- Email: [email protected]
Diaphragmatic Reconstruction Using Combined Reversed Extended Latissimus Dorsi and Serratus Anterior Fascia Flaps
922
CASE REPORT SINNA ET AL DIAPHRAGMATIC RECONSTRUCTION
Fig 2. Wooden toothpick covered with blood clots retrieved from the left lower lobe bronchus during the operation.
Comment
FEATURE ARTICLES
Despite the fact that tuberculosis and bronchiectasis have become less prevalent, the most common causes of massive hemoptysis include lung cancer, lung abscess, and aspergilloma, as well as tuberculosis, bronchiectasis, and broncholith [1]. Less common causes include bronchial adenoma, pulmonary embolism, mitral stenosis, congenital heart disease, aortic aneurysms, coagulation disorders, and pulmonary parenchymal diseases. Massive hemoptysis involves disruption of high-pressure bronchial vessels that proliferate with various pulmonary diseases [1]. The prognosis of massive hemoptysis is poor, and mortality of operable patients treated nonsurgically has ranged from 23% to 85%, whereas the mortality of surgically treated patients ranges from 15% to 25% [1]. Thus, most investigators recommend immediate surgery. Conservative methods have also been used successfully in some cases, including bronchoscopic balloon tamponade [4] and selective bronchial artery embolization [5]. In the case of our patient, operative management was chosen because of the presence of a foreign body on preoperative computerized tomographic scan that could not be retrieved by bronchoscopy. This case illustrates an unusual presentation of massive hemoptysis. Retained foreign bodies in the bronchial tree seldom present with hemoptysis, and may be difficult to remove endoscopically. According to the literature, a more common complication of undiagnosed and retained foreign bodies in the tracheobronchial tree is bronchiectasis that may require pulmonary resection [6]. Correct diagnosis is usually obtained with contrast computed tomographic scan after bronchoscopy [7]. We conclude that early thoracotomy is recommended in cases presenting with massive hemoptysis, unless the foreign body can be retrieved endoscopically and the bleeding can be controlled effectively.
References 1. Thompson AB, Teschler H, Rennard SI. Pathogenesis, evaluation, and therapy for massive hemoptysis. Clin Chest Med 1992;13:69 – 82. 2. Metin M, Sayar A, Turna A, et al. Emergency surgery for massive haemoptysis. Acta Chir Belg 2005;105:639 – 43. 3. Clark JG, Shaw RC. Pulmonary cavitation and massive hemoptysis caused by an unsuspected intraparenchymal foreign body. Chest 1980;78:776 –7. 4. Kato R, Sawafuji M, Kawamura M, Kikuchi K, Kobayashi K. Massive hemoptysis successfully treated by modified bronchoscopic balloon tamponade technique. Chest 1996;109: 842–3.
© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2011;91:922– 4
5. Poyanli A, Acunas B, Rozanes I, et al. Endovascular therapy in the management of moderate and massive haemoptysis. Br J Radiol 2007;80:331– 6. 6. Cataneo AJ, Reibscheid SM, Ruiz Junior RL, Ferrari GF. Foreign body in the tracheobronchial tree. Clin Pediatr (Phila) 1997;36:701– 6. 7. Shin SM, Kim WS, Cheon JE, et al. CT in children with suspected residual foreign body in airway after bronchoscopy. Am J Roentgenol 2009;192:1744 –51.
