Ann Thorac Cardiovasc Surg 2015; 21: 496–499
Case Report
Online May 25, 2015 doi: 10.5761/atcs.cr.14-00349
Two Cases of Single-Stage Closure of a Bronchopleural Fistula Using Latissimus Dorsi Musculocutaneous Flaps after Lung Surgery Yuki Nakajima,1 Hirohiko Akiyama,1 Hiroyasu Kinoshita,1 Takuya Inoue,1 Atsumori Hamahata,2 and Hidetaka Uramoto1
Two cases of successful primary closure of a bronchopleural fistula with favorable infection control using latissimus dorsi musculocutaneous flaps are reported. Case 1 was a 70-year-old man who underwent resection of the right lower pulmonary lobe due to right lung metastasis of sigmoid colon cancer. A bronchopleural fistula was found on day 28 after surgery. Infection was controlled by antibiotic administration and tube drainage. Closure of the bronchopleural stump, thoracoplasty and plombage of latissimus dorsi muscles were performed for single-stage closure without open treatment, based on a negative pleural effusion culture. Case 2 was a 64-year-old man who underwent right lower pulmonary lobe resection due to right lung cancer. A bronchopleural fistula was found on day 14 after surgery. In single-stage closure, thoracoplasty and plombage of latissimus dorsi muscles were performed due to infection control and a negative pleural effusion culture. Both cases had a good postoperative course. Keywords: bronchopleural fistula, single-stage closure, latissimus dorsi muscle, redo surgery, lung surgery
Introduction Bronchopleural fistula (BPF) after lung surgery is difficult to treat and has high mortality.1) The aims of treatment are infection control and prevention of aspiration pneumonia, and these require appropriate drainage, purging of pyothorax, and closing of the bronchopleural stump and pyothorax. A BPF after segmental or pulmonary lobar resection can be treated using tube drainage alone, and small fistulas may be treated by transbronchial Division of Thoracic Surgery, Saitama Cancer Center, Ina, Kitaadachi, Saitama, Japan 2Division of Plastic Surgery, Saitama Cancer Center, Ina, Kitaadachi, Saitama, Japan 1
Received: December 16, 2014; Accepted: February 24, 2015 Corresponding Author: Yuki Nakajima. Division of Thoracic Surgery, Saitama Cancer Center, 780, Komuro, Ina, Kitaadachi, Saitama 362-0806, Japan Email: [email protected] ©2015 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved. 496
injection or with fibrin adhesives.2–5) Surgery is required for large fistulas or cases with pyothorax, and open treatment and purging of pyothorax after plombage is performed in cases with poor infection control.6) Open emergency treatment is safe, but places a heavy burden on the patient and medical staff. Single-stage closure may be applicable in cases with favorable infection control. Reclosing the bronchopleural stump is first considered for closing a fistula, but exfoliating the bronchopleural walls to make the fistula closeable is difficult and has the risk of damaging the pulmonary artery due to frequent embedding of the stump during re-surgery. Vascular insufficiency of the stump and recurrence of bronchopleural fistula are likely to occur, even if reclosing is successful.7) Therefore, covering or wedging of the bronchopleural stump with musculocutaneous flaps or omenta has been used.6–8) Herein, we describe two cases of successful primary closure of a BPF without open treatment. Ann Thorac Cardiovasc Surg Vol. 21, No. 5 (2015)
Single-Stage Closure of a Bronchopleural Fistula
Case Report Case 1 The patient was a 70-year-old man with diabetes who had undergone surgery for sigmoid colon cancer at the age of 59, and surgery for right lung metastasis at 63. Resection of the right lower pulmonary lobe and sampling of lymph nodes were performed for a metastatic pulmonary tumor in January 2014. He was discharged from our hospital on postoperative day (POD) 8 due to a favorable postoperative course. Coughing appeared on POD 23, blood tests showed a strong inflammatory response, and the patient was rehospitalized on POD 24. At admission, the patient had WBC 10170 /ml, ALB 2.6 g/dl, CRP 20.1 mg/dl, HbA1c 6.9%, height 