Interact CardioVasc Thorac Surg 2008;7:621-625. doi:10.1510/icvts.2007.166546
© 2008 European Association of Cardio-Thoracic Surgery
Institutional report - Thoracic general |
The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients
Morris Beshayb,*,
Giovanni Carbonia,
Beatrix Hokscha,
Marc A. Reymondb and
Ralph A. Schmida
a Division of General Thoracic Surgery, University Hospital of Berne, Switzerland
b Division of General Thoracic Surgery, Centre of Pulmonary Diseases, Evangelic Hospital, Bielefeld, Germany
Received 8 September 2007;
received in revised form 26 February 2008;
accepted 26 February 2008
 Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.
*Corresponding author. Division of General Thoracic Surgery, Evangelic Hospital Bielefeld, Burgsteig 4, 33617 Bielefeld, Germany. Tel.: +49 521 77277499; fax: +49 521 77277498.
E-mail address: morris.beshay{at}evkb.de (M. Beshay).
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Abstract
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Bronchus stump insufficiency (BSI) is one of the major complications after pneumonectomy; we analyzed all patients who underwent extra pleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) in order to detect the role of muscle flap (MF) on preventing early and late stump insufficiency. From January 2000 until December 2005, there were 42 patients admitted with MPM for further intervention at our institution. Thirty patients were suitable for surgery and thus received a multimodal treatment with neo-adjuvant chemotherapy using Cisplatin® and Gemcitabin (Gemzar®), EPP followed by 54 Gray (Gy) adjuvant radiotherapy. Data were collected from the surgical and oncological records. There were 37 male patients (88%), the median age was 65 years (range 40–83 years). Seven (17%) patients had concomitant diseases. Forty patients (95%) had asbestos exposition. The operative procedures were EPP with muscle flap through an anterolateral thoracotomy. Univariate and multivariate analyses were done. One patient (3%) died on the 2nd postoperative day due to lung embolism. Mild complications were noticed in the early postoperative phase in 8 (25%) patients. There was no early or late stump insufficiency during the 15-month follow-up. Surgical techniques using muscle flap seems to play a major role in the prevention of bronchus stump insufficiency especially after neo-adjuvant chemotherapy.
Key Words: Bronchus stump insufficiency; Muscle flap; Pneumonectomy; Pleural mesothelioma
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1. Introduction
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The incidence of malignant pleural mesothelioma (MPM) is expected to continue to increase over the next 20 years after long latent period of asbestos exposition [1–3]. Although many controversial issues still exist in the treatment of MPM, aggressive, multimodal therapy (MT) with neo-adjuvant chemotherapy followed by extra pleural pneumonectomy (EPP) thereafter adjuvant thoracic radiation remains the most optimal therapy [4–6]. For patients who are eligible candidates, EPP plays an important role for lacal control of the disease. An encouraging 60% 2-year survival rate has been reported for patients with early-stage disease (disease affected only one side without infiltration of the thoracic wall or mediastinal fat on CT-scan and no mediastinal lymph node metastasis after mediastinoscopic biopsy) who undergo EPP [4, 7, 8]. Post-pneumonectomy stump insufficiency is a rare but serious complication after neo-adjuvant therapy followed by pneumonectomy. The accompanied post-pneumonectomy empyema (PPE) is often associated with significant morbidity and prolonged hospital stay. Patients enrolled for multimodality therapy have a high risk of developing stump insufficiency after EPP [9]. Despite the use of different surgical methods, a successful technique to prevent stump insufficiency remains difficult. There are very few reports about the role of muscle flap (MF) in the management of bronchopleural fistula after pneumonectomy [10–12], some authors reported the effect of muscle flap as a primary technique to cover the bronchial stump (BS) after pneumonectomy to prevent SI in diabetic patients [13], but no English reports were found on the use of muscle flap as a primary technique after EEP. This important ongoing issue, due to the increasing number of patients who are suitable for multimodal therapy, is of great interest. We retrospectively analyzed all patients who underwent EPP with primary muscle flap cover of the bronchus stump.
