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Protection and revascularization of bronchial anastomoses by the intercostal pedicle flap
Protection and revascularization of bronchial anastomoses by the intercostal pedicle flap We used an improved method for preparation of the intercostal pedicle flap for encircling bronchial anastomoses, and we studied its vascular supply after the operation. The flap was used in 56 patients undergoing various types of sleeve resection and in three patients undergoing single lung transplantation. The technique is simple, fast, and causes neither extra surgical trauma nor complications. It allows satisfactory isolation and sealing of the bronchial anastomosis. Even if complete anastomotic dehiscence occurs (one case), the flap preserves the continuity of the airway, thus avoiding bronchopleural fistulas or other complications. The postoperative arteriographic study of the intercostal artery supplying the flap (performed in 14 patients) demonstrated the fuD patency of the vessel in all cases. It also showed that a fine vascular network develops around the anastomosis early in the postoperative period. (J THORAC CARDIOVASC SURG 1994;107:1251-4)
Erino A. Rendina, MD, Federico Venuta, MD, Paolo Ricci, MD,a G. Franco Fadda, MD, Diego A. Bognolo, MD, Costante Ricci, MD, and Plinio Rossi, MD,a Rome. Italy
Etection of the bronchial anastomosis is important after bronchoplastic procedures such as sleeve lobectomy 1,2 or sleeve pneumonectomy with carina I resection. 3,4 The risk of erosion ofthe adjacent pulmonary artery may be minimized by encircling the anastomosis with well vascularized tissue, and bronchopleural fistulas caused by dehiscence may be avoided. In addition, the revascularization of the distal bronchus avoids problems related to ischemia. We hereby report our experience with an improved method for preparation of the intercostal pedicle flap as a means of protection and revascularization of bronchial anastomoses.
Patients and methods The intercostal pedicle flap was used in 59 patients between May 1989 and May 1992. Three patients underwent right pneumonectomy with carinal resection, and 53 underwent various types of sleeve resection. Three additional patients underFrom the Departments of Thoracic Surgery and Radiology;University of Rome "La Sapienza," Rome, Italy Received for publication May 19, 1993. Accepted for publication Aug. 19, 1993. Address for reprints: E. A. Rendina, MD, Cattedra di Chirurgia Toracica, Universita ' di Roma"La Sapienza," Policlinico Umberto I, 00161 Roma, Italy. Copyright @ 1994 by Mosby-Year Book, Inc. 0022-5223/94 $3.00 + 0 12/1/50931
went single lung transplantation with no anastomotic problems. Excluding patients who underwent transplantation, the indications included lung cancer (n = 45), bronchial carcinoid (n = 9), and other benign lesions (n = 2). Technique. With the patient in the lateral decubitus position, a standard posterolateral thoracotomy incision is made. The dorsalis major and serratus anterior muscles are divided, and the costal plane is exposed. The preparation of the flap is performed before opening the chest, and the rib retractor is not inserted until the procedure is completed to avoid crushing the intercostal vessels. The periosteum of the fifth rib is incised and then separated from the bone in continuity with the underlying intercostal muscle (Fig. I). The periosteum is not treated with silver nitrate. Care must be taken to preserve the muscular insertion to the periosteum to avoid injuring the intercostal neurovascular bundle. The fifth rib is then gently retracted upward, and the parietal pleura is separated by finger dissection from the chest wall to create a wide pleural flap in continuity with the intercostal muscle (Fig. I). The preparation of the cranial aspect of the pedicle is thus completed. The intercostal muscle is now incised in the vicinity of the underlying sixth rib, but the muscular insertion and the periosteum are left in place (Fig. 2). This maneuver is important for two reasons. First, it reduces the thickness of the flap without jeopardizing its vascular supply; a thin flap is easier to slide between the pulmonary artery and the bronchus and does not compress the pulmonary artery. Second, the periosteum and muscle fibers left in place will fill the gap between the ribs when closing the chest, thus avoiding the occurrence of subcutaneous emphysema. At this point the sixth rib is gently retracted downward, and the parietal pleura, en bloc with the intercostal muscle, is separated by finger dissection from the chest wall (Fig. 2). Care must be taken not to separate the pleura from the muscle to avoid damaging the pleural vascular supply. The
1 25 I
The Journal of Thoracic and Cardiovascular Surgery May 1994
I 2 5 2 Rendina et al.
