The pectoral muscle flaps in the treatment of bronchial stump fistula following pneumonectomy

Abstract

Between 1975 and June 1992, pneumonectomy was performed in 594 patients, of whom 33 (5.6%) developed bronchopleural fistulae postoperatively. Until 1989 25 cases were reoperated: 5 patients were treated by thoracoplasty primarily, 20 by repair of the stump with sutures and by covering the stump with pericardial tissue or intercostal muscle, of whom 10 suffered from empyema. In 5/20 patients (25%) chronic fistulae developed making further interventions necessary. Since 1989 seven patients with bronchial stump fistulae have been reoperated with a delay of less than 12 h after diagnosis. Surgery consisted of reclosure of the stump with sutures in five patients. In addition, every patient was treated with the intrathoracic transposition of a petiolated ipsilateral pectoral muscle graft, which was the only treatment in two patients. Neither recurrence of the bronchopleural fistula nor empyema was seen in this group of patients (0%). We conclude that bronchial stump fistulae in patients after pneumonectomy can be treated successfully by the use of pectoral muscle flaps either combined with a closure of the leak using sutures or as the only measure. The method proved to be simple, safe and without major impairment of the patient. In combination with early reintervention, postpneumonectomy empyema including a disfiguring thoracoplasty can thereby often be avoided.

Current surgical treatment of thoracic empyema in adults

“…Half of the BPFs develop within 4 weeks following surgery [69]. Right-sided BPF develops in 75-100% [64,66,67,70,72] of the cases. The closer the onset of the stump insufficiency is to the time of surgery, the worst the prognosis [64,70].…”

“…Remodelling the osteomuscular chest wall and/or facilitation of granulation, further on external tissue plombage, are the methods of space management as were discussed above. Chronic fistulas frequently require two or more procedures [58,66,67]. Decision-making can hardly be overselective.…”

“…It can be applied either as a definite treatment with intent to cure, a preliminary procedure prior to definite treatment [58,64] or as a last resort procedure when others have failed to achieve a relatively stable disease [35,65]. Muscle transposition is proposed as the space becomes sterile-cleansed [61,66]. Recurrent cancer, poor function and persisting local infections are common causes of open window failure [67].…”

“…Postpneumonectomy thoracic empyema is a result of bronchopleural fistula in 80-100% of the cases [56,69,70], with a mortality ranging between 5% and 25% on average [66] with up to 40% if pleuropneumonectomy is performed [71] with a maximum value of 75% [35].…”

Role of Thoracomyoplasty Procedures in Modern Surgery for Intrathoracic Suppurations

“…Another common way of mobilization is based on the perforator branches that arise from the internal thoracic and anterior intercostal vessels in the parasternal region. The pectoralis flap is usefull for defects located in the apical region (Kalweit et al, 1994, Nomori et al, 2001, although it's mobilization is difficult through a standard thoracotomy incision; it is also frequently used to prevent and treat infectious complications after median sternotomy (Gao et al, 2010). The rectus abdominis flap can be mobilized based on the superior epigastric vessels, which continue the internal thoracic ones.…”