Ann Thorac Surg 2005;79:2130-2132
© 2005 The Society of Thoracic Surgeons
Case report
A Novel Procedure Using a Tissue Expander for Management of Persistent Alveolar Fistula After Lobectomy
Yasushi Sakamaki, MDa,*,
Tetsuo Kido, MDa,
Takashi Fujiwara, MDb,
Katsuki Kuwae, MDb,
Motomu Maeda, MDb
a Department of Chest Surgery, Osaka Police Hospital, Osaka, Japan
b Department of Plastic Surgery, Osaka Police Hospital, Osaka, Japan
Accepted for publication November 25, 2003.
* Address reprint requests to Dr Sakamaki, Department of Chest Surgery, Osaka Police Hospital, Kitayamacho 10-31, Tennoji, Osaka 543-8502, Japan (E-mail: sak{at}serenade.plala.or.jp).
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Abstract
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We treated a patient with postlobectomy persistent alveolar fistula using a tissue expander, which is a prosthesis widely used in plastic surgery. The patient had thoracic empyema develop after right bilobectomy for lung cancer, and consequently underwent drainage of empyema followed by muscle flap closure for alveolar fistula. A residual space remained, and air leak persisted. However, implanting and expanding a tissue expander enabled us to tightly fix the flap on the raw pulmonary surface, which eventually solved the air leak. The tissue expander greatly contributed to muscle flap closure for a persistent alveolar-pleural fistula with a large remaining thoracic space.
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Introduction
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Alveolar-pleural fistula complicating pulmonary lobectomy often causes thoracic empyema and leads to a prolonged hospital stay. Air leak may persist when a dead space remains in the pleural cavity, despite established techniques such as muscle flap closure and thoracoplasty. We report the utility of applying a tissue expander (an implantable prosthesis frequently used in plastic surgery) to treat persistent alveolar air leak after lobectomy.
A 61-year-old man underwent right middle and lower lobectomy for T2N1 lung squamous cell carcinoma. Due to a prolonged air leak complicating the bilobectomy, a tube thoracostomy was required until postoperative day 15 when the air leak had finally disappeared. Two days after removing the tube the patient had an infection develop, which was evidenced by clinical symptoms and laboratory tests. Computed tomography demonstrated that considerable air space remained in the right hemithorax with a moderate amount of effusion and multiple air-fluid levels (Fig 1). These findings strongly suggested postsurgical empyema, and single thoracentesis confirmed the diagnosis by aspiration of purulent collected fluid. Bronchofiberscopy ruled out the breakdown of the bronchial stump. The patient then underwent thoracoscopic surgery on postoperative day 23 for drainage of the empyema cavity. Intraoperative examination found an alveolar fistula with a persistent air leak on the surface of the remaining upper lobe. The fistula was located near the apex and faced the mediastinum. Spraying fibrin glue over the raw surface failed to close the fistula. A week later when the cavity became aseptic by routine drainage and appropriate administration of antibiotics, single pleurodesis using minocycline was attempted unsuccessfully, resulting in aspiration of the agent into the proximal airway through the alveolar fistula. On postbilobectomy day 37, closure of the persistent fistula was performed using a free flap of the rectus abdominis muscle transposed into the remaining space. After resection of the eighth and ninth ribs, the flap was transposed into the cavity with its feeders anastomosed to the thoracodorsal vessels. However, this procedure initially failed to fill up the remaining space and resulted in a persistent air leak as revealed by a water-seal test. Thus we decided to use a tissue expander (Tissue Expander, rectangle type A-1426 [Koken, Tokyo, Japan]), which is a silicone rubber, expandable prosthesis (Fig 2). Instead of additional excision of the ribs or transposition of muscle flap, a tissue expander was then implanted in the cavity and expanded with 200 mL of saline so as to further reduce the remaining cavity and compress the myocutaneous flap. This technique fixed the flap more adequately on the raw pulmonary surface and enabled the flap to tightly cover the fistula. There was no air leak observed in the postoperative period thereafter. Follow-up computed tomography demonstrated that the tissue expander was appropriately expanded and fixed in the thoracic cavity (Fig 3). Under satisfactory informed consent, the patient was discharged 3 weeks after implantation. He underwent step-wise deflation of the tissue expander in our outpatient clinic until it was removed on day 215 after implantation. No disease signs, such as infection, air leak, or laceration of the tissue expander were detected during this period.