Fig. 1. Preparation of the cranial aspect of the intercostal flap. Periosteum is harvested in continuity with the muscle to preserve the intercostal vessels.
Fig. 2. Preparation of the inferior aspect of the intercostal flap. Part of the muscular insertion on the sixth rib and the periosteum are left in place.
pleura is now incised far enough from the muscle on the upper and lower side, thus creating a wide muscular-pleural flap attached anteriorly and posteriorly to the chest wall. Only at this time is the rib spreader inserted, and the anterior insertion of the flap is divided. The blood flow in the intercostal artery is checked, and the pedicle is ligated at its anterior extremity (Fig. 3). The flap is now wrapped in a moist warm gauze and laid in the chest. When the bronchial anastomosis is completed, a large right-angle clamp is slid between the pulmonary artery and the bronchus, and the suture at the extremity of the flap is grasped (Fig . 4). The clamp is then withdrawn, and the flap is slid backward around the bronchial anastomosis and between the bronchus and the pulmonary artery. The flap is then twisted until its pleural side is in contact with the bronchial anasto-
Fig. 3. Appearance of the pedicle after the preparation is completed . The muscle is in continuity with a wide bilateral flap of parietal pleura.
Fig. 4. The flap is positioned around the bronchial anastomosis. See text for description.
mosis and the pleura is secured to the bronchus by interrupted absorbable 4-0 sutures (Fig. 5) .
Results Bronchoscopy was performed in all patients before extubation and on the first postoperative day. The anastomosis appeared satisfactory in all patients. Routinely, bronchoscopy was also performed I, 3, 6, 12, and 24 months after the operation in uncomplicated cases. Osteoneogenesis of the periosteum, whenever it may have occurred, did not cause stenosis or other problems. Anastomotic complications occurred after 6 to 12 days in three
The Journal of Thoracic and Cardiovascular Surgery Volume 107, Number 5
Fig. 5. The flap is secured to the bronchus. The muscular bulk guarantees retraction and protection of the pulmonary artery from the bronchial suture. The wide pleural flap ensures ideal isolation of the anastomosis.
patients: one patient had a complete dehiscence and two patients had partial dehiscences associated with granuloma formation on the bronchial edges. The complication rate was 5%. The continuity of the airway, however, was maintained by the flap, and no bronchopleural or bronchovascular fistulas occurred. In the patient with complete dehiscence, the pleural surface of the flap was visible bronchoscopically, bulging in the bronchial lumen. The bronchus was fully recanalized by yttrium-aluminum-garnet laser, and the patency of the airway was assured by the insertion of a silicone rubber endobronchial prosthesis, which was removed after 6 to 12 months with no further complications. In 14 patients, after informed consent was obtained, selective angiograms of the intercostal artery were obtained in the seventh (n = 6) and fourteenth (n = 8) (Fig. 6) postoperative days. In all cases the patency of the artery could be demonstrated, and at only 7 days after the operation a fine vascular network surrounding the anastomosis was visible. Discussion
Many techniques have been proposed for encircling the bronchial anastomosis after either bronchoplastic procedures''? or lung transplantation.v" Omentopexy has the disadvantage of requiring abdominal exploration, and pleural, pericardial, thymic, or mediastinal tissue flaps are often insufficient in length, width, consistency, or vascularization. Intrathoracic transposition of an intercostal pedicle flap is not new in thoracic surgery9-13; however, we have
Rendina et al.