159.1 cm, weight 55.1 kg, heart rate 87/min, blood pressure 122/66 mmHg, temperature 36.4°C, and SpO2 97%. TAZ/PIPC administration and blood sugar control by insulin were started after admission. Brown serous sputum appeared on day 3 of hospitalization. Thoracic drains were inserted on day 4 due to a finding of diastasis of the bronchopleural stump in pectoral computed tomography (CT). A pleural effusion culture was twice found to be negative. Surgery was performed on day 14. In surgery, latissimus dorsi muscles were first collected with partially-attached skin to enhance the volume. The epidermis was decorticated due to its deciduousness (Fig. 1). Thoracoplasty was subsequently performed. The 7th to 9th ribs above the air space were partially resected with preservation of the intercostal muscles and thickened parietal pleura. Thoracotomy on the 7th rib was performed. A fistula of about 3 mm in size was found on the top of the bronchopleural stump. The fistula, despite thinning, was closed by three stitches with 4-0 nonabsorbable monofilament thread (Fig. 2). Intrapleural plombage of latissimus dorsi musculocutaneous pedicle flaps and fixing on the thoracic walls proximal to the bronchopleural stump were performed. The drains in the thorax and subcutis were retained. The surgical time was 233 min and the amount of bleeding was 225 g. The subcutaneous drain was removed on POD 4 after the BPF surgery, and the intrapleural drain was removed on POD 12. The patient was discharged from hospital on POD 20 and has not had any problems in the subsequent 9 months since the fistula surgery. Case 2 The patient was a 64-year-old man who had previously undergone resection of polyps in the colon at age 62. Ann Thorac Cardiovasc Surg Vol. 21, No. 5 (2015)
(a)
(b)
Fig. 1 (A) Operative finding showing the harvest of a substantial proportion of the latissimus dorsi musculocutaneous flap. (B) The surface skin was decorticated using surgical scissors.
Resection of the right lower pulmonary lobe and dissection of mediastinal lymph nodes were performed for right lung adenocarcinoma in October 2012. A drain was removed on POD 5. Antibiotic treatment was started on POD 6 due to fever. Drainage was started on POD 12 due to suspected pyothorax with no improvement of inflammatory response. A pleural effusion culture was negative. Leakage appeared on POD 14. Discoloration and pinholes of a peripheral bronchopleural stump were found by bronchoscopy, and surgery was performed on POD 27. In surgery, latissimus dorsi muscles were first collected with partially-attached skin to enhance the volume. The epidermis was decorticated due to its deciduousness. Thoracoplasty was subsequently performed. The 9th and 10th ribs above the air space were partially exsected and the intercostal muscles and thickened parietal pleura were preserved. A fistula of 2 mm in size was found, but could not be closed due to the absence of bronchopleural walls because of complete embedding of the bronchopleural stump. Intrapleural plombage of pedicle flaps was performed. The drains in the thorax and subcutis were retained. The surgical time was 187 min and the amount of bleeding was 34 g. The subcutaneous drain was removed on POD 6 after the fistula surgery, and the intrapleural drain was removed on POD 21. The patient was discharged from hospital on POD 28 and has had no problems in 25 months since the fistula surgery.
Discussion Both cases showed a strong inflammatory response at the time of discovery of the bronchopleural fistula, but had no complication of aspiration pneumonia and a negative pleural effusion culture. Single-stage closure without open treatment was applied in both cases due to favorable infection control by antibiotic administration and tube drainage. Re-expansion by drainage was unsuccessful due 497
Nakajima Y, et al. (a)
(b)
(c)
Fig. 2 O perative finding shows the empyema cavity. (A) the bronchial stump with air bubbles is indicated by the arrows. (B) mechanical staples are observed close to the bronchial stump. (C) the bronchial stump was closed using 3-0 unobservable monofilament thread.
