FREE LATISSIMUS DORSI MUSCLE FLAP FOR CHRONIC BRONCHOPLEURAL FISTULA

INTRODUCTION

Complicated defects of the chest cavity still present a serious problem. Often these develop as a result of empyema and are also complicated by the bronchial fistula. Such defects are addressed by transposition of the local muscle flaps to the chest cavity (1). However, in some cases the condition keeps recurring, and since the local muscles have been cut or used earlier as a result of the earlier thoracotomies, they are not suitable for reconstruction. In such cases it is possible to use free-flap with its vascular pedicle and connect it to the extrathoracic blood vessels (2, 3, 4, 5). We present the case of a male where this technique was used to solve a complicated defect of the chest cavity.

CASE STUDY

A 58-year-old male suffered a gunshot injury on the right side of the thorax with severe lung laceration requiring removal of two lobes of his right lung. Post surgical course after the original treatment was without complications. Four yeas later the patient developed respiratory insufficiency with sepsis due to formation of bronchopleural fistula. We evacuated the empyema, completed right-side pneumonectomy and put in a drain. However, the fistula recurred, and in the course of another year the patient underwent several operations to close up the fistula. The first attempt was to transpose the serratus anterior muscle. However, the fistula with empyema recurred and the patient underwent pleurostomy. Another attempt to close the fistula with the use of tissue glue followed. The last attempt was the use of custom-made stent-graft which only reduced the fistula. At this stage a plastic surgeon was brought in. Due to the earlier right-side thoracotomy the latissimus dorsi muscle was cut, and it was not possible to use it for reconstruction. Based on these facts and due to the extent of the cavity that needed to be filled it was decided to use contralateral latissimus dorsi muscle as a free-flap.

At the beginning of the surgery the skin in the area of thoracostomy and in the area of the acceptor blood vessels or the right-side thoracodorsal vascular bundle was first mobilized. After examination of the patency of the blood vessels excochleation of the thoracic cavity was completed. Latissimus dorsi muscle was harvested from the left side. The muscle was pulled into the thoracic cavity through the thoracostomy. The distal end of the muscle was anchored by several stitches near the fistula. The muscle also filled the thoracic cavity for the most part, and Redon drains were inserted. The proximal end of the muscle was anchored by stitches to the muscles in proximity to the acceptor blood vessels to avoid pulling in the area of blood vessels anastomoses. Blood vessel anastomoses were completed, and the transferred muscle received good blood supply. Closure of the skin followed.

Blood supply to the flap was post surgically monitored by Doppler flow meter and was without problems. The patient was on a ventilator. The planned three-day ventilation was extended to five days. On the fourth post surgical day the patient developed subcutaneous emphysema which disappeared spontaneously within one week. We completed a bronchoscopy, which did not reveal fistula. The next course of wound healing was without complications, and then the patient was discharged.

At the 2-monthly check up the patient was fully independent, without signs of infection, emphysema or dyspnea. Repeated bronchoscopy did not indicate the presence any fistula. By that time the patient was able to walk briskly for 3 km without stopping. (Fig. 1–5.)

DISCUSSION

Muscle flaps are very well vascularized tissues which are resistant to infection - more resistant than skin or subcutaneous tissue. Due to these characteristics muscle flaps are ideal tissue that can be used for transposition into the chest cavity. Many authors present their good experience with the use of pedicle muscle flaps for empyema complicated by bronchopleural fistula. These patients usually undergo many surgical procedures in an effort to eliminate the infection and close the fistula. However, in some patients the local muscles that can be used for transfer into the intrathoracic cavity where needed are not available, because they were cut during previous thoracotomy or as a result of earlier failed transposition. In these patients free muscle flap from a distant part of their body with the use of the local acceptor blood vessels can offer sufficient amount of well vascularized tissue for reconstruction. The choice of flap depends on the size of the intrathoracic cavity, position and size of the fistula and distance to the acceptor blood vessels. Thoracodorsal vessels are usually used as the acceptor blood vessels because they are constant, they have with sufficient caliber and they are easily accessible. A free flap of the latissimus dorsi muscle with the connection to this vascular bundle allows for reconstruction in nearly all parts of the thoracic cavity.

In our case this method lead to complete closure of the bronchopleural fistula, and the patient is doing well four years after the surgery; he is able to perform completely normal physical activities.

Address for correspondence:

M. Tvrdek, M.D.
Department of Plastic Surgery
3^rd Medical Faculty Charles University, Prague
Šrobárova 50
100 34 Prague 10
Czech Republic
E-mail: tvrdek@fnkv.cz