I253
Fig. 6. Selective angiography of the intercostal artery supplying the flap (small arrows) taken in thefourteenth postoperative day. The arterial loop around the bronchial anastomosis and a fine vascular network are evident (medium arrow). A fine vascular network is also evident in the area of the reimplanted bronchus (large arrow).
demonstrated that, with the technique that we have used, the sealing of the anastomosis is satisfactory even in cases of complete dehiscence. In comparison with omentopexy, the intercostal flap technique is faster and simpler, and it neither requires extra surgical trauma nor exposes the patient to the risk of abdominal complications. It also has advantages over the pericardium, pleura, thymus, or mediastinal fat: the muscular-pleural flap can always be wrapped completely around the bronchus with a continuous layer of tissue, which is well vascularized and thin, notwithstanding its good consistency. The flap can therefore be easily tailored and sutured to the bronchus to ensure positive isolation and protection of the anastomosis. It may be prepared simply and quickly before opening the chest and may be replaced between the ribs at chest closure if not needed. We used this technique successfully in 56 sleeve resections and three single lung transplantations; three patients with bronchogenic carcinoma who had preoperative irradiation had an anastomotic dehiscence (one complete and two partial). In none of the patients did a bronchopleural fistula or further complication occur, and the patients fully recovered after 6 to 12 months. Revascularization of the donor bronchus distal to the anastomosis is a major issue in bronchoplastic surgery and especially in lung transplantation. Fell? and Morgan" and their associates demonstrated early revascularization of the bronchial mucosa in canine models by using the intercostal muscle and the omentum; the latter method
I 254
The Journal of Thoracic and Cardiovascular Surgery May 1994
Rendina et al.
has gained popularity also in human lung transplantation. However, the viability of bronchial revascularization with the intercostal muscle has not been confirmed in human beings. The arteriographic images that we have obtained demonstrate that a properly prepared, well vascularized intercostal flap may facilitate bronchial revascularization after a sleeve resection early in the postoperative period. This finding requires specific investigation before being applyed to transplantation because of the many physiopathologic differences involved. We thank M. Seminara and M. Passacantilli for preparing the illustrations. REFERENCES I. Kittle CF. Atypical resections of the lung: bronchoplasties sleeve resections and segmentectomies. Curr Prob Surg 1989;26:57-132. 2. Vogt-MoykopfI, Fritz T, Meier G, Bulzerbruck H, Daskos G. Bronchoplastic and Angioplastic operation in bronchial carcinoma. Int Surg 1986;71 :211-20. 3. Deslauriers J, Beaulieu M, Benazera A, et al. Sleeve pneumonectomy for bronchogenic carcinoma. Ann Thor Surg 1979;28:465-72. 4. Tsuchiya R, Goya T, Naruke T, Suemasu K. Resection of tracheal carina for lung cancer. J THORAC CARDIOVASC SURG 1990;99:779-8. 5. Mathisen DJ, Grillo HG, Vlahakes GJ, Dagget WM. The
6.
7.
8.
9.
10.
II.
12.
13.
omentum in the management of complicated cardiothoracic problems. J THORAC CARDIOVASC SURG 1988;95: 677-84. Morgan E, Lima 0, Goldberg M, Ferdman A, Luk SK, Cooper JD. Successful revascularization of totally ischemic bronchial autografts with omental pedicle flap in dogs. J THORAC CARDIOVASC SURG 1982;84:204-10. Fell SC, Mollenkopf FP, Montefusco CM, et al. Revascularization of ischemic bronchial anastomoses by an intercostal pedicle flap. J THORAC CARDIOVASC SURG 1985; 90:172-8. Noirclerc MJ, Metras D, Vaillant A, et al. Bilateral bronchial anastomosis in double lung and heart-lung transplantation. Eur J Cardiothorac Surg 1990;4:314-7. Blair E. Study of the via ble intercostal pedicle graft in tracheobronchial surgery. J THORAC CARDIOVASC SURG 1958;36:869-78. Brayant LR, Eiseman B. Experimental evaluation of intercostal pedicle grafts in esophageal repair. J THORAC CARDIOVASC SURG 1965;50:626-33. Hankins JR, Miller JE, McLaughlin JS. The use of chest wall muscle flap to close bronchopleural fistulas: experience with 21 patients. Ann Thorac Surg 1978;25:491-9. Papp C, Parker P, Boeheim C, McCraw JB. Experimental use of intercostal muscle flaps for repair of induced cardiac defects. J THORAC CARDIOVASC SURG 1985;90:261-4. Gustafson RA, Hrabovsky EE. Intercostal muscle and myoosseous flaps in difficult pediatric thoracic problems. J Pediatr Surg 1982;17:541-5.