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2. Patients and methods
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Over a five-year period we analyzed the records of all patients admitted with MPM; out of 42 patients, 30 patients had stage I or II disease and were enrolled for multimodal therapy. Twelve patients were excluded from surgery according to selective criteria. All patients underwent routine preoperative evaluation. Concomitant diseases such as ischemic heart disease, arrhythmia, peripheral vascular disease, other lung disease, diabetes mellitus, renal failure, other malignant tumors, and gastrointestinal diseases were systematically evaluated. A lung ventilation perfusion scan was performed if the first–second forced expiratory volume (FEV1) was <2.000 ml. The staging protocol was performed in all cases with a computed tomography (CT) scan of the chest including the upper abdominal organs, and/or abdominal ultrasound, brain CT-scan, skeletal isotope scan or 18F-fluorodeoxyglucose positron-emission tomography (PET). Video-assisted mediastinoscopy for mediastinal lymph node assessment was performed in all patients suitable for surgery. VATS performed in cases of isolated aortopulmonary lymph node enlargement on the healthy side. Patients suitable for surgery received three cycles of preoperative chemotherapy with cisplatin and gemcitabin. The chemotherapy was received over 24–28 h hospitalization time. All patients met the standard cardiopulmonary criteria for elective surgery. Surgical procedures of EPP entail removal of all the parietal pleura, the pericardium, the hemi-diaphragm, and the whole lung on the affected side. All patients received a muscle sparing antero-lateral thoracotomy. The heavy wire linear stapler TLH30 (Ethicon Endo-Surgery, Inc., 4545 Creek, Road, Cincinnati, OH, USA) was used for division of the bronchus. Thereafter, latissimus dorsi muscle or serratus anterior muscle was used to cover the bronchus stump in all patients. The muscle flap (MF) is prepared usually to its origin from the iliac crest distally and approximately 3–4 cm away from the mid line to its pedicle near the inferior angle of the scapula, making sure that both of the arteries and the vein are intact (Fig. 1). A 3x5 cm hole was prepared in the thoracic wall after removal of a small piece of the 4th rib in the middle axillary line. The muscle flap is passed though this opening into the thoracic cavity using an Alice clamp. The pedicle is prepared to be accommodated through the thoracic wall opening without compression of the vessels. The MF is fixed on the bronchus stump in a sandwich technique using three interrupted PDS*II 3/0 monofilament absorbable sutures (Polydioxanon, Johnson&Johnson Intl.) from behind and in front (Fig. 2a,b). Thereafter, the bronchus stump is tested intra-operatively for any air leakage, which would be reinforced with the same PDS*II 3/0 sutures. The viability of the MF is tested before closure of the thoracotomy. Thoracic and subcutaneous drains are routinely inserted. Patients were admitted to the intensive care unit (ICU) for postoperative monitoring over 24 h. Preoperative and postoperative data were obtained retrospectively from clinical records. Follow-up data were obtained by contacting the patients themselves or their family doctors. The software package SPSS v11.0 (SPSS Inc., Chicago, IL) was used to perform the statistical analysis. Univariate analysis of data using Fisher's exact test, unpaired t-test and ANOVA were conducted where appropriate. Multivariate analysis was carried out using logistic regression method. The following were significant factors: right-sided disease, type of closure of the stump, operation time, and preoperative mediastinoscopy. P-values were considered significant if P<0.05.
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Fig. 1. Latissimus dorsi muscle (LDM) prepared from its origin on the iliac crest to its pedicle proximally.
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Fig. 2. The latissimus dorsi muscle flap; a) fixation from behind with PDS*II sutures, b) fixation from in front with PDS*II sutures.
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3. Results
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There were 42 patients with MPM admitted for further evaluation from January 2000 to December 2005. There were 37 male patients (88%); the median age was 65 years (range 40–83 years). There was 57% MPM (n=24) on the right side. Forty patients presented with shortness of breath due to large pleural effusion (95%), two patients had a chest pain due to thoracic wall infiltration of the tumor. Diagnosis of MPM was obtained by trans-thoracic biopsy (n=2), or VATS (n=39). Cytological examination of the pleural effusion was not conclusive (n=4) and, positive for MPM (n=2) in all of them, VATS confirmed the diagnosis apart from one patient. Forty-one patients received talc pleurdesis to control the pleural effusion, which was done in the same session of VATS. The histological findings in all patients were: a) epithelial (n=32), b) papillary (n=2), c) biphasic (n=2), and d) sarcomatoid type (n=4). In one patient there was a mixed epithelial and sarcomatoid histological finding. In another patient the histology was not conclusive for MPM even after VATS biopsy; this patient did not receive any kind of therapy but was strictly followed-up with CT-scan of the chest every three months. Eleven months later he developed paraplegia due to local invasion of MPM into the spinal cord at the level of the 9th thoracic inter-vertebral disc. After decompression of the spinal cord, the histology showed MPM. Forty patients (95%) had occupational asbestos exposition. The other two patients had no occupational exposition; one patient had positive family exposition to asbestos. Thirty-five patients (83%) had a history of tobacco smoking (mean, 20 packs per year), but 40% of them had not consumed tobacco for more than one year. The mean FEV1 was 78%. Mediastinoscopy was performed in 31 patients who were suitable for surgery (71%) who had potentially respectable clinical stage I or II. There was one N2 situation. Twelve patients (29%) were excluded from surgery due to a) locally advanced disease (n=2), b) sarcomatoid type (n=4), c) mediastinal lymph node metastases (n=1), d) over 