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Successful management of a recalcitrant bronchopleural fistula associated with infection after total pneumonectomy
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e180ee182
CORRESPONDENCE AND COMMUNICATION
Successful management of a recalcitrant bronchopleural fistula associated with infection after total pneumonectomy Successful management of this life-threatening condition after pneumonectomy still presents a real challenge even
to plastic surgeons who are often asked by their thoracic surgery colleagues in a medical centre to treat this potentially lethal complication. Although an adjacent muscle flap, such as latissimus dorsi muscle flap, has been used to close the fistula and to obliterate the empyema space with good success,1 the flap is frequently transected during previous pneumonectomy and, for this reason, a distant flap or a free flap has occasionally been used to treat bronchopleural fistula.2,3 This article presents a patient, with a complicated bronchopleural fistula associated with
Figure 1 (A) Large open chest wound associated with right bronchopleural fistula was found in this devastating patient when the plastic surgery service was consulted. The air leak (Pointed by an arrow) was easily visible. (B) Intraoperative view showing a midabdominal TRAM flap which was elevated and tunnelled over the right subcostal area. (C) An intrathoracic placement of the entire de-epithelized right mid-abdominal TRAM flap.(The pedicle of the flap is pointed by an arrow) The Zones 1 and 2 of the flap was facing the site of the bronchopleural fistula and the stump of the pulmonary vessels and the Zones 3 and 4 was facing out.(Pointed by two arrows) The part of the flap was sutured to wrap around the repaired bronchopleural fistula site and the rest of the flap was then placed inside the chest with interrupted sutures.(D) Closure of the entire chest wound after intrathoracic placement of the mid-abdominal TRAM flap. 1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.02.080
Correspondence and communication
e181
Figure 2 (A) Recurrent bronchopleural fistula with small open chest wound about 4 months after her initial flap surgery. (B) Intraoperative view showing a successfully transferred free latissimus dorsi musculocutaneous flap after microvascular anastomoses. (C) An intrathoracic placement of the de-epithelized free flap. (Pointed by an arrow) The recurrent fistula repaired with additional suture and fascial patch graft was covered with the muscular port of the flap and the remaining dead space was also completely obliterated by the flap with de-epithelized portion facing out. (D) Follow-up visit has demonstrated well healed right chest wound and ‘closed’ bronchopleural fistula now over one and an half years after the total pneumonectomy.
recalcitrant air leak and infection, who was managed successfully. The treatment strategy for such a recalcitrant bronchopleural fistula is also discussed. The patient was a 49-year-old white female who underwent right total pneumonectomy for stage IIIA non-small cell lung cancer. She had preoperative radiation and chemotherapy for treatment of her advanced cancer. About 2 weeks postoperatively, she was found to have right bronchopleural fistula with air leak and vancomycin-resistant enterococcus infection as well as methicillin-resistant Staphylococcus aureus infection. A right thoracoplasty was initially performed by the thoracic surgeon for the control of the bronchopleural fistula. She had a very complicated hospital course including emergent cardiopulmonary bypass for control of the bleeding from the right pulmonary artery stump. She was brought to the operating room by the plastic surgery service about 5 weeks after her right total pneumonectomy. After careful debridement to remove all necrotic, infected or colonised tissues within the right chest, a midabdominal transverse rectus abdominal musculocutaneous (TRAM) flap was designed based on the right superior epigastric vessels. The reason for selecting a mid-abdominal TRAM flap was because of her previous lower abdominal midline scar and also to ensure the near-total survival of the mid-abdominal TRAM flap based on its large peri-umbilical perforators.4 The entire flap was elevated, tunnelled through the right subcostal area and placed inside the right chest without tension after the skin paddle (30 12 cm) of
the flap was de-epithelised. Postoperatively she was doing well, except a deep venous thrombosis of the right upper extremity that was treated accordingly. Her air leak and infection appeared to be resolved and she was discharged from the hospital 2 months later (Figure 1). This patient unfortunately developed recurrent bronchopleural fistula about 4 months after her first flap surgery, with a small open wound on her right chest and persistent air leak. She was otherwise doing well without evidence of infection. At this point, it became clear that additional well-vascularised tissue would be required not only to cover the recurrent bronchopleural fistula but also to obliterate the remaining dead space within the thoracic cavity. She was then brought to the operating room for the second intrathoracic flap transfer. The left latissimus dorsi musculocutaneous flap was elevated as a free flap and the right thoracodorsal vessels were explored for the recipient vessels. After successful end-to-end microvascular anastomoses for both artery and vein, the entire flap appeared to be well perfused. The de-epithelialised flap could be placed freely anywhere inside the chest cavity. With the combined efforts of the thoracic and plastic surgeons, the recurrent bronchopleural fistula was repaired. With concerns of the flap being buried inside the chest, it was observed for an hour in the operating room after both microvascular anastomoses before the chest wound was closed. It reassured the surgeon that both microvascular anastomoses were patent and there were no technical
e182 errors in the free tissue transfer. The patient tolerated the entire procedure well and was extubated the next day. She was found to have no further air leak after the second flap surgery and was discharged from the hospital 2 weeks postoperatively. During the subsequent follow-ups, the patient had no evidence of recurrent bronchopleural fistula and her right chest wound healed well (Figure 2). Adequate debridement of infected or necrotic tissue in the thoracic cavity, closure of bronchopleural fistula with muscle flaps and minimisation of the dead space with thoracoplasty and muscle flaps are the principles of modern approach for bronchopleural fistula associated with infection after total pneumonectomy.2However, management of a recalcitrant bronchopleural fistula associated with infection can be challenging, and multiple flaps or procedures are often needed to close the air leak, to obliterate most of the dead space and to eliminate the infection.5 The author proposes a treatment strategy using a major distant flap, such as a mid-abdominal TRAM flap, for initial intrathoracic placement to close the bronchopleural fistula and to obliterate a significant portion of the dead space within the chest. If such an effort fails, a major free tissue transfer, such as a contralateral latissimus dorsi musculocutaneous as a second procedure, should be considered. This large free flap itself can provide additional wellvascularised tissue for more sophisticated flap inset to close the fistula and to further obliterate the dead space within the thoracic cavity. Such a combination is often necessary and should be considered when managing this devastating post-pneumonectomy complication.