Erino A. Rendina, MD, Federico Venuta, MD, Paolo Ricci, MD,a G. Franco Fadda, MD, Diego A. Bognolo, MD, Costante Ricci, MD, and Plinio Rossi, MD,a Rome. Italy
Etection of the bronchial anastomosis is important after bronchoplastic procedures such as sleeve lobectomy 1,2 or sleeve pneumonectomy with carina I resection. 3,4 The risk of erosion ofthe adjacent pulmonary artery may be minimized by encircling the anastomosis with well vascularized tissue, and bronchopleural fistulas caused by dehiscence may be avoided. In addition, the revascularization of the distal bronchus avoids problems related to ischemia. We hereby report our experience with an improved method for preparation of the intercostal pedicle flap as a means of protection and revascularization of bronchial anastomoses.
Patients and methods The intercostal pedicle flap was used in 59 patients between May 1989 and May 1992. Three patients underwent right pneumonectomy with carinal resection, and 53 underwent various types of sleeve resection. Three additional patients underFrom the Departments of Thoracic Surgery and Radiology;University of Rome "La Sapienza," Rome, Italy Received for publication May 19, 1993. Accepted for publication Aug. 19, 1993. Address for reprints: E. A. Rendina, MD, Cattedra di Chirurgia Toracica, Universita ' di Roma"La Sapienza," Policlinico Umberto I, 00161 Roma, Italy. Copyright @ 1994 by Mosby-Year Book, Inc. 0022-5223/94 $3.00 + 0 12/1/50931
went single lung transplantation with no anastomotic problems. Excluding patients who underwent transplantation, the indications included lung cancer (n = 45), bronchial carcinoid (n = 9), and other benign lesions (n = 2). Technique. With the patient in the lateral decubitus position, a standard posterolateral thoracotomy incision is made. The dorsalis major and serratus anterior muscles are divided, and the costal plane is exposed. The preparation of the flap is performed before opening the chest, and the rib retractor is not inserted until the procedure is completed to avoid crushing the intercostal vessels. The periosteum of the fifth rib is incised and then separated from the bone in continuity with the underlying intercostal muscle (Fig. I). The periosteum is not treated with silver nitrate. Care must be taken to preserve the muscular insertion to the periosteum to avoid injuring the intercostal neurovascular bundle. The fifth rib is then gently retracted upward, and the parietal pleura is separated by finger dissection from the chest wall to create a wide pleural flap in continuity with the intercostal muscle (Fig. I). The preparation of the cranial aspect of the pedicle is thus completed. The intercostal muscle is now incised in the vicinity of the underlying sixth rib, but the muscular insertion and the periosteum are left in place (Fig. 2). This maneuver is important for two reasons. First, it reduces the thickness of the flap without jeopardizing its vascular supply; a thin flap is easier to slide between the pulmonary artery and the bronchus and does not compress the pulmonary artery. Second, the periosteum and muscle fibers left in place will fill the gap between the ribs when closing the chest, thus avoiding the occurrence of subcutaneous emphysema. At this point the sixth rib is gently retracted downward, and the parietal pleura, en bloc with the intercostal muscle, is separated by finger dissection from the chest wall (Fig. 2). Care must be taken not to separate the pleura from the muscle to avoid damaging the pleural vascular supply. The
1 25 I
The Journal of Thoracic and Cardiovascular Surgery May 1994
I 2 5 2 Rendina et al.
Fig. 1. Preparation of the cranial aspect of the intercostal flap. Periosteum is harvested in continuity with the muscle to preserve the intercostal vessels.
