Ann Thorac Surg 2008;86:1022-1025. doi:10.1016/j.athoracsur.2008.02.052
© 2008 The Society of Thoracic Surgeons
Case Reports
Bronchopleural Fistula Repair Using Combined Breast Parenchymal and Pectoralis Major Musculocutaneous Flap
Emily Ridgway, MDa,
Malcolm DeCamp, MDb,
Donald Morris, MDa,*
a Division of Plastic Surgery, Department of Surgery, beth Israel Deaconess Medical Center, Boston, Massachussetts
b Division of Thoracic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachussetts
Accepted for publication February 18, 2008.
* Address correspondence to Dr Morris, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 235 Cypress St, #210, Boston, MA 02445 (Email: dmorris{at}lpsmd.com).
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Abstract
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A technique is reported for repair of a bronchopleural fistula and obliteration of an empyema cavity using a combined breast parenchymal and expanded, musculocutaneous pectoralis major flap. An empyema after right upper lobectomy and radiation for squamous cell carcinoma developed in a 53-year-old woman. After debridement, a bronchopleural fistula was noted. Her latissimus dorsi muscle was divided during the initial thoracotomy. Local and free flaps were considered. Her breast contained the largest volume of tissue available as she weighed 80 pounds. This report illustrates the use of a tissue-expanded, combined breast and musculocutaneous pectoralis flap in the management of a difficult problem.
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Introduction
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Many therapeutic strategies have been implemented in the treatment of bronchopleural fistulas and the associated empyema cavities. Bronchial closure through re-suturing or re-stapling are occasionally successful, but recurrence of the fistula commonly follows. Recently developed minimally invasive techniques have been applied to bronchial closure and have included fibrin glue application, stent insertion, or endobronchial one-way valve placement. Use of the Clagett thoracic window and modified Eloesser flap to manage the empyema cavity are associated with considerable morbidity.
The purpose of this article is to describe a technique using a musculocutaneous, pectoralis major flap including the overlying breast tissue.
A 53-year-old woman underwent a right upper lobectomy with en bloc chest wall resection for a T3N0 squamous carcinoma 6 years earlier. The chest wall was initially reconstructed with polypropolene mesh, and the patient was treated with adjuvant radiation therapy. Her hospital course was complicated by early development of an empyema. She recovered and remained well for 6 years when a soft tissue mass over her right posterior tenth rib developed. The mass was incised revealing a fluid-filled cavity that communicated with the thoracic apex (where a chronic air space had remained since her original surgery). Bronchoscopy was performed and failed to reveal an identifiable bronchopleural fistula. She was diagnosed with empyema necessitans. Exploration through a prior thoracotomy incision revealed the mesh in continuity with the cavity. All mesh was removed, a Clagett window was created, the space was marsupialized and a percutaneous endoscopic gastrostomy was performed due to her poor nutritional status. The patient was discharged on oral antibiotics and dressing changes.
A large bronchopleural fistula developed within the site of the Clagett window (Fig 1). The patient was referred to the plastic surgery service to assist with closure in conjunction with an additional chest collapsing procedure. Because the posterior ribs had been previously removed, the plan was to remove the anterior ribs at this stage (Fig 2). Her options for individual or combined flaps to cover the bronchial closure and fill the remaining radiated pleural space were considered. Her right latissimus dorsi muscle had been previously divided. Pedicled ipsilateral rectus abdominis, serratus anterior, and pectoralis major muscles and free flaps using the contralateral latissimus dorsi or an anterolateral thigh flap were considered. The largest potential volume of tissue was that of her breast and underlying pectoralis major. Although not large, in comparison with the remaining options, the breast–muscle combination offered the greatest available tissue mass.
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Fig 1. Preoperative (A) anterior and (B) posterior chest wall images demonstrating site of empyema necessitans.
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Fig 2. (A) Stage 1: preoperative chest x-ray scan demonstrating prior Clagett window. (B) Stage 2: postoperative chest computed tomographic scan.
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A two-stage reconstruction was performed. Stage 1 consisted of subpectoralis tissue expander insertion and delay of the pectoralis flap. An incision was made along the costal margin from the midline to the anterior axillary line, followed by elevation of the pectoralis muscle, leaving the pectoralis minor undisturbed. The intercostal and internal mammary artery perforators were identified and ligated, leaving the pectoralis major perfused by the thoracoacromial pedicle. The tissue expander was placed deep to the pectoralis major and filled to 120 cc. Subsequent expansions were performed to a final volume of 420 cc (Fig 3).
