Muscle Flap Transposition for the Management of Intrathoracic Fistulas

Abstract

Background: Intrathoracic fistulas pose unique challenges for thoracic and reconstructive surgeons. To decrease the incidence of fistula recurrence, pedicled flaps have been suggested to buttress the repair site. The authors aimed to report their experience with muscle flap transposition for the management of intrathoracic fistulas. Methods: A retrospective review of all patients who underwent intrathoracic muscle flap transposition for the management of intrathoracic fistulas from 1990 to 2010 was conducted. Patient demographics, surgical characteristics, and complication rates were abstracted and analyzed. Results: A total of 198 patients were identified. Bronchopleural fistula was present in 156 of the patients (79 percent), and 48 had esophageal fistula (24 percent). A total of 238 flaps were used, constituting an average of 1.2 flaps per patient. After the initial fistula repair, bronchopleural fistula complicated the course of 34 patients (17 percent), and esophageal fistula occurred in 13 patients (7 percent). Partial flap loss was identified in 11 flaps (6 percent), and total flap loss occurred in four flaps (2 percent). Median follow-up was 27 months. At the last follow-up, 182 of the patients (92 percent) had no evidence of fistula, 175 (89 percent) achieved successful chest closure, and 164 (83 percent) had successful treatment. Preoperative radiation therapy and American Society of Anesthesiologists score of 4 or greater were identified as risk factors for unsuccessful treatment. Conclusions: Intrathoracic fistulas remain a source of major morbidity and mortality. Reinforcement of the fistula closure with vascularized muscle flaps is a viable option for preventing dehiscence of the repair site and can be potentially life-saving. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Iliocostalis Muscle Rotational Flap: A Novel Flap for Esophagopleural Fistula Repair

“…A robust, well-vascularized flap is required to provide an airtight layer to close the defect, as they have been shown to improve rates of infection, morbidity, and mortality and minimize fistula recurrence. 3,[6][7][8] Commonly used extrathoracic muscles were compromised in the previous surgical and radiation field, and thus not available as reconstructive options. History of exploratory laparotomy also precluded the use of omentum.…”

“…1,2 Extra-thoracic muscle flaps such as the serratus anterior, latissimus dorsi, and pectoralis major are primarily utilized for repair. 3 Recently, perforator-based intercostal artery muscle flaps have also been utilized. 4 However, there are patients for whom commonly utilized regional muscle flaps are not available, for reasons including prior thoracotomy and radiation fibrosis.…”

Intractable Bronchopleural Fistula After Lung Resection in Mycobacterial Infection; Surgical and Endoscopic Treatment With Fibrin Glue Application Followed by Latissimus Dorsi Musculocutaneous Flap Coverage: A Case Report

“…Thirdly, after the closure of the BPF is secured and the air leak has not been detected, the vascularized muscular flap coverage should be performed simultaneously or as soon as possible. 3 Thereby, we suggest that the coverage of the defect should be consecutively done in the same operation after the BPF closure. Finally, the postoperative BPF patients usually confront with other sophisticated medical problems.…”

“…1,2 This condition is a rare condition but challenging problem for multidisciplinary health care team. 3 After BPF has occurred, it causes pneumothorax and contamination from the airway to pleural space which leads to chronic infection of pleural space and empyema thoracis. 2 One of the major causes of BPF results from unhealed bronchial stump after lung surgery (pneumonectomy, lobectomy and segmentectomy).…”

Perforator-Based Intercostal Artery Muscle Flap: A Novel Approach for the Treatment of Tracheoesophageal or Bronchoesophageal Fistulas

“…2 In this case, a serratus muscle flap is still achievable. 3 Facing such complex situations led us to adapt our strategy and to develop the perforator-based intercostal artery muscle flap, 4,5 aiming to reach three major objectives regarding the flap properties: (1) sufficient length to cover a distal defect on the airway tree; (2) availability even after previous thoracotomy with muscle sacrifice; and (3) involvement of a lining surface able to cover a large defect, in an airtight way.…”