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eComment. Routine or selective reinforcement of bronchial stump after pneunonectomy?
eComment. Skin isle as a potential bronchoscopic monitoring isle in latissimus dorsi flap surgery for bronchus stump insufficiency
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Efstratios Apostolakis Cardiothoracic Surgery Department of University Hospital of Patras, 22500 Rion Patras, Greece, Nikolaos D. Panagopoulos, Dimitrios Dougenis
stratisapostolakis{at}yahoo.gr Efstratios Apostolakis, et al.
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Interactive CardioVascular and Thoracic Surgery 2008,
doi:10.1510/icvts.2007.166546B © 2008 European Association of Cardio-Thoracic Surgery We would like to make the following comment on the recent report by Beshay et al. [1]. The usefulness of bronchial stump reinforcement after a pneumonectomy procedure has been well documented. According to Asamura et al. [2], pneumonectomy is considered one of the principal risk factors for bronchopleural fistula formation. Bronchial reinforcement has been strongly supported especially in high-risk patients with administration of neo-adjuvant therapy, as reported in the recent work by Beshay et al. [1], as well as in diabetic patients [3]. Patients with a highly morbid pathology, such as the malignant pleural mesothelioma, usually present with anemia upon admission. After conduction of an extended surgical procedure, as is the extrapleural pneumonectomy [1], anemia is more profound due to increased blood losses intra-operatively. Additionally, creation of a muscular flap by mobilizing the latissimus dorsi muscle exposes the patient to an additional unfavorable procedure, increasing intra-operative time, and exaggerates further the blood losses, prolonging the post-operative hospital stay. A high percentage of these patients (60%) required blood transfusion [1]; this may contribute to an increased incidence of bronchopleural fistula, regardless of the type of bronchial stump coverage. According to our experience, right bronchial stump reinforcement should be routinely performed in all patients who are undergoing a pneumonectomy procedure, while the left bronchial stump does not necessarily require this(except in very rare cases, because it is protected by the surrounding tissues and the neighbouring aortic arch). In our cohort of 221 patients, we noticed bronchopleural fistula formation only in 3.2% (all presenting on the right side 5/91, in contrast to no fistula formation on the left side 0/130); a rather low percentage according to the literature. It is also worth mentioning that in 91% of our right pneumonectomy cases, we used a pleural flap with partial mobilization of the azygos vein that was attached to the bronchial stump, ensuring the integrity of the bronchial stump and maintaining an adequate vascular supply. The remaining was covered with intercostal muscle flap or pericardial fat pad. Our technique is not time-consuming (no more than 10 min) and relatively bloodless, in contrast to the much more copious procedures, such as the mobilization of latissimus dorsi or serratus anterior muscular flaps proposed in your article [1]. Furthermore, intercostal muscle flaps do not necessitate the removal of part of the 4th rib in order to create a hole on the thoracic wall for tunnelling the muscular flap [1]. Routine reinforcement of the bronchial stump, using either the pleura surrounding the azygos vein, a mobilized intercostal muscle or pericardial fat pad, is not associated with any postoperative complications presented after pneumonectomy. In conclusion, application of our suggestion as a routine may protect patients from highly morbid conditions associated with these types of extended operations, leading sometimes to death or condemning patients by prolonging their postoperative hospital stay. References [1] Beshay M, Carboni G, Hoksch B, Reymond M, Schmid R. The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients. Interac CardioVasc Thorac Surg doi:10.1510/icvts.2007.166546. [2] Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulas associated with lung cancer operations univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992;104:1456–63. [3] Sfyridis P, Kapetanakis E, Baltayiannis N, Bolanos N, Ánagnostopoulos D, Markogiannakis A, Chatzimichalis A. Bronchial stump buttressing with an Intercostals muscle flap in diabetic patients. Ann Thorac Surg 2007;84:967–971. |
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Karsten Knobloch Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover 30625, Germany, Andreas Gohritz, Marcus Spies, Peter M. Vogt
kknobi{at}yahoo.com Karsten Knobloch, et al.
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Interactive CardioVascular and Thoracic Surgery 2008,
doi:10.1510/icvts.2007.166546A © 2008 European Association of Cardio-Thoracic Surgery We read with great interest the recent report by Dr. Beshay and coworkers [1]. Bronchus stump insufficiency with or without the development of the post-pneumonectomy empyema is one of the most serious conditions after pneumonectomy. The authors reported on 28 patients receiving a buried pedicled latissimus flap without any skin isle. This muscle flap is 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 deepithelized skin side rather than muscle is sutured to an opening of the bronchus. However, it remains unclear why a deepithelized skin should be superior in this situation. 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 1cm 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 visualisation via bronchoscopy. References [1] Beshay M, Carboni G, Hoksch B, Reymond MA, Schmid RA. The role of muscle flap in preventing bronchus stump insufficiency after pneumectomy for malignant pleural mesothelioma in high-risk patients. Interact Cardiovasc Thorac Surg doi:10.1510/icvts.2007.166546. [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;53:440-2. [4] Knobloch K, Gohritz A, Vogt PM. Noninvasive monitoring of microcirculatory perfusion and oxygenation in subcutaneous microsurgical flaps. J Reconstr Microsurg 2008;24:69. |
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