70 years old (n=3), e) myocardial infarction (n=1), f) no clear histological diagnosis after VATS (n=1). VATS talc pleurodeses was performed in 41 patients (97%). Only 30 patients were suitable for surgery (71%) and therefore were enrolled for multimodal therapy, thus they received three cycles of preoperative chemotherapy with Cisplatin® and Gemcitabin (Gemzar®). There were no serious complications during this course apart from nausea (n=17), vomiting (n=12) or general weakness and fatigue (n=24). All patients received a preoperative peri-dural anesthesia (PDA) for pain control. EPP was performed through an antero-lateral thoracotomy, an additional, smaller 10 cm lateral thoracotmy was performed (n=22) to ensure the complete removal in the deepest part of the pleural sac. The bronchus was divided using the heavy wire linear stapler TLH30 (Ethicon Endo-Surgery, Inc., 4545 Creek, Road, Cincinnati, OH, USA) in all patients (n=30), the bronchus stump was covered with latissimus dorsi muscle flap (n=28) or four strips of serratus anterior muscle of the operated side (n=2). The time of the operation was 50 min longer than a usual pneumonectomy (mean 148 min; P=0.031). All patients received one thoracic drain for postoperative monitoring which was removed on the next day after surgery (n=28); in two patients the drain was left until the second postoperative day due to a large amount of hemorrhagic secretion. All patients were routinely monitored at the ICU for 24 h (n=25) and 36 h (n=5). There were no intra-operative complications or intra-operative mortality. Eighteen (60%) patients received 2–6 bottles of blood transfusion. One patient (3%) died on the 2nd postoperative day at the ICU due to massive lung embolism; this patient had known varicose veins. Mild complications were noticed in the early postoperative phase in eight patients (27%); atrial fibrillation (n=4), hypokalemia (n=2), local wound seroma needing drainage (n=1), and urinary tract infection (UTI) (n=1). Adjuvant thoracic radiotherapy with 54 Gy was done in all patients at 4–5 weeks after surgery. The adjuvant radiotherapy was well tolerated from the patients, no or mild complications in the form of general weakness or mild nausea were reported by some patients. There were no pulmonary complications in the form of infection, atelectases or pneumonia. There was no early or late stump insufficiency during the 15-month follow-up (P<0.001). One patient had local recurrence within three months postoperatively (3%) and died two months later. Six- and 12-month follow-up showed local recurrence in eight (27%) patients, one patient (3%) had a malignant pleural mesothelioma on the other side. Five patients received Alimta® over a period of four months and three patients refused chemotherapy. The overall survival over the follow-up period of 12 months is 62%.
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4. Discussion
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MPM is difficult to treat using a single therapy [14]; therefore, many centers are using a multimodal regimen and this combination therapy is a growing issue which needs to be established in the next few years. Multimodal therapy of MPM on the one hand seems to be feasible and effective, a method which has been reported by many authors with variable results [4–6]. On the other hand, the use of neo-radio chemotherapy is reported to be associated with higher risk of morbidity and complications [9, 15]. Stump insufficiency with or without the development of post-pneumonectomy empyema is one of the most serious conditions after pneumonectomy. The management of this condition is still one of the most challenging situations for thoracic surgeons. In the last few years we achieved low rates of bronchus stump insufficiency after using muscle flap to cover the bronchus stump in the case of pneumonectomy after neo-adjuvant therapy for stage IIIA NSCLC, thus we decided to perform this technique routinely for EEP due to malignant pleural mesothelioma. In our experience, in contrast to other authors, only mild complications occurred in this series, although with the use of multimodal therapy. There was no single stump insufficiency on the right side or after staging mediastinoscopy. We adopt strict selective criteria to select the most suitable patients for multimodal therapy. The exclusion criteria are either of the following: 1) sarcomatoid and mixed type of MPM, 2) patients over 70 years old, 3) severe concomitant disease, 4) other uncontrollable malignancy, 5) severe progression under neo-adjuvant chemotherapy, 6) psychologically unstable patients. We usually perform muscle-sparing antero-lateral thoracotomy as it is well tolerated by the patients due to less pain and it gives a good access to the whole thoracic cavity. On the one hand, the development of new anesthetic techniques, good intraoperative and postoperative management are important factors for the outcome, the use of routine muscle flap to cover the bronchial stump, on the other hand, seems to be an effective method to prevent bronchus stump insufficiency. We prefer to use the latissimus muscle flap rather than the serratus anterior flap, although the latter is quicker and easier to prepare but not as long and big enough to be fixed on the bronchial stump without tension. Although the time of the operation was prolonged through the muscle flap, a higher rate of complications was not noticed. This technique is a cost-effective method compared to the complicated course if bronchus stump insufficiency would occur. In this series there was no single insufficiency after extra-pleural pneumonectomy even on the right side. We propose that this is an effective method to prevent stump insufficiency after pneumonectomy especially in high-risk patients. The use of this sandwich technique (Fig. 3) ensures the secure effect of the muscle flap. The role of the muscle flap may be through one or a combination of the following factors: assisting the healing process of the bronchus stump due to good blood supply to the muscle; preventing any minimal air leak; and localizing minimal infection from reaching the whole pleural cavity. The multimodal therapy of MPM is not accompanied by more complications than any other regimens. Further studies are needed to confirm these observations.