Acknowledgement The author expresses his appreciation to Timothy W. Mullett, MD, Division of Cardiothoracic Surgery, University of
Correspondence and communication Kentucky, Lexington, Kentucky, USA for his excellent medical care provided to this challenging patient.
Financial disclosure The author has no commercial associations and financial interests for the drugs, products, or instruments used in this study.
References 1. Arnold PG, Pairolero PC. Intrathoracic muscle flaps: a 10-year experience in the management of life-threatening infections. Plast Reconstr Surg 1989;84:92e9. 2. Michaels BM, Orgill DP, Decamp MM, et al. Flap closure of postpneumonectomy empyema. Plast Reconstr Surg 1997;99: 437e42. 3. Chen H-C, Tang Y-B, Noordhoff MS, et al. Microvascular free muscle flaps for chronic empyema with bronchopleural fistula when the major local muscles have been divided e one-stage operation with primary wound closure. Ann Plast Surg 1990;24: 510e6. 4. Gabbay JS, Eby JB, Kulber DA. The mid-abdominal TRAM flap for breast reconstruction in morbidly obese patients. Plast Reconstr Surg 2005;115:764e70. 5. Seify H, Mansour K, Miller J, et al. Single-stage muscle flap reconstruction of the postpneumonectomy empyema space: the Emory experience. Plast Reconstr Surg 2007;120:1886e91.
Lee L.Q. Pu Division of Plastic Surgery, University of California, Davis, Sacramento, CA, USA E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION
Successful management of a recalcitrant bronchopleural fistula associated with infection after total pneumonectomy Successful management of this life-threatening condition after pneumonectomy still presents a real challenge even
to plastic surgeons who are often asked by their thoracic surgery colleagues in a medical centre to treat this potentially lethal complication. Although an adjacent muscle flap, such as latissimus dorsi muscle flap, has been used to close the fistula and to obliterate the empyema space with good success,1 the flap is frequently transected during previous pneumonectomy and, for this reason, a distant flap or a free flap has occasionally been used to treat bronchopleural fistula.2,3 This article presents a patient, with a complicated bronchopleural fistula associated with
Figure 1 (A) Large open chest wound associated with right bronchopleural fistula was found in this devastating patient when the plastic surgery service was consulted. The air leak (Pointed by an arrow) was easily visible. (B) Intraoperative view showing a midabdominal TRAM flap which was elevated and tunnelled over the right subcostal area. (C) An intrathoracic placement of the entire de-epithelized right mid-abdominal TRAM flap.(The pedicle of the flap is pointed by an arrow) The Zones 1 and 2 of the flap was facing the site of the bronchopleural fistula and the stump of the pulmonary vessels and the Zones 3 and 4 was facing out.(Pointed by two arrows) The part of the flap was sutured to wrap around the repaired bronchopleural fistula site and the rest of the flap was then placed inside the chest with interrupted sutures.(D) Closure of the entire chest wound after intrathoracic placement of the mid-abdominal TRAM flap. 1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.02.080
Correspondence and communication
e181
Figure 2 (A) Recurrent bronchopleural fistula with small open chest wound about 4 months after her initial flap surgery. (B) Intraoperative view showing a successfully transferred free latissimus dorsi musculocutaneous flap after microvascular anastomoses. (C) An intrathoracic placement of the de-epithelized free flap. (Pointed by an arrow) The recurrent fistula repaired with additional suture and fascial patch graft was covered with the muscular port of the flap and the remaining dead space was also completely obliterated by the flap with de-epithelized portion facing out. (D) Follow-up visit has demonstrated well healed right chest wound and ‘closed’ bronchopleural fistula now over one and an half years after the total pneumonectomy.
