Ann Thorac Surg 2009;87:1615-1616. doi:10.1016/j.athoracsur.2008.09.006
© 2009 The Society of Thoracic Surgeons
Case Reports
Obliteration of Empyema Space by Vascularized Anterolateral Thigh Flaps
Masaya Okuda, MDa,*,
Hiroyasu Yokomise, MDa,
Gan Muneuchi, MDb,
Shinya Ishikawa, MDa
a Department of General Thoracic, Breast and Endocrinological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
b Department of Plastic Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
Accepted for publication September 2, 2008.
* Address correspondence to Dr Okuda, Department of General Thoracic, Breast and Endocrinological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan (Email: okuda{at}med.kagawa-u.ac.jp).
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Abstract
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Closure of the fistula and an appropriate choice of obliterating agents are crucial for the treatment of empyema with bronchopleural fistula. The choice of the material to be used for obliteration of the pleural space is a difficult one in some patients, such as those with empyema, developing after omentectomy, laparotomy, posterolateral thoracotomy, and so forth. The use of free anterolateral thigh flaps for obliteration of the pleural space generally needs a satisfactory vascular network around the thorax. We report two successfully treated cases of empyema with bronchial fistula, which were otherwise difficult to manage, in which a free anterolateral thigh musculocutaneous flap anastomosed to the superior thyroid vessels used to obliterate the pleural space.
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Introduction
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Empyema is known among thoracic surgeons as a refractory and agonizing disease. In the case of empyemas with a bronchopleural fistula, drainage alone does not usually result in a cure. The treatment strategy in such cases would consist of closure of the fistula and obliteration of the empyema cavity with one of a variety of fillings [1]. The materials used for obliteration of the empyema cavity are usually omentum and local chest wall muscles overlying the empyema cavity [2]. This article reports the results of two cases in which the obliteration was conducted with a vascularized anterolateral thigh flap anastomosed to the superior thyroid vessels.
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Case Reports
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Patient 1
The complication of empyema with a bronchopleural fistula developed in a 60-year-old man who had undergone completion pneumonectomy for asynchronous lung cancers. Single-stage closure by decortication and obliteration with an omental flap through the diaphragm and simple suturing of the fistula was performed. However, the empyema recurred after 2 weeks; therefore, open window thoracotomy and daily packing were undertaken. The empyema cavity became clean 9 months after open window thoracotomy. We then decided to obliterate the empyema cavity using a free anterolateral thigh flap, because he did not have any local chest wall muscles, and his omentum had been manipulated in the previous operation. A musculocutaneous flap from the left vastus lateralis muscle was used to completely close the dead space and cover the fistula (Fig 1). The length of the vascular pedicle was 3.5 cm. Vessels from the graft were anastomosed to the right superior thyroid artery and vein through a subcutaneous tunnel. Although the patient appeared well at the 6-month follow-up, a small loculated empyema and a small skin hole were found again at 1-year follow-up. The graft continued to remain satisfactorily transplanted and epithelialized at the 3-year follow-up after the obliteration operation.
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Fig 1. (A) Free anterolateral thigh flap of the vastus lateralis muscle and skin (B) after obliteration of the empyema cavity. The graft vessels were anastomosed to the superior thyroid vessels on the right side.
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Patient 2
A 74-year-old man with a medical history of gastrectomy for peptic ulcer was diagnosed to have synchronous multiple lung cancer; a small cell carcinoma, and a squamous cell carcinoma, both in the right upper lobe. He was treated by chemoradiotherapy for the small cell lung carcinoma and right upper lobectomy through a posterolateral thoracotomy for the squamous cell carcinoma. Complicating bronchopleural fistula developed 8 weeks after the operation. An open window thoracotomy was performed with daily packing that continued for 4 months. Thereafter, we scheduled obliteration of the dead space. The patient had unsatisfactory local thoracic muscles and no omentum for use as a flap. We performed the obliteration using a vascularized musculocutaneous flap from the left quadriceps (rectus femoris and vastus lateralis muscle). The length of the vascular pedicle was 2 cm. Vessels from the graft were anastomosed to the superior thyroid artery and vein through a subcutaneous tunnel (Fig 2). Transplantation was successfully completed. However, the small cell carcinoma recurred at 2 months after the obliteration, and the patient died of small cell carcinoma in the absence of the empyema.
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Fig 2. The end to end anastomoses of superior thyroid vessels and vascular pedicle of the anterolateral thigh flap (ALT).
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Comment
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The radical treatment for empyema with bronchopleural fistula consists of closure of the fistula and filling of the dead space around the stump. In general, thoracic surgeons select the omentum, local thoracic muscles, or other distant muscles as the materials for obliteration. Popularly used free flaps for this purpose include those of the rectus abdominis and the contralateral latissimus dorsi [3, 4]. The graft artery and vein are anastomosed to the thoracic vessels (internal thoracic artery and vein, innominate vein, small branch of the superior vena cava, and so forth) [4]. Furthermore, there are cases in which the abdominal muscles may not be available. In those cases, the quadricep muscles (rectus femoris, in particular) have recently been used for the obliteration operation at our hospital. Quadriceps flaps are easy to harvest safely and reliably with its various components (ie, skin, fascia, long vessels), have a rich vascular supply, and rarely cause weakness of leg strength [5]. Tsai and colleagues [6] reported on the use of free anterolateral thigh flaps for obliteration of chronic empyema with the thoracodorsal and internal thoracic vessels as the recipient vessels [6]. However, intrathoracic or local thoracic vessels are usually spoiled by the infections causing or treatments used for the empyema. Therefore, we selected the superior thyroid vessels as the recipient vessels, the anastomosis being conducted through a subcutaneous tunnel, and have obtained reasonable results.
In conclusion, we are occasionally faced with the problem of selecting the appropriate material for obliteration of an empyema cavity, because few materials and recipient vessels are available for such obliteration during a radical operation. When the traditional materials for obliteration and recipient vessels cannot be used, we must consider using other suitable muscles, like the quadricep femoris as the obliteration material, and suitable recipient vessels such as the superior thyroid vessels.
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References
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- Miller JI, Mansour KA, Nahai F, Jurkiewicz MJ, Hatcher Jr CR. Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication Ann Thorac Surg 1984;38:227-231.[Abstract/Free Full Text]
- Yokomise H, Takahashi Y, Inui K, et al. Omentoplasty for postpneumonectomy bronchopleural fistulas Eur J Cardiothorac Surg 1994;8:122-124.[Abstract/Free Full Text]
- Michaels BM, Orgill DP, Decamp MM, Pribaz JJ, Eriksson E, Swanson S. Flap closure of postpneumonectomy empyema Plast Reconstr Surg 1997;99:437-442.[Medline]
- Hammond DC, Fisher J, Meland NB. Intrathoracic free flaps Plast Reconstr Surg 1993;91:1259-1264.[Medline]
- Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases Plast Reconstr Surg 1998;102:1517-1523.[Medline]
- Tsai FC, Chen HC, Chen SH, et al. Free de-epithelialized anterolateral thigh myocutaneous flaps for chronic intractable empyema with bronchopleural fistula Ann Thorac Surg 2002;74:1038-1042.[Abstract/Free Full Text]
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Abstract
Introduction