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Conference discussion
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Dr. A. Oliaro (Torino, Italy): In your presentation you don't ever present the modality of bronchial suture, I think with the stapler. What do you think about the no stapler suture in right pneumonectomy?
Dr. Beshay: We use routinely the heavy wire stapler from Ethicon. We do not use suture from any kind of absorbable or non-absorbable materials. In this series, it was the same technique used in all patients, yes.
Dr. Lang-Lazdunski (London, UK): What is the evidence in your study to say that multimodality therapy is the best possible management for malignant mesothelioma? I don't think there are any data to support this in this series. I was wondering why you used specifically the anterolateral thoracotomy for doing EPP, is it to save the latissimus dorsi?
Dr. Beshay: That's right.
Dr. Lang-Lazdunski: Okay.
Dr. Beshay: For the first question, we depend on the last few reports for the multimodal therapy, which they could show better survival using multimodal therapy after extrapleural pneumonectomy. Our study is not yet for a long time. We just studied this over the last 15 months. So perhaps we have to wait for a little bit more time.
Dr. V. Pischik (St. Petersburg, Russia): You use the anterolateral thoracotomy, and what intercostal space you use for that? And how is it convenient to repair the diaphragm and dissect the posterior mediastinum?
Dr. Beshay: This part I didn't show in my slides because of the time. We use anterolateral thoracotomy in the 5th intercostal space. And in many cases of these 30 patients, we had to do a second smaller thoracotomy about 8–10 cm in the 8th or 9th intercostal space.
Dr. W. Waller (Leicester, UK): Could I suggest to you a median sternotomy approach to the right side.
Dr. Beshay: We didn't choose in our center. We use the anterolateral and we find this approach is not associated with either longer operative time or more pain. All patients would have epidural catheter and there is no problem for pain control. We do anterolateral thoracotomy because it is easier to reach the deepest part of the diaphragm from behind through this approach.
Dr. Waller: Have you tried using a simpler muscle flap like the intercostal muscle flap?
Dr. Beshay: No, we didn't. We use usually latissimus or serratus anterior. And this perhaps because we had from our experience, after pneumonectomy for non-small lung cancer, more complications using such small muscles. So we decided, because these patients, they usually receive chemotherapy before surgery, they are at high risk, to choose a bigger muscle.
Dr. Waller: So you use this muscle flap for non-small cell lung cancer pneumonectomies as well?
Dr. Beshay: Yes.
Dr. van Schil (Antwerp, Belgium): You were very lucky not to have a bronchopleural fistula. In case you have used the latissimus dorsi muscle and you have a bronchopleural fistula, because they are occurring in real life, what would you do then?
Dr. Beshay: Well, in the paper, this technique is discussed, I have to make it here very short. But in such case, another muscle flap is to be recommended. We used to do what's called a sandwich technique. We used to put the muscle above and behind the stump using absorbable suture. So the bronchial stump is stuck in between the muscle fibers from above and behind. Perhaps that is what makes our technique effective, but I don't know why exactly.
Dr. van Schil: At which stage of the operation do you prepare the muscle flap, at the beginning when you make the thoracotomy incision, or do you first perform an exploration and then prepare the muscle flap?
Dr. Beshay: Yes. We finish the whole extrapleural pneumonectomy and then we prepare the flap.
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Abstract
1. Introduction