Diaphragmatic Reconstruction Using Combined Reversed Extended Latissimus Dorsi and Serratus Anterior Fascia Flaps Raphael Sinna, MD, Florence De Dominicis, MD, Quentin Quassemyar, MD, David Fuks, MD, David Perignon, MD, Jean-Marc Regimbeau, MD, PhD, and Pascal Berna, MD Department of Reconstructive, Plastic and Aesthetic Surgery, Amiens North Hospital, Amiens; Federation of Digestive Diseases, France, Amiens North Hospital, Amiens; and Department of Thoracic Surgery, Amiens South Hospital, Amiens, France
The autologous or “extended” latissimus dorsi flap is a standard technique in breast reconstruction. The authors report a case of gastrobronchial fistula after sleeve gastrectomy managed by a new option, combing a reversed “extended” latissimus dorsi flap and a serratus anterior fascia flap. It provides good quality autologous living tissue to treat thoracoabdominal infection associated with diaphragmatic necrosis. Aggressive management, such as surgical resection, should be performed for these patients with a benign but life-threatening disease. (Ann Thorac Surg 2011;91:922– 4) © 2011 by The Society of Thoracic Surgeons
T
he autologous or “extended” latissimus dorsi flap is a standard technique in breast reconstruction. No other indication for this flap has been reported in the international literature [1, 2]. The latissimus dorsi flap based on secondary segmental vessels (reverse) was first described in the early 1980s [3]. Muscle flaps have an important role in reconstructive surgery for empyema [4]. Postoperative gastrobronchial fistula is a life-threatening, but rare complication of laparoscopic sleeve gastrectomy. Recurrences of pulmonary and abdominal abscesses require large debridement associated with a muscle flap to treat this complication. A 23-year-old woman underwent laparoscopic sleeve gastrectomy for morbid obesity. On postoperative day 3, a sudden onset of the left upper quadrant abdominal pain was suggestive of postoperative gastric fistula. Sur-
Accepted for publication Aug 16, 2010. Address correspondence to Dr Berna, Department of Thoracic Surgery, Amiens South Hospital, University of Picardie, Amiens, F-80054, France; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.08.027
Fig 1. (A) Coronal reformatted, (B) axial, and (C, D) oblique reformatted unenhanced thoracic and abdominal computed tomographic scan with upper gastrointestinal contrast showing (A, B) postoperative gastric fistula with low abundance left pleural effusion and (C, D) disruption of the left-side diaphragm.
gical drainage and jejunostomy were initially performed. Antibiotics and somatostatin analogues permitted the patient to be discharged 4 weeks later. Five months later, she was readmitted with fever associated with cough, dyspnea, and sputum. A computed tomographic scan revealed rupture of the left hemi-diaphragm associated with moderate left pleural effusion and an abdominal subphrenic abscess (Fig 1). The patient was managed medically by a combination of antibiotics, parenteral nutrition, somatostatin analogues, percutaneous drainage of the abdominal abscess, and several endoscopic procedures with injection of biological glue through the gastric leakage tract. Four weeks after treatment, the patient was discharged from the hospital and resumed oral feeding. However, after two other recurrences of pulmonary and abdominal abscesses, another computed tomographic scan with water-soluble upper gastrointestinal contrast demonstrated a gastrobronchial fistula. Therefore, it was decided to perform radical and aggressive surgery. The surgical procedure started with harvesting of the composite latissimus dorsi flap and serratus anterior fascia flap (Fig 2). Then a left posterolateral thoracotomy in the sixth intercostal space was performed associated with posterior arch rib resection. The thoracotomy was situated lower than usual to allow harvesting of the flap for diaphragm reconstruction. This large incision totally released the intercostal space, allowing insertion of the flap without compressing the blood supply. An en-bloc
CASE REPORT SINNA ET AL DIAPHRAGMATIC RECONSTRUCTION
923
resection of the left lower lobe (corresponding to the infected and fistulated pulmonary zone), including the left hemi-diaphragm, but sparing its parietal insertions was performed. The full stapler line of the sleeve gastrectomy was cellulitic and necrotic; therefore, we preferred to perform a radical procedure instead of a conservative management as we did in the last 9 months. A total gastrectomy and intrathoracic esophagojejunostomy were then performed through a midline laparotomy. The left hemi-diaphragm was reconstructed using the extended latissimus dorsi flap. The posterior arch rib resection and complete section of the intercostal muscles of this space were sufficient to avoid compression of the blood supply without requiring total resection of the sixth rib. The latissimus dorsi was tightened above the sixth rib and sutured to the preserved insertions of the left hemidiaphragm. Only the last three digitations of the serratus were partially harvested (Fig 2) to avoid any kinetic problem. The reverse serratus anterior flap was then used as reinforcement over the mediastinal esophagojejunostomy. Therefore, muscle detachment underneath the sixth intercostal space was not performed, preventing the formation of a seroma. Dual chest tube drainage and abdominal drainage were performed with no drainage of the flap harvest zone. Postoperative outcome was acceptable. The computed tomographic scan and endoscopy confirmed the absence of fistula. The patient was discharged from the hospital 4 weeks after the extended resection. Pathologic examination confirmed the gastrobronchial fistula. With a follow-up of 24 months, the patient is healthy and can eat normally. Chest roentgenogram confirmed that the left hemi-diaphragm was motionless, but she had no dyspnea and respiratory tests were above normal.
