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Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Shanghai Tongji University, Shanghai, China
Accepted for publication November 20, 2007.
* Address correspondence to Dr Jiang, Department of Thoracic Surgery, Shanghai Pulmonary Hospital, No. 507 Zhengming Rd, Shanghai, 200433, China (Email: jgnwp{at}yahoo.com.cn).
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Introduction |
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Technique |
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Surgical treatments were divided into two phases. The first phase was open-window thoracostomy (Fig 1A). Under general anesthesia with the use of a double-lumen endobronchial tube, the patients were put in the supine position with the operative side rotated upward 30°. Because all cavities were in the upper part of the thorax, resection of the anterior segments of the second, third, or fourth ribs overlying the cavity was generally enough to allow good exposure of the entire cavity and the underlying lung. After removal of infected debris, the skin edges were sutured to the underlying pleura. Postoperatively, wet gauze dressings soaked with 0.25% neomycin solution were applied daily for several months. Closure of defects in the second phase of treatment was not attempted until the infection was totally controlled and healthy granulation tissue was present (Fig 1B).
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The patients were then repositioned in the full supine position. The full length of the rectus abdominis muscle ipsilateral to the empyema tract was elevated from the pubis to the costal margin. The medial perforators to the longitudinal fusiform-shaped skin island were harvested with the underlying anterior rectus sheath and rectus abdominis muscle. The area of skin, usually about 12 x 6 cm, was tailored to fit the defect on the chest wall so that it easily covered the entire wall defect. Furthermore, the area of anterior sheath involved in the dissection was approximately one-half the size of the skin island to decrease the tension on the incision closure. The full-thickness structure, including the rectus abdominis muscle, anterior sheath, subcutaneous tissue, and the skin itself, was then released from the posterior sheath after the superior epigastric vessels were divided. During this maneuver, full attention was paid to avoiding injury to the inferior epigastric vessels, the 5-cm nutrient vessels (1 artery and 2 veins) for this musculocutaneous flap. Subsequently, the flap was loosely wrapped with saline solution-soaked wet gauze at room temperature. No heparin was used. The stumps of the superior epigastric vessels were ligated, with no connection to the transferred flap. The donor sites were then primarily closed.
The free flap thus was put into thoracic cavity with its upper end fixed to the apex of the thorax. The vascular pedicle of the flap was passed through a previously developed subcutaneous tunnel between thoracic cavity and the recipient vessels. The stumps of the vessels were first trimmed shear with the redundant connective tissue outside the vessel adventitia and were washed with heparin solution to remove blood clot in the ends of the vessels.
A microvascular end-to-end anastomosis between the inferior epigastric artery and vein and their thoracodorsal counterparts can be done at the anterior border of the latissimus dorsi muscle. Starting with artery anastomosis, we usually like to use interrupted nonresorbable 8-0 sutures with 16 to 18 stitches for the anastomoses. An operating microscope at original magnification x10 is used.
After removal of vascular clamps from the artery, quick color changes of flap muscle from dark red to bright red indicates there is sufficient blood supply for the transplant; the vein with larger blood flow and wider diameter then was chosen as drainage vein, and another vein was ligated. Care was necessarily taken to avoid kinking or twisting of vessels and to ensure a good blood supply for the flap.
Two large drainage tubes were routinely placed in the apex and in the most dependent part of the cavity, respectively. Finally, the empyema tract was closed with a skin island covering the chest wall defect, which had been trimmed to fit the irregular defect. The mean blood loss was 500 mL and the mean duration of flap transplantation was 8 hours, respectively.
Postoperatively, blood supply for the flap was continuously inspected through observing color changes of the skin island at 2-hour intervals for a period of 3 days in the intensive care unit. Ipsilateral upper limbs movements were also restricted for 2 weeks. Anticoagulant was given intravenously to prevent vascular thrombosis for a 5-day period, and no hemostatic drugs were used after the operation.
The 3 patients had an uneventful postoperative course. The mean hospital stay after operation was 30.7 days. With a mean follow-up time of 23.7 months, no late postoperative complications occurred. Quality of life in these patients has been significantly improved.
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The following discussion presents our experiences with free rectus abdominis muscle flap for PPE with BPF based on these limited successful patients. First, the treatment course of free rectus abdominis flap transfer should have two steps of surgical procedures. Before closures of the bronchial stumps, it must be stressed that complete control of the pleural infection is an important component of therapy. An open-window thoracostomy remains our first procedure of choice for such conditions. After long-term dressing changes and repeated débridements, healthy granulation tissue gradually presented throughout the pleural spaces, and the sizes of fistulas notably decreased by degrees in the second patient and even fully healed in the first and third patients. If a fistula was still large with severe air leaks, surgery might be postponed; otherwise, the probability of failure might be much higher. Once a BPF recurred after operation, prolonged air leaks and intrathoracic pneumatosis could preclude removal of drainage tubes and prevent the flaps form growing onto the cavity wall. Thus, the denervated free flaps would become progressively atrophic and would not have sufficient bulk to obliterate the space entirely in the future, leading to failure of surgical management.
Second, as with all muscle transpositions, there should be no tension on the muscle itself or its blood supply. In favor of neovascularization across the interface, attention should be given to let the muscle flap be closely attached to inner wall of empyema cavity, especially at the apex of the pleural space.
Third, compared with muscular flaps, the musculocutaneous flaps described in this report not only provided adequate volume for complete empyema obliteration (Fig 1C), but the skin island was also useful for chest wound closure, eliminating the need for a skin graft. In addition to these advantages, graft ischemia could easily be detected in time by the color variation of the skin island (Fig 1D).
In conclusion, we suggest that free rectus abdominis musculocutaneous flap transposition is a promising method of treatment for chronic PPE with BPF.
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This article has been cited by other articles:
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  M. D. Walsh, A. D. Bruno, M. W. Onaitis, D. Erdmann, W. G. Wolfe, E. M. Toloza, and L. S. Levin The Role of Intrathoracic Free Flaps for Chronic Empyema Ann. Thorac. Surg., March 1, 2011; 91(3): 865 - 868. [Abstract] [Full Text] [PDF]
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