Intercostal Flap Research Articles

409. TWO-STAGE OPERATIVE PROCEDURE FOR A BENIGN, COMPLICATED TRACHEOESOPHAGEAL FISTULA CAUSED BY FOREIGN BODY IMPACTION

Abstract Background Benign Tracheoesophageal fistula (TOF) caused by foreign body impaction is a rare condition requiring technical expertise. There are choices available based on the individual patient's situation, including endoscopic management, local resection and defect closure, and, in rare cases, esophagectomy. Methods A 58-year-old male had a history of artificial tooth dislodgement that got impacted in the esophagus, resulting in dysphagia. Endoscopy showed an impacted denture with an underlying transmural esophageal perforation, closed with clips and an endoloop. Two weeks later, partially covered SEMS was placed. Failure to retrieve the SEMS after repeated attempts due to tissue ingrowths, he was referred for management. CECT showed a stent in situ with a small air-filled cavity left lateral to the tracheal bifurcation. Bronchoscopy revealed the compression of the posterior tracheal wall and the presence of an endoclip in the posterior wall of the left main bronchus (LMB). Results The patient was planned for a two-stage operation. In the first stage, esophagus was mobilized along with the stent and the fistulous tract was excised. The esophagus was divided at both ends in the thorax. Up to this part, the procedure was done with single-port VATS without CO2 and in the left semi-prone position with a bronchial blocker in the right main bronchus. The fistula with the LMB was closed with an intercostal muscle flap and a bovine pericardial patch with transient apnoea. During this part, we extended the incision in the fourth space to raise the flap. Cervical esophagostomy was matured, and a feeding jejunostomy was created. The postoperative phase was uneventful, and he was discharged on the 5th postoperative day. After 4 weeks, we did the second phase of surgery, where we made a 4 cm retrosternal gastric conduit and performed the hand-sewn anastomosis with the cervical esophagus, which was taken down from the skin. The patient had an uneventful postoperative course and was allowed to be taken orally on day five and discharged subsequently two days later. Conclusions TOF demands a multidisciplinary treatment strategy. Successful outcomes are determined by patient triage, delineation of the location and size of the defect, mediastinal contamination, and the availability of expertise.

The methods of bronchial stump buttressing in post-pneumonectomy bronchopleural fistula prevention: a systematic review

Introduction The bronchopleural fistula remains one of the most severe complications after pneumonectomy. Several surgical methods may enhance bronchial stump healing and reduce the occurrence of BFP. Usually, surgeons use tissue buttressing, such as intercostal muscle flap, parietal pleura, pericardium fat pad, or mediastinal fat, to reinforce the bronchial stump. This paper reviews the literature describing the impact of different buttressing tissues on the occurrence of early post-pneumonectomy bronchopleural fistula.Material and methods We included all studies that described the use of bronchial stump buttressing in patients after pneumonectomy. Studies written in languages other than English were excluded. The search was performed using PubMed, Google Scholar, Embase, COCHRANE databases, and the clinical trial registry (www.clinicaltrials.gov) on December 1, 2023. We used the following search input: "lung cancer" AND "pneumonectomy" AND ("bronchopleural fistula" OR "BPF") AND ("tissue buttressing" OR "intercostal muscle flap" OR "mediastinal fat pad"). We analyzed the types of studies, the numbers of patients, and the most important conclusions. We performed descriptive statistics.Results Twenty-seven articles on the use of bronchial tissue buttressing were identified. Nine papers were rejected due to small sample size (<20 patients), surgical operation other than pneumonectomy or lobectomy, or papers older than 30 years. Ultimately, sixteen articles were included in the analysis. Among them, three papers highlighted the statistically significant influence of bronchial stump buttressing in reducing the risk of bronchopleural fistula (BPF) formation. Descriptive statistics were reported in nine studies, and two papers included the assessment of the blood perfusion in the buttressing tissue. Only one study was a randomized trial featuring a control group for comparison.Discussion Buttressing the bronchial stump remains a controversial issue in thoracic surgery. It could be beneficial for high-risk patients. Among different tissues, the ideal one has still not been identified. Future research should incorporate control groups and intraoperative assessments of the blood supply to the tissue employed for bronchial buttressing.