(a)
(b)
Fig. 3 C hest CT showing viable latissimus dorsi musculocutaneous flaps around the bronchial stump (7 POD) ([A] horizontal sectional view, [B] coronal section image). CT: computed tomography; POD postoperative day
to relatively large pyothorax after exsection of the right lower pulmonary lobe. Re-closure was expected to be difficult because the pulmonary artery and bronchopleural stump were contiguous, as shown by pectoral CT. Surgery involves collection of latissimus dorsi musculocutaneous flaps, thoracoplasty because of insufficient plombage, and closure of the bronchopleural stump. Closure is possible for a case with thin bronchopleural walls (Case 1), but not for a fistula without bronchopleural walls (Case 2). Thoracoplasty in pyothoracic closure has been used in cases with insufficient plombage with musculocutaneous flaps or omenta. Favorable outcomes of applying pedicle omenta for treatment of pyothorax have been obtained, since the pedicle omenta have excellent infection control and are expected to improve topical blood flow.9) However, laparotomy is highly invasive, even if a laparoscopic approach might be harmful based on the potential for a future abdominal operation. Thus, reduced invasiveness is one advantage of applying musculocutaneous flaps using latissimus dorsi muscles proximal to thoracotomy wounds. Applying musculocutaneous flaps is certainly an alternative for cases with no omenta after gastrointestinal tract surgery or anticipated high adhesion. Cases with persistent infection treated by plombage of omenta have been reported, but patients should be selected carefully 498
because of the ineffectiveness of plombage of musculocutaneous flaps in cases with infection.10) The following points were considered in the surgery. Cutaneous flaps with 20 cm × 7 cm-sized skin were sufficient for intrapleural plombage. Manipulation was performed with the assistance of two plastic surgeons. The epidermis was decorticated due to its deciduousness and potential as an infection source. We believe that musculocutaneous flaps might be advantageous for maintenance of maximum volume over time without shrinkage, in contrast to use of a muscular flap alone. The bronchopleural stump is located in the topmost pyothorax after exsection of the right lower pulmonary lobe. The musculocutaneous flaps were fixed to the most proximal thoracic walls to the bronchopleural stump for direct closing of the bronchopleural stump or closing of peripheral lung tissues, due to the danger of damaging peripheral tissues by defection by applying tension on standing. Remaining small cavities around the bronchopleural stump were found in both cases on postoperative CT (Fig. 3). The cavities in Case 2 were completely closed in one year. Application of gauze to thoracoplastic regions and compressing the cavities by pectoral girdles were performed after the surgery.
Conclusion Healing of a bronchopleural fistula with favorable infection control and a negative result in a pleural effusion culture was enhanced by sufficient closure of pyothorax without open treatment. Plombage of omenta has often been applied in these cases. The two cases reported here indicate that latissimus dorsi musculocutaneous flaps are also applicable for this procedure.
Disclosure Statement The authors report no conflict of interest. Ann Thorac Cardiovasc Surg Vol. 21, No. 5 (2015)
Single-Stage Closure of a Bronchopleural Fistula
References 1) Uramoto H, Hanagiri T. The development of bronchopleural fistula in lung cancer patients after major surgery: 31 years of experience with 19 cases. Anticancer Res 2011; 31: 619-24. 2) Kirsh MM, Rotman H, Behrendt DM, et al. Complications of pulmonary resection. Ann Thrac Surg 1975; 20: 215-36. 3) So T, Uramoto H, Hanagiri T, et al. Successful treatment of lung adenocarcinoma in an 18-year-old man. Gen Thorac Cardiovasc Surg 2011; 59: 616-8. 4) Opie JC, Vaughn CC, Comp RA, et al. Endobronchial closure of a postpneumonectomy bronchopleural fistula. Ann Thorac Surg 1992; 53: 686-8. 5) Jessen C, Sharma P. Use of fibrin glue in thoracic surgery. Ann Thorac Surg 1985; 39: 521-4.
Ann Thorac Cardiovasc Surg Vol. 21, No. 5 (2015)
6) Yokomise H, Kobayashi J, Yagi K, et al. The treatment of postpneumonectomy bronchopleural fistula; possible role of omentoplasty. Jpn J Chest Surg 1993; 7: 519-23. 7) Matsuura M, Fujiwara T, Kataoka K, et al. Two cases of closure of bronchopleural fistula after right pneumonectomy using omental pedicled flap. Jpn J Chest Surg 2009; 23: 838-42. 8) Miller JI, Mansour KA, Nahai F, et al. Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984; 38: 227-31. 9) Williams R, White H. The greater omentum: its application to cancer surgery and cancer therapy. CPS 1986; 23: 789-865. 10) Virkkula L. Treatment of the bronchopleural fistula. Ann Thorac Surg 1978; 25: 489-90.
