Effective treatment of bronchopleural fistula with empyema by pedicled latissimus dorsi muscle flap transfer

Abstract

Rationale: Bronchopleural fistula (BPF) is a dreaded complication after lobectomy or pneumonectomy and is associated with high morbidity and mortality. Successful management remains challenging when this condition is combined with empyema, and the initial treatment is usually conservative and endoscopic, but operative intervention may be required in refractory cases. Patient concerns: Two patients diagnosed with BPF with empyema were selected to undergo surgery in our hospital because they could not be cured by conservative and endoscopic therapy for 1 or more years. One was a 70-year-old man who had a 1-year history of fever and cough after he received a minimally invasive right lower lobectomy for intermediate lung adenocarcinoma and chemotherapy 2 years ago; the other was a 73-year-old man who had a 2-year history of cough and fever after he underwent a minimally invasive right upper lobectomy for early lung adenocarcinoma 3 years earlier. Diagnosis: Both patients were diagnosed with BPF with empyema. Interventions: After receiving conservative and endoscopic therapies, both patients underwent pedicled latissimus dorsi muscle flap transfers for complete filling of the empyema cavity. Outcomes: The patients recovered very well, with no recurrence of BPF and empyema during postoperative follow-up. Lessons: It is crucial to not only completely control infection and occlude BPFs, but also obliterate the empyema cavity. Thus, pedicled latissimus dorsi muscle flap transfer associated with conservative and endoscopic therapies for BPF with empyema is a useful treatment option, offering feasible and efficient management with promising results.

Bronchopleural Fistula after Pulmonary Resection: Risk Factors, Diagnoses and Management

“…Stump coverage was previously discussed as a preventive measure for BPF. The objective in treating a BPF with vascularized tissue is to obliterate the postpneumonectomy pleural space [25,71,75,77]. Deciding which muscle flap to use depends on which muscle was preserved or damaged from the previous thoracotomy and the amount of space to be filled [71,75,77].…”

“…The objective in treating a BPF with vascularized tissue is to obliterate the postpneumonectomy pleural space [25,71,75,77]. Deciding which muscle flap to use depends on which muscle was preserved or damaged from the previous thoracotomy and the amount of space to be filled [71,75,77]. The most common muscles used in the pleural space to treat a BPF are serratus anterior, pectoralis major, pectoralis minor, latissimus dorsi, and intercostal muscles [25,71,75,77,78].…”

“…Deciding which muscle flap to use depends on which muscle was preserved or damaged from the previous thoracotomy and the amount of space to be filled [71,75,77]. The most common muscles used in the pleural space to treat a BPF are serratus anterior, pectoralis major, pectoralis minor, latissimus dorsi, and intercostal muscles [25,71,75,77,78]. The latissimus dorsi is the most reliable and largest muscle but A.…”

“…With too much inflammation, the stump may need to be sutured closed. (Sugarbaker D, Bueno R, Burt B, et al, editors may not be sufficient to obliterate the postpneumonectomy cavity if it was already divided in the original thoracotomy [77,78]. The greater omentum consists of a large fold of peritoneum with excellent blood supply and antibacterial effect, lymphoid tissue, and fat [76,78].…”

“…The greater omentum consists of a large fold of peritoneum with excellent blood supply and antibacterial effect, lymphoid tissue, and fat [76,78]. Using large muscles as the latissimus dorsi, greater omentum and serratus anterior has the advantage to contribute bulk to fill some of the dead postpneumonectomy space sugar [76][77][78]. In a study by Mazzella et al 2017, fourteen patients with early BPF were treated with surgical repair of the bronchial stump via thoracoscopy (2) or thoracotomy (12) with omentum and fibrin glue (2) parietal pleural (3), intercostal muscle (1) or pericardial patch (2) with no recurrence of BPF after surgery [79].…”