Ann Thorac Surg 2004;77:351-353
© 2004 The Society of Thoracic Surgeons
How to do it
Protection of right pneumonectomy bronchial sutures with a pedicled thymus flap
Maurizio V. Infante, MD*a,
Marco Alloisio, MDa,
Luca Balzarini, MDb,
Umberto Cariboni, MDa,
Alberto Testori, MDa,
Matteo A. Incarbone, MDa,
Paolo Macri, MDa,
Gianluigi Ravasi, MDa
a Department of Thoracic Surgery, Milan, Italy
b Department of Radiology—NMR, Humanitas Hospital (Istituto Clinico Humanitas), Milan, Italy
* Address reprint requests to Dr Infante, Department of Thoracic Surgery, Istituto Clinico Humanitas, Via Manzoni 56, 20089 Rozzano, Milan, Italy
e-mail: maurizio.infante{at}humanitas.it
Presented at the Poster Session of the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.
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Abstract
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A pedicled flap obtained by mobilizing the right lobe of the thymus was used to protect bronchial sutures in 29 consecutive patients undergoing a right pneumonectomy and in 4 additional patients. Fourteen patients had received preoperative chemotherapy with or without radiotherapy. The flap procedure was, in general, easy to do, required an average time of 20.4 minutes, and did not cause added operative morbidity. Postoperative magnetic resonance imaging, performed in 21 of the 29 patients who had pneumonectomy, showed a viable flap in every instance. One bronchopleural fistula occurred in a pneumonectomy patient after induction chemotherapy plus radiotherapy in a patient in the pneumonectomy group in whom adult respiratory distress syndrome developed postoperatively and who required prolonged mechanical ventilation.
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Introduction
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The thymus flap has been reported for use in tracheal reconstructive operations [1]. A flap obtained from the right lobe of the thymus can also be used to reduce the risk of bronchopleural fistula after pneumonectomy. Although a similar flap was first described in 1953 [2], it has not been used widely thereafter, perhaps because, as Brewer and associate [2] and others [3, 4] pointed out, the flap often tends to be too short. A modified technique to obtain a suitable flap from the right lobe of the thymus is described here.
In adulthood, the intrathoracic portions of the two thymic lobes remain as fibrofatty tissue pads lying on the anterior-superior pericardium. A separate and consistent blood supply for each lobe comes from the superior pericardial branches of the mammary arteries [1].
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Technique
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In our center, right pneumonectomy bronchial stumps are routinely stapled. The flap procedure is as follows: The limits of the flap are identified; starting from the distal end, the mediastinal pleura is incised along its retrosternal and posterior borders (Fig 1).
The flap is retracted laterally by its tip and progressively separated from the pericardial sac and from the contralateral thymic lobe by dividing loose adhesions and small bridging vessels by electrocautery. The dissection is continued toward the junction of the mammary vein with the left innominate vein (Fig 2).
The pedicle can be elongated by dividing adhesions to the contralateral thymic lobe at the level of the left innominate vein and adhesions to the mediastinal pleura at the base of the flap. The superior vena cava is separated from the ascending aorta, and the flap is passed between them to reach the right main bronchus without tension (Fig. 3).
Rarely, if it is long enough, the flap can be brought back directly over the superior vena cava. Finally, the flap is fixed to the main carina and posterior mediastinal pleura using interrupted 3-0 sutures to cover the bronchial stump completely.
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Fig 1. Operative field after right pneumonectomy. The venous pedicle of the thymus flap (F) is shown. (B = bronchial stump; D = diaphragm; E = esophagus; N = phrenic nerve; V = superior vena cava.)
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Fig 2. A fully mobilized thymus flap (F) is being retracted laterally to uncover the underlying pericardium and great vessels. (Ao = ascending aorta; B = bronchial stump; D = diaphragm; E = esophagus; V = superior vena cava.)
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Fig 3. End of procedure. The thymus flap (F) covers the bronchial stump (B) completely. The arterial pedicle of the flap is shown departing from the mammary artery (Ma). (Ao = ascending aorta; D = diaphragm; E = esophagus; V = superior vena cava.)
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From May 2000 to June 2002, the thymus flap was used in all patients undergoing a right pneumonectomy and in a few other patients. Whenever possible, magnetic resonance imaging of the chest was carried out postoperatively to detect alterations in the flap (Fig 4).
Pertinent data were prospectively recorded.
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Fig 4. Magnetic resonance imaging of thymus flap (broken line). The flap and the adjacent mediastinal tissue have similar signals which indicates there are no flap alterations. (Ao = ascending aorta; B = bronchial stump; E = esophagus; V = superior vena cava.)
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Results
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Thirty-three patients (27 males, and 6 females) underwent the flap procedure. Twenty-nine had consecutive right pneumonectomies (3, a completion pneumonectomy), 3 had right upper lobectomies, and 1 required tracheal repair. Indications for operation were primary lung cancer in 30 patients, lung metastasis in 2, and emergency repair of an extensive tracheal intubation injury in 1 patient. Fourteen patients (42%) had received preoperative chemotherapy (cis-platinum and gemcitabine hydrochloride), and 5 (15%) had also received preoperative radiotherapy (50 to 55 Gy).
The thymus flap was relatively large and easy to prepare in 27 patients (82%). In the remaining 6, some dissection was needed to elongate it. In 28 patients (85%), the flap was passed between the superior vena cava and the ascending aorta. Chemoradiotherapy-induced mediastinal fibrosis was not a problem. It was always possible to complete the thymus flap procedure, and its average time was 20.4 ± 5 minutes. No morbidity related to the procedure was observed.
There were five deaths postoperatively. Two patients in the pneumonectomy group died of a myocardial infarction, and 3 others in that group and the patient who underwent tracheal repair died of adult respiratory distress syndrome.
Magnetic resonance imaging was performed within 6 days postoperatively for 19 patients in the pneumonectomy group; for 2 more, it was done 30 and 160 days postoperatively. A normal enhancement signal, indicating a viable flap, was demonstrated in every instance.
One bronchopleural fistula occurred, although the flap appeared normal at magnetic resonance imaging. The patient had the development of adult respiratory distress syndrome after induction chemotherapy plus radiotherapy and right pneumonectomy and required positive-pressure ventilation for 2 weeks.
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Comment
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Although the thymus flap can appear short before it is mobilized, a suitable flap was obtained every time in this series with this technique. The results of magnetic resonance imaging indicate that the flap has a reliable vascular supply. The procedure is reasonably simple to perform and has the advantage of avoiding additional functional and cosmetic damage. The thymus flap appears to be a valuable alternative for protecting tracheobronchial sutures.
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Acknowledgments
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We thank Penelope Taylor for her linguistic supervision.
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References
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- LoCicero J., 3rd, Michaelis L.L. Interposition of the thymus as a pedicled flap in tracheal reconstructive surgery. J Trauma 1990;30:741-744.[Medline]
- Brewer L.A., King E.l, Lilly L.J., et al. Bronchial closure in pulmonary resection: a clinical and experimental study using a pedicled pericardial fat graft reinforcement. J Thorac Surg 1953;26:507-532.
- Riquet M., Zouaoui A., Thomer M., Debesse B., Hidden G. Sero-fatty fringes of the pericardium: anatomical and radiological preoperative assessment of their availability for the protection of bronchial sutures. Surg Radiol Anat 1990;12:153-154.[Medline]
- Anderson T.M., Miller J.I., Jr Use of pleura, azygos vein, pericardium, and muscle flaps in tracheobronchial surgery. Ann Thorac Surg 1995;60:729-733.[Abstract/Free Full Text]
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Abstract
Introduction