recalcitrant air leak and infection, who was managed successfully. The treatment strategy for such a recalcitrant bronchopleural fistula is also discussed. The patient was a 49-year-old white female who underwent right total pneumonectomy for stage IIIA non-small cell lung cancer. She had preoperative radiation and chemotherapy for treatment of her advanced cancer. About 2 weeks postoperatively, she was found to have right bronchopleural fistula with air leak and vancomycin-resistant enterococcus infection as well as methicillin-resistant Staphylococcus aureus infection. A right thoracoplasty was initially performed by the thoracic surgeon for the control of the bronchopleural fistula. She had a very complicated hospital course including emergent cardiopulmonary bypass for control of the bleeding from the right pulmonary artery stump. She was brought to the operating room by the plastic surgery service about 5 weeks after her right total pneumonectomy. After careful debridement to remove all necrotic, infected or colonised tissues within the right chest, a midabdominal transverse rectus abdominal musculocutaneous (TRAM) flap was designed based on the right superior epigastric vessels. The reason for selecting a mid-abdominal TRAM flap was because of her previous lower abdominal midline scar and also to ensure the near-total survival of the mid-abdominal TRAM flap based on its large peri-umbilical perforators.4 The entire flap was elevated, tunnelled through the right subcostal area and placed inside the right chest without tension after the skin paddle (30 12 cm) of
the flap was de-epithelised. Postoperatively she was doing well, except a deep venous thrombosis of the right upper extremity that was treated accordingly. Her air leak and infection appeared to be resolved and she was discharged from the hospital 2 months later (Figure 1). This patient unfortunately developed recurrent bronchopleural fistula about 4 months after her first flap surgery, with a small open wound on her right chest and persistent air leak. She was otherwise doing well without evidence of infection. At this point, it became clear that additional well-vascularised tissue would be required not only to cover the recurrent bronchopleural fistula but also to obliterate the remaining dead space within the thoracic cavity. She was then brought to the operating room for the second intrathoracic flap transfer. The left latissimus dorsi musculocutaneous flap was elevated as a free flap and the right thoracodorsal vessels were explored for the recipient vessels. After successful end-to-end microvascular anastomoses for both artery and vein, the entire flap appeared to be well perfused. The de-epithelialised flap could be placed freely anywhere inside the chest cavity. With the combined efforts of the thoracic and plastic surgeons, the recurrent bronchopleural fistula was repaired. With concerns of the flap being buried inside the chest, it was observed for an hour in the operating room after both microvascular anastomoses before the chest wound was closed. It reassured the surgeon that both microvascular anastomoses were patent and there were no technical
e182 errors in the free tissue transfer. The patient tolerated the entire procedure well and was extubated the next day. She was found to have no further air leak after the second flap surgery and was discharged from the hospital 2 weeks postoperatively. During the subsequent follow-ups, the patient had no evidence of recurrent bronchopleural fistula and her right chest wound healed well (Figure 2). Adequate debridement of infected or necrotic tissue in the thoracic cavity, closure of bronchopleural fistula with muscle flaps and minimisation of the dead space with thoracoplasty and muscle flaps are the principles of modern approach for bronchopleural fistula associated with infection after total pneumonectomy.2However, management of a recalcitrant bronchopleural fistula associated with infection can be challenging, and multiple flaps or procedures are often needed to close the air leak, to obliterate most of the dead space and to eliminate the infection.5 The author proposes a treatment strategy using a major distant flap, such as a mid-abdominal TRAM flap, for initial intrathoracic placement to close the bronchopleural fistula and to obliterate a significant portion of the dead space within the chest. If such an effort fails, a major free tissue transfer, such as a contralateral latissimus dorsi musculocutaneous as a second procedure, should be considered. This large free flap itself can provide additional wellvascularised tissue for more sophisticated flap inset to close the fistula and to further obliterate the dead space within the thoracic cavity. Such a combination is often necessary and should be considered when managing this devastating post-pneumonectomy complication.
Acknowledgement The author expresses his appreciation to Timothy W. Mullett, MD, Division of Cardiothoracic Surgery, University of
Correspondence and communication Kentucky, Lexington, Kentucky, USA for his excellent medical care provided to this challenging patient.
Financial disclosure The author has no commercial associations and financial interests for the drugs, products, or instruments used in this study.
References 1. Arnold PG, Pairolero PC. Intrathoracic muscle flaps: a 10-year experience in the management of life-threatening infections. Plast Reconstr Surg 1989;84:92e9. 2. Michaels BM, Orgill DP, Decamp MM, et al. Flap closure of postpneumonectomy empyema. Plast Reconstr Surg 1997;99: 437e42. 3. Chen H-C, Tang Y-B, Noordhoff MS, et al. Microvascular free muscle flaps for chronic empyema with bronchopleural fistula when the major local muscles have been divided e one-stage operation with primary wound closure. Ann Plast Surg 1990;24: 510e6. 4. Gabbay JS, Eby JB, Kulber DA. The mid-abdominal TRAM flap for breast reconstruction in morbidly obese patients. Plast Reconstr Surg 2005;115:764e70. 5. Seify H, Mansour K, Miller J, et al. Single-stage muscle flap reconstruction of the postpneumonectomy empyema space: the Emory experience. Plast Reconstr Surg 2007;120:1886e91.
Lee L.Q. Pu Division of Plastic Surgery, University of California, Davis, Sacramento, CA, USA E-mail address: [email protected]