Fig 2. Composite extended latissimus dorsi flap and serratus anterior fascia flap harvested. (FE ⫽ fatty extension; LD ⫽ latissimus dorsi; SA ⫽ serratus anterior; T ⫽ tendon of latissimus dorsi.)
FEATURE ARTICLES
Ann Thorac Surg 2011;91:922– 4
924
CASE REPORT KANG ET AL BENIGN METASTASIZING LEIOMYOMA
Comment
FEATURE ARTICLES
The treatment of this gastrobronchial fistula required meticulous interdisciplinary planning to estimate the preoperative risk, delineate the required extent of resection, and plan for cover and anatomic restoration with low postoperative morbidity involving digestive, thoracic, and plastic surgeons. Reconstruction of the diaphragm has been performed in various ways. Synthetic meshes have been used in a variety of clinical applications involving the large chest wall or diaphragmatic defects [5], but the use of synthetic mesh for surgical repair of major diaphragm defects, particularly in a potentially contaminated operative field, is usually avoided. Avella and colleagues [6] described the use of a biological prosthesis (Alloderm, LifeCell Corporation, Branchburg, NJ) for diaphragmatic reconstruction in a case of secondary empyema. The “extended” or “autologous” latissimus dorsi flap is used in breast reconstruction because of its large muscle and adipose volume [7]. Compared with the classical latissimus dorsi flap, the dissection technique of the extended version harvests the fatty extension above (between the fascia superficialis and the muscle) and around the muscle to increase the volume and in this case the surface of the flap. It allows having a larger flap especially around the tendinous portion to perform better closure of the medial part of the diaphragm. The serratus anterior fascia was harvested with the thoraco-dorsal pedicle with a reverse vascularization from the lumbar-perforating blood vessels of the latissimus dorsi to cover the fistula. This flap was used to cover mediastinal sutures and anastomoses to limit the risk of secondary fistula. Bulky tissue is not required for this purpose, and serratus anterior fascia was enough. In conclusion, gastrobronchial fistula is a very rare complication after laparoscopic sleeve gastrectomy. Large resection and debridement is sometimes necessary to treat complex infection. The combined reversed extended latissimus dorsi flap and serratus anterior fascia flap provides good quality autologous living tissue to treat thoracoabdominal infection associated with diaphragmatic necrosis.
References 1. Delay E, Jorquera F, Pasi P, Gratadour AC. Autologous latissimus breast reconstruction in association with the abdominal advancement flap: a new refinement in breast reconstruction. Ann Plast Surg 1999;42:67–75. 2. Delay E, Gounot N, Bouillot A, Zlatoff P, Rivoire M. Autologous latissimus breast reconstruction: a 3-year clinical experience with 100 patients. Plast Reconstr Surg 1998;102:1461–78. 3. Bostwick J 3rd, Scheflan M, Nahai F, Jurkiewicz MJ. The “reverse” latissimus dorsi muscle and musculocutaneous flap: anatomical and clinical considerations. Plast Reconstr Surg 1980;65:395–9. 4. Belmahi A, Ouezzani S, El Aziz S. Muscular flaps and reconstructive surgery of empyema: about 12 cases. Ann de Chir Plast Esthet 2008;53:1– 8. © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2011;91:924 – 6
5. Haciibrahimoglu G, Solak O, Olcmen A, Bedirhan MA, Solmazer N, Gurses A. Management of traumatic diaphragmatic rupture. Surg Today 2004;34:111– 4. 6. Avella D, Garcia LJ, Nikfarjam M, et al. Alloderm mesh an innovative tool for diaphragmatic reconstruction in patients with large retroperitoneal sarcomas. J Surg Res 2008;144:347. 7. Chang DW, Youssef A, Cha S, Reece GP. Autologous breast reconstruction with the extended latissimus dorsi flap. Plast Reconstr Surg 2002;110:751–9.