Fig. 2. Preparation of the inferior aspect of the intercostal flap. Part of the muscular insertion on the sixth rib and the periosteum are left in place.
pleura is now incised far enough from the muscle on the upper and lower side, thus creating a wide muscular-pleural flap attached anteriorly and posteriorly to the chest wall. Only at this time is the rib spreader inserted, and the anterior insertion of the flap is divided. The blood flow in the intercostal artery is checked, and the pedicle is ligated at its anterior extremity (Fig. 3). The flap is now wrapped in a moist warm gauze and laid in the chest. When the bronchial anastomosis is completed, a large right-angle clamp is slid between the pulmonary artery and the bronchus, and the suture at the extremity of the flap is grasped (Fig . 4). The clamp is then withdrawn, and the flap is slid backward around the bronchial anastomosis and between the bronchus and the pulmonary artery. The flap is then twisted until its pleural side is in contact with the bronchial anasto-
Fig. 3. Appearance of the pedicle after the preparation is completed . The muscle is in continuity with a wide bilateral flap of parietal pleura.
Fig. 4. The flap is positioned around the bronchial anastomosis. See text for description.
mosis and the pleura is secured to the bronchus by interrupted absorbable 4-0 sutures (Fig. 5) .
Results Bronchoscopy was performed in all patients before extubation and on the first postoperative day. The anastomosis appeared satisfactory in all patients. Routinely, bronchoscopy was also performed I, 3, 6, 12, and 24 months after the operation in uncomplicated cases. Osteoneogenesis of the periosteum, whenever it may have occurred, did not cause stenosis or other problems. Anastomotic complications occurred after 6 to 12 days in three
The Journal of Thoracic and Cardiovascular Surgery Volume 107, Number 5
Fig. 5. The flap is secured to the bronchus. The muscular bulk guarantees retraction and protection of the pulmonary artery from the bronchial suture. The wide pleural flap ensures ideal isolation of the anastomosis.
patients: one patient had a complete dehiscence and two patients had partial dehiscences associated with granuloma formation on the bronchial edges. The complication rate was 5%. The continuity of the airway, however, was maintained by the flap, and no bronchopleural or bronchovascular fistulas occurred. In the patient with complete dehiscence, the pleural surface of the flap was visible bronchoscopically, bulging in the bronchial lumen. The bronchus was fully recanalized by yttrium-aluminum-garnet laser, and the patency of the airway was assured by the insertion of a silicone rubber endobronchial prosthesis, which was removed after 6 to 12 months with no further complications. In 14 patients, after informed consent was obtained, selective angiograms of the intercostal artery were obtained in the seventh (n = 6) and fourteenth (n = 8) (Fig. 6) postoperative days. In all cases the patency of the artery could be demonstrated, and at only 7 days after the operation a fine vascular network surrounding the anastomosis was visible. Discussion
Many techniques have been proposed for encircling the bronchial anastomosis after either bronchoplastic procedures''? or lung transplantation.v" Omentopexy has the disadvantage of requiring abdominal exploration, and pleural, pericardial, thymic, or mediastinal tissue flaps are often insufficient in length, width, consistency, or vascularization. Intrathoracic transposition of an intercostal pedicle flap is not new in thoracic surgery9-13; however, we have
Rendina et al.
I253
Fig. 6. Selective angiography of the intercostal artery supplying the flap (small arrows) taken in thefourteenth postoperative day. The arterial loop around the bronchial anastomosis and a fine vascular network are evident (medium arrow). A fine vascular network is also evident in the area of the reimplanted bronchus (large arrow).
