwent three cycles of chemotherapy (Cisplatine plus Gemcitabine) followed by radiotherapy (50 Gy) for an anterior apical NSCLC. Residual disease was diagnosed at the end of medical treatment, thus a "salvage" surgery was planned. Preoperative staging was performed by means of total body computed tomographic (CT) scan, broncoscopy, and esophagoscopy, that did not show any signs of extrathoracic deposits.
The patient was operated on by means of a right transmanubrial approach and anterolateral thoracotomy as previously reported (Fig 1)
[3], and he underwent right upper lobectomy, tracheal resection with radical lymph node dissection, partial resection of the esophageal muscular wall, and, finally, right brachiocephalic vein (RBCV) and partial SVC resections. Because of the stenosis of the left brachiocephalic vein due to the previous mediastinal radiotherapy, the RBCV was replaced by a ringed No. 12 polytetrafluoroethylene (PTFE) prosthesis anastomosed between the jugular/subclavian veins’ confluence and the origin of the SVC. The tracheal anastomosis was covered by a pericardial fat flap. Pathological examination showed a T4 epidermoid carcinoma with only one lymph node metastasis near the lesion with an overall number of 27 lymph nodes resected (8 hilar and 19 mediastinal nodes). The resection was complete. Fourteen days after surgery, he developed empyema due to a small tracheal membranous fistula (Fig 2).
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Fig 1. The patient was operated on using a right transmanubrial approach and a lateral muscle-sparing thoracotomy. Through these combined approaches, a right brachiocephalic vein resection with polytetrafluoroethylene graft replacement was performed.
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Fig 2. (A) Computed tomographic thoracic scan shows a small tracheal membranous fistula after tracheal resection (continuous arrow). The polytetrafluoroethylene graft is fully patent (dotted arrow). (B) Operative picture during myoplasty shows the prevertebral plane in contact with tracheal fistula (continuous arrow) and the prosthesis near the site of infection (dotted arrow).
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The patient was reoperated on using a posterolateral approach; the prosthesis was clearly contaminated by empyema but it was left in site (Fig 2). After having carefully debrided and washed the thorax, a right latissimus dorsi and serratus anterior muscle flap intrathoracic transposition was performed. The muscles were previously harvested by using an X-shaped skin incision to preserve the common vascular pedicle. A thoracic wall window was created by resecting the third rib, and the flaps were inserted in the cavity through this opening. The myoplasty completely filled the upper part of the right thorax. At the end of the operation, a percutaneous tracheostomy was performed. Thirty-five days after the first operation, the patient was discharged without clinical signs of infection and with the closure of the tracheal fistula at the bronchoscopic examination; the chest x-ray film showed the upper part of the chest completely filled by the myoplasty.
At the first outpatient follow-up (1 month after discharge), the clinical examination as well as the blood analysis did not show any signs of infection; the CT thoracic scan showed closure of the tracheal fistula and patency of the vascular graft without radiological signs of infection (Fig 3).
Unfortunately, the patient was readmitted 2 months later for hemoptysis, and a diagnosis of vascular fistula between an innominate artery and the previous tracheostoma was diagnosed. He was reoperated on and, at the mediastinal exploration, a tight contact with a fistula between the artery and the tracheostoma was present. No macroscopical signs of mediastinal infection were present and the PTFE was completely wrapped by the myoplasty. The patient died 1 month later in the intensive care unit due to respiratory failure.
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Fig 3. Follow-up computed tomographic thoracic scan shows myoplasty fully filling the upper part of the right thorax. No radiological signs of tracheal fistula or infection were present. Note the patency of the polytetrafluoroethylene graft.
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Comment
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Prosthesis infection is a serious event usually secondary to lung complications after SVC resection for lung cancer. In a recent multicenter study [1], 7% of patients who underwent SVC resection with prosthetic replacement for NSCLC developed this devastating complication. Prosthetic infection requires prompt treatment, but the "ideal" therapeutic strategy is not standardized. In this situation, the prosthesis cannot be removed because of the onset of acute fatal superior vena cava syndrome, and prosthetic replacement alone does not resolve the infection. In addition, thoracostomy or the Claggett procedure pose a high risk of failure with a fatal outcome [2].
The rationale for the use of muscle flaps is based in the ability to control local contamination and fill dead space. It has been experimentally demonstrated that muscle flaps may contain and treat local infection by delivering oxygen and leukocytes [4]. From a clinical point of view, its efficacy in the treatment of infected vascular grafts has been recognized [5]. A previous study reports the efficacy of myoplasty in the treatment of prosthetic infection after SVC replacement for NSCLC. In this study, a completion pneumonectomy was performed to treat the lung abscess, and an intrathoracic muscle flap was used to fill the thorax and cover the prosthesis [2].
The prevention of lung complications (eg, broncopleural fistula, lung abscess, pneumonia) after pulmonary resection in patients requiring SVC prosthetic replacement is mandatory to avoid vascular graft complications; however, after the development of prosthetic infection, intrathoracic myoplasty transposition could rescue the patient. Even though our patient had an unfavorable outcome, this was not related to an indolent infection of the graft; in fact, no signs of infection were observed during the follow-up. In addition, intraoperatively, we did not observe any signs of infection and the PTFE graft was wrapped by the myoplasty. The cause of death was the erosion of the innominate artery as sometimes occurs in tracheal surgery. The lessons learned from this case: (A) Intrathoracic myoplasty transposition can cure prosthetic infection; and (B) in salvage surgery mainly performed after chemoradiation therapy, the risk of multiple fatal postoperative complications is very high.
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References
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- Spaggiari L., Thomas P., Magdeleinat P., et al. Superior vena cava resection with prosthetic replacement for non small cell lung cancer: long term results of a multicentric study. Eur J Cardiothorac Surg 2002;21:1080-1086.[Abstract/Free Full Text]
- Alifano M., Puyo P., Magdeleinat P., Levasseur P., Regnard J.F. Management of empyema complicating lobectomy with superior vena cava replacement. Ann Thorac Surg 2000;70:1720-1721.[Abstract/Free Full Text]
- Spaggiari L., Pastorino U. Transmanubrial approach with antero-lateral thoracotomy for apical chest tumor. Ann Thorac Surg 1999;68:590-593.[Abstract/Free Full Text]
- Chang N., Mathes S.J. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. Plast Reconstr Surg 1982;70:1-9.[Medline]
- Maser B., Vedder N., Rodriguez D., Johansen K. Sartorious myoplasty for infected vascular graft in the groin. Safe durable and effective. Arch Surg 1997;132:522-525.[Abstract/Free Full Text]
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Abstract
Introduction