Benign Metastasizing Leiomyoma: Metastasis to Rib and Vertebra Min-Woong Kang, MD,* Shin Kwang Kang, MD,* Jae Hyeon Yu, MD, Seung Pyung Lim, MD, Kwang Sun Suh, MD, Jae-Sung Ahn, MD, and Myung Hoon Na, MD Department of Thoracic and Cardiovascular Surgery, Pathology, and Orthopaedic Surgery, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
Benign metastasizing leiomyoma is very rare and characterized by the presence of pelvic, peritoneal, nodal, or pulmonary nodules in women with a history of uterine leiomyomas. We report a case of benign metastasizing leiomyoma in a 30-year-old woman who had undergone a prior myomectomy due to uterine cellular leiomyoma 3 years earlier. The patient had a mass on the right sixth rib and 2 masses in the sixth thoracic vertebra. Pathologically, these masses were diagnosed as cellular leiomyomas. Estrogen and progesterone receptors were both positive in the metastatic tumors as well as in the uterine leiomyomas. The diagnosis of benign metastasizing leiomyoma can only be made after careful examination of the primary tumor to exclude small foci of malignant change. (Ann Thorac Surg 2011;91:924 – 6) © 2011 by The Society of Thoracic Surgeons
B
enign metastasizing leiomyoma is a nebulous condition in which metastatic smooth muscle tumor forms in other organs from a benign leiomyoma of the uterus. In most cases, benign metastasizing leiomyoma occurs in the pelvic cavity and lung, and rarely, in the vertebrae or skull base. In this report, we report a 30-year-old woman presenting with benign metastasizing leiomyoma that metastasized to the rib and vertebra, which has been rarely reported in literature. A 30-year-old woman (para 0, gravida 0) presented with a rib mass and a 3-month history of recurrent back pain that started 1-week before menstruation and stopped at the beginning of the period. She had undergone a myomectomy for a 13- ⫻ 12- ⫻ 7-cm-sized uterine myoma about 3 years earlier. Pathologic findings of that uterine
Accepted for publication Aug 16, 2010. *These authors contributed equally to the article. Address correspondence to Dr Na, Department of Thoracic and Cardiovascular Surgery, College of Medicine, Chungnam National University, Daejeon, 301-721, Republic of Korea; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.08.030
CASE REPORT SINNA ET AL DIAPHRAGMATIC RECONSTRUCTION
Fig 2. Wooden toothpick covered with blood clots retrieved from the left lower lobe bronchus during the operation.
Comment
FEATURE ARTICLES
Despite the fact that tuberculosis and bronchiectasis have become less prevalent, the most common causes of massive hemoptysis include lung cancer, lung abscess, and aspergilloma, as well as tuberculosis, bronchiectasis, and broncholith [1]. Less common causes include bronchial adenoma, pulmonary embolism, mitral stenosis, congenital heart disease, aortic aneurysms, coagulation disorders, and pulmonary parenchymal diseases. Massive hemoptysis involves disruption of high-pressure bronchial vessels that proliferate with various pulmonary diseases [1]. The prognosis of massive hemoptysis is poor, and mortality of operable patients treated nonsurgically has ranged from 23% to 85%, whereas the mortality of surgically treated patients ranges from 15% to 25% [1]. Thus, most investigators recommend immediate surgery. Conservative methods have also been used successfully in some cases, including bronchoscopic balloon tamponade [4] and selective bronchial artery embolization [5]. In the case of our patient, operative management was chosen because of the presence of a foreign body on preoperative computerized tomographic scan that could not be retrieved by bronchoscopy. This case illustrates an unusual presentation of massive hemoptysis. Retained foreign bodies in the bronchial tree seldom present with hemoptysis, and may be difficult to remove endoscopically. According to the literature, a more common complication of undiagnosed and retained foreign bodies in the tracheobronchial tree is bronchiectasis that may require pulmonary resection [6]. Correct diagnosis is usually obtained with contrast computed tomographic scan after bronchoscopy [7]. We conclude that early thoracotomy is recommended in cases presenting with massive hemoptysis, unless the foreign body can be retrieved endoscopically and the bleeding can be controlled effectively.
