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eComment: The latissimus dorsi flap surgery for bronchus stump insufficiency – an alternative?

Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover 30625, Germany

The posterior membranous flap technique for bronchial closure after pneumonectomy

We read with great interest the recent report by Dr. Kakadellis et al. regarding the use of the posterior membranous flap for bronchial closure after pneumonectomy [1]. They used the posterior membranous flap in 45 patients after pneumonectomy. We congratulate the authors for their excellent clinical results in the 45 patients. The authors report a thirty-day mortality of 6.6%, all because of cardiorespiratory insufficiency.

Bronchus stump insufficiency with or without the development of the postpneumonectomy empyema is one of the most serious conditions after pneumonectomy. One patient in the aforementioned study developed an empyema in the pneumonectomy cavity but no fistula was found. The empyema was treated by drainage only.

Besides the aforementioned technique, which may be used as a preventive tool, the pedicled muscle flap has been proposed as another option for closure of evident bronchus stump insufficiency. The latissimus dorsi flap has been a work horse in plastic reconstructive surgery for soft tissue coverage since its introduction by Dr. Igidio Tansini in 1906 for thoracic wall defects more than 100 years ago [2]. The use of a pedicled latissimus dorsi muscle flap to cover bronchial fistulas has been reported [3]. The latter authors stress that a de-epithelialized skin side rather than muscle is sutured to an opening of the bronchus. However, it remains unclear why de-epithelialized skin should be superior in this occasion.

We propose a slight modification of the aforementioned technique. Since flap monitoring is essential to evaluate flap perfusion and to determine as early as possible arterial occlusion or venous congestion necessitating revision surgery, a buried flap is not approached by visual external inspection. Non-invasive laser Doppler and spectrophotometry systems, such as the oxygen-to-see system (LEA Medizintechnik, Giessen, Germany), which has been reported in buried flap monitoring up to 1 cm tissue depth [4], are not in range from the chest surface.

We report a case of a bronchus stump insufficiency after pneumonectomy in a homeless male suffering open tuberculosis. A latissimus flap was harvested with a skin isle which was sutured onto the bronchus stump. The skin perfusion was monitored by serial bronchoscopies. The additional skin isle is easy to harvest and the closure of the harvesting defect is uncomplicated. The skin isle allows flap monitoring in these patients by direct visualization via bronchoscopy.

	References

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1. Kakadellis J, Karfis EA. The posterior membranous flap technique for bronchial closure after pneumectomy. Interact CardioVasc Thorac Surg 2008;7:638–642.[Abstract/Free Full Text]
2. Tansini I. Sopra il mio nuovo processo di amputazione della mammella. Gazetta Medica Italiana 1906;57:141.
3. Katsuragi N, Nakajima Y, Shiraishi Y, Hashizume M, Takahashi N. Closure of a large bronchial fistula with a latissimus dorsi myocutaneous flap. Jpn J Thorac Cardiovasc Surg 2005;53:440–442.[Medline]
4. Knobloch K, Gohritz A, Vogt PM. Noninvasive monitoring of microcirculatory perfusion and oxygenation in subcutaneous microsurgical flaps. J Reconstr Microsurg 2008;24:69.[CrossRef][Medline]

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