Stage 2 of the two-stage reconstruction that was performed consisted of fistula repair and flap transfer. The patient was positioned supine and a double-lumen endotracheal tube was inserted. The right breast was de-epithelialized using a dermatome, and the nipple was removed and sent to pathology. No malignancy was identified. The de-epithelialized skin was saved and ultimately used to graft the donor site. The patient was then repositioned in the left lateral decubitus position. The right scapula was released, and the second through fourth ribs were removed anterolaterally. The expander was removed. The de-epithelialized musculocutaneous flap, including the right breast tissue was then transferred into the most anterior and inferior portion of the defect covering the fistula tract. The residual defect was filled using the remaining three cm of latissimus dorsi muscle, and the wound closed over a drain. The donor site was grafted using the skin harvested from the right breast and from the left anterior thigh. A vacuum assisted closure sponge bolster was placed over the skin graft.
The procedure was well-tolerated and the postoperative course was unremarkable. The patient was discharged on intravenous cefepime for 4 weeks and has been closely followed for 11 months without recurrence of infection or evidence of the bronchopleural fistula (Fig 4).
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Comment
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Successful management of bronchopleural fistulas and empyema cavities after pulmonary resections remains a challenging problem. Techniques have been developed to address this difficult problem ranging from repeat thoracotomy with debridement and irrigation, the Claggett thoracic window procedure, and various flaps to fill the space [1, 2]. In attempts to limit the morbidity and improve the efficacy of these procedures, authors have described mediastinal flaps, intercostal, lower trapezius, latissimus, serratus, omental, and rectus flaps [3–5]. In a review of the literature, no report of a de-epithelialized breast and musculocutaneous pectoralis flap was identified.
Previously, a workhorse flap in primary head and neck reconstruction, the pectoralis major musculocutaneous flap now has limited applications. Its role in contemporary head and neck surgery is largely limited to salvage procedures for orocutaneous fistula repair, free-flap failure, or vascular coverage. The pectoralis major flap has also been used in salvage chest-wall reconstruction [6, 7]. Gingrass writes, "An appropriate candidate might well be an older woman with a chronic, painful, ulcerating wound who is not concerned about the deficiency of the transposed breast" [7].
However, the advantages of the "breast" flap in cases of bronchopleural fistula are numerous [8]. First, the inclusion of breast tissue may provide abundant tissue volume for obliteration of a large empyema cavity. Second, the flap is comparatively uncomplicated and can be performed expeditiously while maintaining a robust blood supply. Third, the pectoralis is a regional flap that does not require microsurgical transfer. Fourth, the breast–pectoralis muscle flap is suitable for upper or middle lobectomy complications, on either side, despite prior thoracotomy; therefore, it has the advantage of wide applicability.
The obvious disadvantage is the considerable aesthetic deformity associated with this flap, reminiscent of a radical mastectomy defect.
In conclusion, this case report illustrates the use of the previously undescribed 2-stage, tissue-expanded, combined breast–pectoralis major musculocutaneous flap in the management of a bronchopleural fistula and associated empyema cavity.
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References
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- Puskas JD, Mathisen DJ, Grillo HC, et al. Treatment strategies for bronchopleural fistula J Thorac Cardiovasc Surg 1995;109:989-995.[Abstract]
- Zaheer S, Allen MS, Cassivi SD, et al. Postpneumonectomy empyema: results after the Clagett procedure Ann Thorac Surg 2006;82:279-286.[Abstract/Free Full Text]
- Michaels B, Orgill DP, Decamp MM, et al. Flap closure of postpneumonectomy empyema Plast Reconstr Surg 1997;99:437-442.[Medline]
- Meyer AJ, Krueger T, Lepori D, et al. Closure of large intrathoracic airway defects using extrathoracic muscle flaps Ann Thorac Surg 2004;77:397-405.[Abstract/Free Full Text]
- Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer Arch Otolaryngol Head Neck Surg 2004;130:181-186.[Abstract/Free Full Text]
- Gingrass R. Flaps for chest wall reconstructionIn: Grabb WCand, Myers MB, editors. Skin Flaps. Boston, MA: Little, Brown; 1975.
- Maier HC. Surgical management of large defects of the thoracic wall Surgery 1947;22:169.
- Whalen WP. Coverage of thoracic wall defects by a split breast flap Plast Reconstr Surg 1953;12:64.
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Abstract
Introduction