References 1. Thompson AB, Teschler H, Rennard SI. Pathogenesis, evaluation, and therapy for massive hemoptysis. Clin Chest Med 1992;13:69 – 82. 2. Metin M, Sayar A, Turna A, et al. Emergency surgery for massive haemoptysis. Acta Chir Belg 2005;105:639 – 43. 3. Clark JG, Shaw RC. Pulmonary cavitation and massive hemoptysis caused by an unsuspected intraparenchymal foreign body. Chest 1980;78:776 –7. 4. Kato R, Sawafuji M, Kawamura M, Kikuchi K, Kobayashi K. Massive hemoptysis successfully treated by modified bronchoscopic balloon tamponade technique. Chest 1996;109: 842–3.
© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2011;91:922– 4
5. Poyanli A, Acunas B, Rozanes I, et al. Endovascular therapy in the management of moderate and massive haemoptysis. Br J Radiol 2007;80:331– 6. 6. Cataneo AJ, Reibscheid SM, Ruiz Junior RL, Ferrari GF. Foreign body in the tracheobronchial tree. Clin Pediatr (Phila) 1997;36:701– 6. 7. Shin SM, Kim WS, Cheon JE, et al. CT in children with suspected residual foreign body in airway after bronchoscopy. Am J Roentgenol 2009;192:1744 –51.
Diaphragmatic Reconstruction Using Combined Reversed Extended Latissimus Dorsi and Serratus Anterior Fascia Flaps Raphael Sinna, MD, Florence De Dominicis, MD, Quentin Quassemyar, MD, David Fuks, MD, David Perignon, MD, Jean-Marc Regimbeau, MD, PhD, and Pascal Berna, MD Department of Reconstructive, Plastic and Aesthetic Surgery, Amiens North Hospital, Amiens; Federation of Digestive Diseases, France, Amiens North Hospital, Amiens; and Department of Thoracic Surgery, Amiens South Hospital, Amiens, France
The autologous or “extended” latissimus dorsi flap is a standard technique in breast reconstruction. The authors report a case of gastrobronchial fistula after sleeve gastrectomy managed by a new option, combing a reversed “extended” latissimus dorsi flap and a serratus anterior fascia flap. It provides good quality autologous living tissue to treat thoracoabdominal infection associated with diaphragmatic necrosis. Aggressive management, such as surgical resection, should be performed for these patients with a benign but life-threatening disease. (Ann Thorac Surg 2011;91:922– 4) © 2011 by The Society of Thoracic Surgeons
T
he autologous or “extended” latissimus dorsi flap is a standard technique in breast reconstruction. No other indication for this flap has been reported in the international literature [1, 2]. The latissimus dorsi flap based on secondary segmental vessels (reverse) was first described in the early 1980s [3]. Muscle flaps have an important role in reconstructive surgery for empyema [4]. Postoperative gastrobronchial fistula is a life-threatening, but rare complication of laparoscopic sleeve gastrectomy. Recurrences of pulmonary and abdominal abscesses require large debridement associated with a muscle flap to treat this complication. A 23-year-old woman underwent laparoscopic sleeve gastrectomy for morbid obesity. On postoperative day 3, a sudden onset of the left upper quadrant abdominal pain was suggestive of postoperative gastric fistula. Sur-
Accepted for publication Aug 16, 2010. Address correspondence to Dr Berna, Department of Thoracic Surgery, Amiens South Hospital, University of Picardie, Amiens, F-80054, France; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.08.027
Fig 1. (A) Coronal reformatted, (B) axial, and (C, D) oblique reformatted unenhanced thoracic and abdominal computed tomographic scan with upper gastrointestinal contrast showing (A, B) postoperative gastric fistula with low abundance left pleural effusion and (C, D) disruption of the left-side diaphragm.