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Fig 2. Photograph of a tissue expander identical to the one used in the present case. (E = expandable silicone envelope; P = injection port; T = tube and connector.)
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Fig 3. Follow-up computed tomography showing the remaining lung (L), myocutaneous flap (F), and tissue expander (E) implanted in the residual cavity of the right hemithorax.
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Comment
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Surgical repair of a refractory pulmonary fistula remains a critical issue in the treatment of postlobectomy empyema [1–3]. Neither a thoracotomy nor another thoracoscopic procedure easily enables surgeons to access a raw pulmonary surface under severe restriction against a surgical approach. In addition, pulmonary tissues near the raw surface are often too fragile to directly suture because of the inflammatory change of the infected pleura.
Although some studies have reported the effectiveness of recent techniques to reduce postlobectomy air leaks using various sealants or a buttressed suture with a stapler, muscle flap, or thoracoplasty, or a combination thereof, these should be used as a radical treatment after empyema occurs in the hemithorax postoperatively [2, 3]. However, these established techniques would fail to prevent air leak, as seen in our case, if transposed tissues could not sufficiently fill up the residual dead space. In such cases, additional thoracoplasty or preparation of the other flaps, or both, would be highly invasive or impossible to utilize.
The tissue expander has been proven applicable to a wide variety of procedures in plastic surgery including reconstruction of the breast, head, and neck [4, 5]. Our technique using the tissue expander was effective in reducing the dead space that had allowed an air leak to persist. The tissue expander placed in the cavity pressed the transposed muscle firmly against the raw surface and overcame the difficulty of securing the flap to the fistula.
Concern for infection of the prosthesis limits the use of the tissue expander for fistula healing in the pleural cavity. In our case, the pleural effusion was aseptic, evidenced by a negative culture for 2 weeks after thoracoscopic drainage. Furthermore, curettage and lavage of the cavity was performed again when it was opened up for muscle flap closure. These findings allowed us to conclude that the pleural space was clean enough to permit placement of prosthesis. However, actual infection of the tissue expander would have necessitated its removal and conversion to some other procedure, such as additional tissue transposition or open thoracostomy with wound packing as a last resort.
Although some authors have reported clinical use of the tissue expander in the field of thoracic surgery [6], no one has clearly identified adverse events during and after long-term use of the tissue expander in treating empyema. Therefore, great care must be taken in the follow-up of our patient, even after removing the tissue expander.
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References
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- Porte HL, Jany T, Akkad R, et al. Randomized controlled trial of a synthetic sealant for preventing alveolar air leaks after lobectomy Ann Thorac Surg 2001;71:1618-1622.[Abstract/Free Full Text]
- Venuta F, Rendina EA, De Giacomo T, et al. Technique to reduce air leaks after pulmonary lobectomy Eur J Cardiothorac Surg 1998;13:361-364.
- Regnard JF, Alifano M, Puyo P, Fares E, Magdeleinat P, Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection J Thorac Cardiovasc Surg 2000;120:270-275.[Abstract/Free Full Text]
- Radovan C. Breast reconstruction after mastectomy using the temporary expander Plast Reconstr Surg 1982;69:195-206.[Medline]
- Azzolini A, Riberti C, Cavalca D. Skin expansion in head and neck reconstructive surgery Plast Reconstr Surg 1992;90:799-807.[Medline]
- Tsunezuka Y, Sato H, Watanabe S, Tamura M, Tsubota M, Seki M. Improved expandable prosthesis in postpneumonectomy syndrome with deformed thorax J Thorac Cardiovasc Surg 1998;116:526-528.[Free Full Text]
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Abstract
Introduction