499
Case Report
Online May 25, 2015 doi: 10.5761/atcs.cr.14-00349
Two Cases of Single-Stage Closure of a Bronchopleural Fistula Using Latissimus Dorsi Musculocutaneous Flaps after Lung Surgery Yuki Nakajima,1 Hirohiko Akiyama,1 Hiroyasu Kinoshita,1 Takuya Inoue,1 Atsumori Hamahata,2 and Hidetaka Uramoto1
Two cases of successful primary closure of a bronchopleural fistula with favorable infection control using latissimus dorsi musculocutaneous flaps are reported. Case 1 was a 70-year-old man who underwent resection of the right lower pulmonary lobe due to right lung metastasis of sigmoid colon cancer. A bronchopleural fistula was found on day 28 after surgery. Infection was controlled by antibiotic administration and tube drainage. Closure of the bronchopleural stump, thoracoplasty and plombage of latissimus dorsi muscles were performed for single-stage closure without open treatment, based on a negative pleural effusion culture. Case 2 was a 64-year-old man who underwent right lower pulmonary lobe resection due to right lung cancer. A bronchopleural fistula was found on day 14 after surgery. In single-stage closure, thoracoplasty and plombage of latissimus dorsi muscles were performed due to infection control and a negative pleural effusion culture. Both cases had a good postoperative course. Keywords: bronchopleural fistula, single-stage closure, latissimus dorsi muscle, redo surgery, lung surgery
Introduction Bronchopleural fistula (BPF) after lung surgery is difficult to treat and has high mortality.1) The aims of treatment are infection control and prevention of aspiration pneumonia, and these require appropriate drainage, purging of pyothorax, and closing of the bronchopleural stump and pyothorax. A BPF after segmental or pulmonary lobar resection can be treated using tube drainage alone, and small fistulas may be treated by transbronchial Division of Thoracic Surgery, Saitama Cancer Center, Ina, Kitaadachi, Saitama, Japan 2Division of Plastic Surgery, Saitama Cancer Center, Ina, Kitaadachi, Saitama, Japan 1
Received: December 16, 2014; Accepted: February 24, 2015 Corresponding Author: Yuki Nakajima. Division of Thoracic Surgery, Saitama Cancer Center, 780, Komuro, Ina, Kitaadachi, Saitama 362-0806, Japan Email: [email protected] ©2015 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved. 496
injection or with fibrin adhesives.2–5) Surgery is required for large fistulas or cases with pyothorax, and open treatment and purging of pyothorax after plombage is performed in cases with poor infection control.6) Open emergency treatment is safe, but places a heavy burden on the patient and medical staff. Single-stage closure may be applicable in cases with favorable infection control. Reclosing the bronchopleural stump is first considered for closing a fistula, but exfoliating the bronchopleural walls to make the fistula closeable is difficult and has the risk of damaging the pulmonary artery due to frequent embedding of the stump during re-surgery. Vascular insufficiency of the stump and recurrence of bronchopleural fistula are likely to occur, even if reclosing is successful.7) Therefore, covering or wedging of the bronchopleural stump with musculocutaneous flaps or omenta has been used.6–8) Herein, we describe two cases of successful primary closure of a BPF without open treatment. Ann Thorac Cardiovasc Surg Vol. 21, No. 5 (2015)
Single-Stage Closure of a Bronchopleural Fistula
Case Report Case 1 The patient was a 70-year-old man with diabetes who had undergone surgery for sigmoid colon cancer at the age of 59, and surgery for right lung metastasis at 63. Resection of the right lower pulmonary lobe and sampling of lymph nodes were performed for a metastatic pulmonary tumor in January 2014. He was discharged from our hospital on postoperative day (POD) 8 due to a favorable postoperative course. Coughing appeared on POD 23, blood tests showed a strong inflammatory response, and the patient was rehospitalized on POD 24. At admission, the patient had WBC 10170 /ml, ALB 2.6 g/dl, CRP 20.1 mg/dl, HbA1c 6.9%, height 159.1 cm, weight 