gical drainage and jejunostomy were initially performed. Antibiotics and somatostatin analogues permitted the patient to be discharged 4 weeks later. Five months later, she was readmitted with fever associated with cough, dyspnea, and sputum. A computed tomographic scan revealed rupture of the left hemi-diaphragm associated with moderate left pleural effusion and an abdominal subphrenic abscess (Fig 1). The patient was managed medically by a combination of antibiotics, parenteral nutrition, somatostatin analogues, percutaneous drainage of the abdominal abscess, and several endoscopic procedures with injection of biological glue through the gastric leakage tract. Four weeks after treatment, the patient was discharged from the hospital and resumed oral feeding. However, after two other recurrences of pulmonary and abdominal abscesses, another computed tomographic scan with water-soluble upper gastrointestinal contrast demonstrated a gastrobronchial fistula. Therefore, it was decided to perform radical and aggressive surgery. The surgical procedure started with harvesting of the composite latissimus dorsi flap and serratus anterior fascia flap (Fig 2). Then a left posterolateral thoracotomy in the sixth intercostal space was performed associated with posterior arch rib resection. The thoracotomy was situated lower than usual to allow harvesting of the flap for diaphragm reconstruction. This large incision totally released the intercostal space, allowing insertion of the flap without compressing the blood supply. An en-bloc
CASE REPORT SINNA ET AL DIAPHRAGMATIC RECONSTRUCTION
923
resection of the left lower lobe (corresponding to the infected and fistulated pulmonary zone), including the left hemi-diaphragm, but sparing its parietal insertions was performed. The full stapler line of the sleeve gastrectomy was cellulitic and necrotic; therefore, we preferred to perform a radical procedure instead of a conservative management as we did in the last 9 months. A total gastrectomy and intrathoracic esophagojejunostomy were then performed through a midline laparotomy. The left hemi-diaphragm was reconstructed using the extended latissimus dorsi flap. The posterior arch rib resection and complete section of the intercostal muscles of this space were sufficient to avoid compression of the blood supply without requiring total resection of the sixth rib. The latissimus dorsi was tightened above the sixth rib and sutured to the preserved insertions of the left hemidiaphragm. Only the last three digitations of the serratus were partially harvested (Fig 2) to avoid any kinetic problem. The reverse serratus anterior flap was then used as reinforcement over the mediastinal esophagojejunostomy. Therefore, muscle detachment underneath the sixth intercostal space was not performed, preventing the formation of a seroma. Dual chest tube drainage and abdominal drainage were performed with no drainage of the flap harvest zone. Postoperative outcome was acceptable. The computed tomographic scan and endoscopy confirmed the absence of fistula. The patient was discharged from the hospital 4 weeks after the extended resection. Pathologic examination confirmed the gastrobronchial fistula. With a follow-up of 24 months, the patient is healthy and can eat normally. Chest roentgenogram confirmed that the left hemi-diaphragm was motionless, but she had no dyspnea and respiratory tests were above normal.
Fig 2. Composite extended latissimus dorsi flap and serratus anterior fascia flap harvested. (FE ⫽ fatty extension; LD ⫽ latissimus dorsi; SA ⫽ serratus anterior; T ⫽ tendon of latissimus dorsi.)
FEATURE ARTICLES
Ann Thorac Surg 2011;91:922– 4
924
CASE REPORT KANG ET AL BENIGN METASTASIZING LEIOMYOMA
Comment
FEATURE ARTICLES
The treatment of this gastrobronchial fistula required meticulous interdisciplinary planning to estimate the preoperative risk, delineate the required extent of resection, and plan for cover and anatomic restoration with low postoperative morbidity involving digestive, thoracic, and plastic surgeons. Reconstruction of the diaphragm has been performed in various ways. Synthetic meshes have been used in a variety of clinical applications involving the large chest wall or diaphragmatic defects [5], but the use of synthetic mesh for surgical repair of major diaphragm defects, particularly in a potentially contaminated operative field, is usually avoided. Avella and colleagues [6] described the use of a biological prosthesis (Alloderm, LifeCell Corporation, Branchburg, NJ) for diaphragmatic reconstruction in a case of secondary empyema. The “extended” or “autologous” latissimus dorsi flap is used in breast reconstruction because of its large muscle and adipose volume [7]. Compared with the classical latissimus dorsi flap, the dissection technique of the extended version harvests the fatty extension above (between the fascia superficialis and the muscle) and around the muscle to increase the volume and in this case the surface of the flap. It allows having a larger flap especially around the tendinous portion to perform better closure of the medial part of the diaphragm. The serratus anterior fascia was harvested with the thoraco-dorsal pedicle with a reverse vascularization from the lumbar-perforating blood vessels of the latissimus dorsi to cover the fistula. This flap was used to cover mediastinal sutures and anastomoses to limit the risk of secondary fistula. Bulky tissue is not required for this purpose, and serratus anterior fascia was enough. In conclusion, gastrobronchial fistula is a very rare complication after laparoscopic sleeve gastrectomy. Large resection and debridement is sometimes necessary to treat complex infection. The combined reversed extended latissimus dorsi flap and serratus anterior fascia flap provides good quality autologous living tissue to treat thoracoabdominal infection associated with diaphragmatic necrosis.