demonstrated that, with the technique that we have used, the sealing of the anastomosis is satisfactory even in cases of complete dehiscence. In comparison with omentopexy, the intercostal flap technique is faster and simpler, and it neither requires extra surgical trauma nor exposes the patient to the risk of abdominal complications. It also has advantages over the pericardium, pleura, thymus, or mediastinal fat: the muscular-pleural flap can always be wrapped completely around the bronchus with a continuous layer of tissue, which is well vascularized and thin, notwithstanding its good consistency. The flap can therefore be easily tailored and sutured to the bronchus to ensure positive isolation and protection of the anastomosis. It may be prepared simply and quickly before opening the chest and may be replaced between the ribs at chest closure if not needed. We used this technique successfully in 56 sleeve resections and three single lung transplantations; three patients with bronchogenic carcinoma who had preoperative irradiation had an anastomotic dehiscence (one complete and two partial). In none of the patients did a bronchopleural fistula or further complication occur, and the patients fully recovered after 6 to 12 months. Revascularization of the donor bronchus distal to the anastomosis is a major issue in bronchoplastic surgery and especially in lung transplantation. Fell? and Morgan" and their associates demonstrated early revascularization of the bronchial mucosa in canine models by using the intercostal muscle and the omentum; the latter method
I 254
The Journal of Thoracic and Cardiovascular Surgery May 1994
Rendina et al.
has gained popularity also in human lung transplantation. However, the viability of bronchial revascularization with the intercostal muscle has not been confirmed in human beings. The arteriographic images that we have obtained demonstrate that a properly prepared, well vascularized intercostal flap may facilitate bronchial revascularization after a sleeve resection early in the postoperative period. This finding requires specific investigation before being applyed to transplantation because of the many physiopathologic differences involved. We thank M. Seminara and M. Passacantilli for preparing the illustrations. REFERENCES I. Kittle CF. Atypical resections of the lung: bronchoplasties sleeve resections and segmentectomies. Curr Prob Surg 1989;26:57-132. 2. Vogt-MoykopfI, Fritz T, Meier G, Bulzerbruck H, Daskos G. Bronchoplastic and Angioplastic operation in bronchial carcinoma. Int Surg 1986;71 :211-20. 3. Deslauriers J, Beaulieu M, Benazera A, et al. Sleeve pneumonectomy for bronchogenic carcinoma. Ann Thor Surg 1979;28:465-72. 4. Tsuchiya R, Goya T, Naruke T, Suemasu K. Resection of tracheal carina for lung cancer. J THORAC CARDIOVASC SURG 1990;99:779-8. 5. Mathisen DJ, Grillo HG, Vlahakes GJ, Dagget WM. The
6.
7.
8.
9.
10.
II.
12.
13.
omentum in the management of complicated cardiothoracic problems. J THORAC CARDIOVASC SURG 1988;95: 677-84. Morgan E, Lima 0, Goldberg M, Ferdman A, Luk SK, Cooper JD. Successful revascularization of totally ischemic bronchial autografts with omental pedicle flap in dogs. J THORAC CARDIOVASC SURG 1982;84:204-10. Fell SC, Mollenkopf FP, Montefusco CM, et al. Revascularization of ischemic bronchial anastomoses by an intercostal pedicle flap. J THORAC CARDIOVASC SURG 1985; 90:172-8. Noirclerc MJ, Metras D, Vaillant A, et al. Bilateral bronchial anastomosis in double lung and heart-lung transplantation. Eur J Cardiothorac Surg 1990;4:314-7. Blair E. Study of the via ble intercostal pedicle graft in tracheobronchial surgery. J THORAC CARDIOVASC SURG 1958;36:869-78. Brayant LR, Eiseman B. Experimental evaluation of intercostal pedicle grafts in esophageal repair. J THORAC CARDIOVASC SURG 1965;50:626-33. Hankins JR, Miller JE, McLaughlin JS. The use of chest wall muscle flap to close bronchopleural fistulas: experience with 21 patients. Ann Thorac Surg 1978;25:491-9. Papp C, Parker P, Boeheim C, McCraw JB. Experimental use of intercostal muscle flaps for repair of induced cardiac defects. J THORAC CARDIOVASC SURG 1985;90:261-4. Gustafson RA, Hrabovsky EE. Intercostal muscle and myoosseous flaps in difficult pediatric thoracic problems. J Pediatr Surg 1982;17:541-5.