55.1 kg, heart rate 87/min, blood pressure 122/66 mmHg, temperature 36.4°C, and SpO2 97%. TAZ/PIPC administration and blood sugar control by insulin were started after admission. Brown serous sputum appeared on day 3 of hospitalization. Thoracic drains were inserted on day 4 due to a finding of diastasis of the bronchopleural stump in pectoral computed tomography (CT). A pleural effusion culture was twice found to be negative. Surgery was performed on day 14. In surgery, latissimus dorsi muscles were first collected with partially-attached skin to enhance the volume. The epidermis was decorticated due to its deciduousness (Fig. 1). Thoracoplasty was subsequently performed. The 7th to 9th ribs above the air space were partially resected with preservation of the intercostal muscles and thickened parietal pleura. Thoracotomy on the 7th rib was performed. A fistula of about 3 mm in size was found on the top of the bronchopleural stump. The fistula, despite thinning, was closed by three stitches with 4-0 nonabsorbable monofilament thread (Fig. 2). Intrapleural plombage of latissimus dorsi musculocutaneous pedicle flaps and fixing on the thoracic walls proximal to the bronchopleural stump were performed. The drains in the thorax and subcutis were retained. The surgical time was 233 min and the amount of bleeding was 225 g. The subcutaneous drain was removed on POD 4 after the BPF surgery, and the intrapleural drain was removed on POD 12. The patient was discharged from hospital on POD 20 and has not had any problems in the subsequent 9 months since the fistula surgery. Case 2 The patient was a 64-year-old man who had previously undergone resection of polyps in the colon at age 62. Ann Thorac Cardiovasc Surg Vol. 21, No. 5 (2015)
(a)
(b)
Fig. 1 (A) Operative finding showing the harvest of a substantial proportion of the latissimus dorsi musculocutaneous flap. (B) The surface skin was decorticated using surgical scissors.
Resection of the right lower pulmonary lobe and dissection of mediastinal lymph nodes were performed for right lung adenocarcinoma in October 2012. A drain was removed on POD 5. Antibiotic treatment was started on POD 6 due to fever. Drainage was started on POD 12 due to suspected pyothorax with no improvement of inflammatory response. A pleural effusion culture was negative. Leakage appeared on POD 14. Discoloration and pinholes of a peripheral bronchopleural stump were found by bronchoscopy, and surgery was performed on POD 27. In surgery, latissimus dorsi muscles were first collected with partially-attached skin to enhance the volume. The epidermis was decorticated due to its deciduousness. Thoracoplasty was subsequently performed. The 9th and 10th ribs above the air space were partially exsected and the intercostal muscles and thickened parietal pleura were preserved. A fistula of 2 mm in size was found, but could not be closed due to the absence of bronchopleural walls because of complete embedding of the bronchopleural stump. Intrapleural plombage of pedicle flaps was performed. The drains in the thorax and subcutis were retained. The surgical time was 187 min and the amount of bleeding was 34 g. The subcutaneous drain was removed on POD 6 after the fistula surgery, and the intrapleural drain was removed on POD 21. The patient was discharged from hospital on POD 28 and has had no problems in 25 months since the fistula surgery.
Discussion Both cases showed a strong inflammatory response at the time of discovery of the bronchopleural fistula, but had no complication of aspiration pneumonia and a negative pleural effusion culture. Single-stage closure without open treatment was applied in both cases due to favorable infection control by antibiotic administration and tube drainage. Re-expansion by drainage was unsuccessful due 497
Nakajima Y, et al. (a)
(b)
(c)
Fig. 2 O perative finding shows the empyema cavity. (A) the bronchial stump with air bubbles is indicated by the arrows. (B) mechanical staples are observed close to the bronchial stump. (C) the bronchial stump was closed using 3-0 unobservable monofilament thread.