References 1. Delay E, Jorquera F, Pasi P, Gratadour AC. Autologous latissimus breast reconstruction in association with the abdominal advancement flap: a new refinement in breast reconstruction. Ann Plast Surg 1999;42:67–75. 2. Delay E, Gounot N, Bouillot A, Zlatoff P, Rivoire M. Autologous latissimus breast reconstruction: a 3-year clinical experience with 100 patients. Plast Reconstr Surg 1998;102:1461–78. 3. Bostwick J 3rd, Scheflan M, Nahai F, Jurkiewicz MJ. The “reverse” latissimus dorsi muscle and musculocutaneous flap: anatomical and clinical considerations. Plast Reconstr Surg 1980;65:395–9. 4. Belmahi A, Ouezzani S, El Aziz S. Muscular flaps and reconstructive surgery of empyema: about 12 cases. Ann de Chir Plast Esthet 2008;53:1– 8. © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2011;91:924 – 6
5. Haciibrahimoglu G, Solak O, Olcmen A, Bedirhan MA, Solmazer N, Gurses A. Management of traumatic diaphragmatic rupture. Surg Today 2004;34:111– 4. 6. Avella D, Garcia LJ, Nikfarjam M, et al. Alloderm mesh an innovative tool for diaphragmatic reconstruction in patients with large retroperitoneal sarcomas. J Surg Res 2008;144:347. 7. Chang DW, Youssef A, Cha S, Reece GP. Autologous breast reconstruction with the extended latissimus dorsi flap. Plast Reconstr Surg 2002;110:751–9.
Benign Metastasizing Leiomyoma: Metastasis to Rib and Vertebra Min-Woong Kang, MD,* Shin Kwang Kang, MD,* Jae Hyeon Yu, MD, Seung Pyung Lim, MD, Kwang Sun Suh, MD, Jae-Sung Ahn, MD, and Myung Hoon Na, MD Department of Thoracic and Cardiovascular Surgery, Pathology, and Orthopaedic Surgery, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
Benign metastasizing leiomyoma is very rare and characterized by the presence of pelvic, peritoneal, nodal, or pulmonary nodules in women with a history of uterine leiomyomas. We report a case of benign metastasizing leiomyoma in a 30-year-old woman who had undergone a prior myomectomy due to uterine cellular leiomyoma 3 years earlier. The patient had a mass on the right sixth rib and 2 masses in the sixth thoracic vertebra. Pathologically, these masses were diagnosed as cellular leiomyomas. Estrogen and progesterone receptors were both positive in the metastatic tumors as well as in the uterine leiomyomas. The diagnosis of benign metastasizing leiomyoma can only be made after careful examination of the primary tumor to exclude small foci of malignant change. (Ann Thorac Surg 2011;91:924 – 6) © 2011 by The Society of Thoracic Surgeons
B
enign metastasizing leiomyoma is a nebulous condition in which metastatic smooth muscle tumor forms in other organs from a benign leiomyoma of the uterus. In most cases, benign metastasizing leiomyoma occurs in the pelvic cavity and lung, and rarely, in the vertebrae or skull base. In this report, we report a 30-year-old woman presenting with benign metastasizing leiomyoma that metastasized to the rib and vertebra, which has been rarely reported in literature. A 30-year-old woman (para 0, gravida 0) presented with a rib mass and a 3-month history of recurrent back pain that started 1-week before menstruation and stopped at the beginning of the period. She had undergone a myomectomy for a 13- ⫻ 12- ⫻ 7-cm-sized uterine myoma about 3 years earlier. Pathologic findings of that uterine
Accepted for publication Aug 16, 2010. *These authors contributed equally to the article. Address correspondence to Dr Na, Department of Thoracic and Cardiovascular Surgery, College of Medicine, Chungnam National University, Daejeon, 301-721, Republic of Korea; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.08.030