(a)
(b)
Fig. 3 C hest CT showing viable latissimus dorsi musculocutaneous flaps around the bronchial stump (7 POD) ([A] horizontal sectional view, [B] coronal section image). CT: computed tomography; POD postoperative day
to relatively large pyothorax after exsection of the right lower pulmonary lobe. Re-closure was expected to be difficult because the pulmonary artery and bronchopleural stump were contiguous, as shown by pectoral CT. Surgery involves collection of latissimus dorsi musculocutaneous flaps, thoracoplasty because of insufficient plombage, and closure of the bronchopleural stump. Closure is possible for a case with thin bronchopleural walls (Case 1), but not for a fistula without bronchopleural walls (Case 2). Thoracoplasty in pyothoracic closure has been used in cases with insufficient plombage with musculocutaneous flaps or omenta. Favorable outcomes of applying pedicle omenta for treatment of pyothorax have been obtained, since the pedicle omenta have excellent infection control and are expected to improve topical blood flow.9) However, laparotomy is highly invasive, even if a laparoscopic approach might be harmful based on the potential for a future abdominal operation. Thus, reduced invasiveness is one advantage of applying musculocutaneous flaps using latissimus dorsi muscles proximal to thoracotomy wounds. Applying musculocutaneous flaps is certainly an alternative for cases with no omenta after gastrointestinal tract surgery or anticipated high adhesion. Cases with persistent infection treated by plombage of omenta have been reported, but patients should be selected carefully 498
because of the ineffectiveness of plombage of musculocutaneous flaps in cases with infection.10) The following points were considered in the surgery. Cutaneous flaps with 20 cm × 7 cm-sized skin were sufficient for intrapleural plombage. Manipulation was performed with the assistance of two plastic surgeons. The epidermis was decorticated due to its deciduousness and potential as an infection source. We believe that musculocutaneous flaps might be advantageous for maintenance of maximum volume over time without shrinkage, in contrast to use of a muscular flap alone. The bronchopleural stump is located in the topmost pyothorax after exsection of the right lower pulmonary lobe. The musculocutaneous flaps were fixed to the most proximal thoracic walls to the bronchopleural stump for direct closing of the bronchopleural stump or closing of peripheral lung tissues, due to the danger of damaging peripheral tissues by defection by applying tension on standing. Remaining small cavities around the bronchopleural stump were found in both cases on postoperative CT (Fig. 3). The cavities in Case 2 were completely closed in one year. Application of gauze to thoracoplastic regions and compressing the cavities by pectoral girdles were performed after the surgery.
Conclusion Healing of a bronchopleural fistula with favorable infection control and a negative result in a pleural effusion culture was enhanced by sufficient closure of pyothorax without open treatment. Plombage of omenta has often been applied in these cases. The two cases reported here indicate that latissimus dorsi musculocutaneous flaps are also applicable for this procedure.
Disclosure Statement The authors report no conflict of interest. Ann Thorac Cardiovasc Surg Vol. 21, No. 5 (2015)
Single-Stage Closure of a Bronchopleural Fistula
References 1) Uramoto H, Hanagiri T. The development of bronchopleural fistula in lung cancer patients after major surgery: 31 years of experience with 19 cases. Anticancer Res 2011; 31: 619-24. 2) Kirsh MM, Rotman H, Behrendt DM, et al. Complications of pulmonary resection. Ann Thrac Surg 1975; 20: 215-36. 3) So T, Uramoto H, Hanagiri T, et al. Successful treatment of lung adenocarcinoma in an 18-year-old man. Gen Thorac Cardiovasc Surg 2011; 59: 616-8. 4) Opie JC, Vaughn CC, Comp RA, et al. Endobronchial closure of a postpneumonectomy bronchopleural fistula. Ann Thorac Surg 1992; 53: 686-8. 5) Jessen C, Sharma P. Use of fibrin glue in thoracic surgery. Ann Thorac Surg 1985; 39: 521-4.
Ann Thorac Cardiovasc Surg Vol. 21, No. 5 (2015)
6) Yokomise H, Kobayashi J, Yagi K, et al. The treatment of postpneumonectomy bronchopleural fistula; possible role of omentoplasty. Jpn J Chest Surg 1993; 7: 519-23. 7) Matsuura M, Fujiwara T, Kataoka K, et al. Two cases of closure of bronchopleural fistula after right pneumonectomy using omental pedicled flap. Jpn J Chest Surg 2009; 23: 838-42. 8) Miller JI, Mansour KA, Nahai F, et al. Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984; 38: 227-31. 9) Williams R, White H. The greater omentum: its application to cancer surgery and cancer therapy. CPS 1986; 23: 789-865. 10) Virkkula L. Treatment of the bronchopleural fistula. Ann Thorac Surg 1978; 25: 489-90.
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