Costal cartilage as a promising technique for large bronchial fistula closure in fistulous empyema: a case report

BackgroundThere is no high level of evidence for the treatment of fistulous empyema. We report here a promising technique for closure of a bronchopleural fistula using costal cartilage as a bronchial embolus.Case presentationThe patient is a 79-year-old man. A computed tomography scan diagnosed a fistulous empyema associated with perforation of lung abscess of right middle lobe. After thoracoscopic curettage of the right empyema cavity, right middle lung resection and intercostal muscle flap coverage over the bronchial stump were performed. Seven months after the surgery, a bronchopleural fistula developed. Bronchoscopy revealed fistulas in the middle lobe bronchus and B3b. After the open window thoracostomy, the empyema cavity was cleaned up. The empyema cavity remained from the anterior to the lateral thoracic region of the second to fourth ribs. A part of the second through fourth ribs that formed the ceiling of the pleural empyema cavity was removed to create space for skin and thickened parietal pleura to fill the cavity. The costal cartilage obtained from the rib resection was trimmed and harvested to fit into the diameter of the bronchopleural fistula. The free costal cartilage was sutured and fixed with five stitches with 3-0 PDS. The visceral pleura was covered with the thickened parietal pleura and skin and fixed airtight. To maintain a tight seal, a Blake® silicone drain was inserted between the visceral pleura and the thickened parietal pleura, and a suction reservoir was utilized to sustain negative pressure. The drain was removed on the 21st day. As of 21 months postoperatively, the skin and thickened parietal pleura flap has maintained its integrity, and there has been no evidence of pus or recurrence of air leaks.ConclusionIn the case of a fistulous empyema extending anteriorly, costal cartilage can be easily harvested, making it a promising option as a lid for fistula closure.

Treatment of Esophago-Airway Fistula after Esophageal Resection.

(1) Background: Esophago-airway fistula after esophageal resection is a rare, life-threatening complication associated with a high postoperative mortality rate. Managing this condition is challenging, and the prognosis for patients is uncertain. The results and our own approach to treatment are presented. (2) Material and Methods: We present a retrospective analysis of a group of 22 patients treated for an esophago-airway fistula between 2012 and 2022, with 21 cases after esophageal resection and one during the course of Hodgkin's disease. (3) Results: Twenty-two patients were treated for an esophago-airway fistula. Among them, a tracheobronchial fistula occurred in 21 (95.4%) patients during the postoperative period, while 1 (4.5%) was treated for Hodgkin's disease. Of these cases, 17 (70.7%) patients underwent esophageal diversion with various treatments, including intercostal flap in most cases, greater omentum in one (4.5%), latissimus dorsi muscle in two (9%), and greater pectoral muscle in one (4.5%). Esophageal stenting was performed in two patients (9.0%), and one (4.5%) was treated conservatively. Unfortunately, one patient (4.5%) died after being treated with bronchial stenting, and two (9.5%) experienced a recurrence of the fistula. (4) Conclusions: The occurrence of an esophago-airway fistula after esophagectomy is a rare but life-threatening complication with an uncertain prognosis that results in several serious perioperative sequelae.

A before and after evaluation of patient reported outcomes assessed by Breast Q following LICAP turnover flap in breast conservative therapy.

Chest-wall perforator-based techniques to replace volume for breast conservative therapy allow excision of large breast areas with minimal sequalae, such as the nipple-areolar complex displacement, parenchymal indentation or contour deformity. Furthermore, chest wall perforator flaps facilitate the maintenance of breast symmetry, hence decreasing the need for contralateral surgery. Lateral intercostal flap was described in numerous variants among which the most famous are the propeller flap and the turnover version. The turnover version is the easiest and fastest version that allows the replacement of large amount of volume. In this paper, we evaluate patients reported outcomes, before and after surgery, collected through the Breast Q. This study was conducted on 21 patients who were admitted to the plastic surgery department. A prospectively maintained database was used to identify the patients and their records were assessed retrospectively. The pre/post operative patients data were collected. The Breast-Q questionnaire was administered before the surgery and at least 1year after. No major surgical complications were reported. Mean Breast-Q scores were evaluated at least 1year after surgery and radiotherapy and compared with pre-surgical scores. Among all the modules, no significant differences between the pre-surgical and post-surgical Breast-Q scores were observed. Until now, the lateral intercostal artery perforator flap has not been widely used, due to a difficult dissection and a challenging preoperative planning. According to the reported surgical technique, the execution is easy. This technique provides the same breast-related quality of life compared to preoperative values, reduces the mastectomy rate and increases the overall survival.

First successful neonatal primary repair of esophageal atresia with distal tracheoesophageal fistula in Belize

Esophageal atresia repair represents the epitome of Pediatric Surgery and it is considered as an indicator of the level of quality of any Surgical Neonatal Service. This article describes the first case completely and successfully treated in Belize, and it is focused on its management strategies. In the midst of COVID-19 pandemic, a full-term male neonate, adequate for gestational age and withnormal birth weight was referred to Karl Heusner Memorial Hospital’s Neonatal Intensive Care Unit and diagnosed with esophageal atresia with distal tracheoesophageal fistula. Primary repair was performed through open thoracotomy, closing the tracheoesophageal fistula and completing end to end esophageal anastomosis with minimal tension. A minor anastomotic leak was identified on postoperative day 9, which was initially managed conservatively but required surgical repair 5 days after, using a pedicled intercostal muscle flap over the re-sutured esophagus. The patient recovered completely with no midterm complications. It is feasible to perform complex neonatal surgical repair such as the AE/TEF in small countries like Belize, when both an experienced surgical team and adequate neonatal intensive care are available. Proper management of major surgical complications is essentialto achieve good results.

Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study

ObjectiveTo evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy. MethodsPatients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality. ResultsDuring the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts. ConclusionsEmpiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.

Surgical treatment of esophago-tracheobronchial fistulas after esophagectomy.

The aim of this study was to evaluate the surgical treatment of esophago-tracheobronchial fistulas (ETBFs) that occurred after esophagectomy with gastric conduit reconstruction in a tertiary referral center for esophageal surgery. All patients who underwent surgical repair for an ETBF after esophagectomy with gastric conduit reconstruction were included in a tertiary referral center. The primary outcome was successful recovery after surgical treatment for ETBF, defined as a patent airway at 90days after the surgical fistula repair. Secondary outcomes were details on the clinical presentation, diagnostics, and postoperative course after fistula repair. Between 2007 and 2022, 14 patients who underwent surgical repair for an ETBF were included. Out of 14 patients, 9 had undergone esophagectomy with cervical anastomosis and 5 esophagectomy with intrathoracic anastomosis after which 13 patients had developed anastomotic leakage. Surgical treatment consisted of thoracotomy to cover the defect with a pericardial patch and intercostal flap in 11 patients, a patch without interposition of healthy tissue in 1 patient, and fistula repair via cervical incision with only a pectoral muscle flap in 2 patients. After surgical treatment, 12 patients recovered (86%). Mortality occurred in two patients (14%) due to multiple organ failure. This study evaluated the techniques and outcomes of surgical repair of ETBFs following esophagectomy with gastric conduit reconstruction in 14 patients. Treatment was successful in 12 patients (86%) and generally consisted of thoracotomy and coverage of the defect with a bovine pericardial patch followed by interposition with an intercostal muscle.

Hemoptysis: unilateral pulmonary artery atresia? a case report

BackgroundAsymptomatic, isolated cases of unilateral pulmonary artery atresia may present in adulthood with symptoms such as recurrent respiratory infections, dyspnea, hemoptysis, and pulmonary hypertension. Unlike previously reported patients that underwent surgical management for this pathology, the patient in this report had no chronic history of recurrent respiratory infections, dyspnea, or pulmonary hypertension, making a diagnosis prior to extensive imaging difficult.Case presentationA 55-year-old male presented to our emergency department (ED) with a 3-day history of recurrent cough with 2–3 tablespoons of hemoptysis per episode, chills, and occasional wheezing. A computed tomography angiography (CTA) was performed, which identified a congenital absence of the left pulmonary artery and a right-sided aortic arch. Hypertrophied left intercostal and bronchial arteries were noted to be perfusing the left lung. V/Q scan confirmed a heterogeneous distribution of gas throughout both lung fields with 97% perfusion to the right lung, but no visualization of the left lung on the perfusion images. Given extensive collateral blood supply to the left lung, interventional radiology performed a GELFOAM® embolization of the hypertrophied left bronchial artery and two parasitized arteries from the left subclavian artery to minimize intra-operative blood loss. This was immediately followed by a left thoracotomy, pneumonectomy, intercostal muscle flap placement, and bronchoscopy. The procedure was 360 min long with a total of 1500 cc blood loss that was salvaged and re-infused. No additional blood products were administered. The patient remained intubated post-operatively and was transferred to the surgical intensive care unit. His postoperative course was complicated by troponin leak, rhabdomyolysis, delirium, and ileus, all of which resolved over time. He was discharged home on postoperative day seven and continues to do well one-year later.ConclusionsThe patient in this report presented with several episodes of isolated hemoptysis but unlike previously reported cases of unilateral pulmonary artery atresia, he had no history of recurrent respiratory infections, dyspnea, or pulmonary hypertension. Although unilateral pulmonary artery atresia is a rare diagnosis, in patients with unexplained, isolated hemoptysis, further examination of the vasculature may be warranted, and surgical management may be beneficial in appropriate, symptomatic patients.

Tracheo-esophageal fistula repair in a positive COVID-19 patient: use of intercostal muscle flap.

Tracheo-esophageal fistula repair in a positive COVID-19 patient: use of intercostal muscle flap.

ЗАДНИЙ МЕЖКОСТНЫЙ ЛОСКУТ ПРЕДПЛЕЧЬЯ В РЕКОНСТРУКЦИИ ДЕФЕКТОВ МЯГКИХ ТКАНЕЙ КИСТИ

Purpose: to asses and to analyze early and long-term results of the hand reconstructions of the extensive soft tissue defects with posterior interosseous flap of the patients with hand injuries. Objective: find out whether this type of operation is optimal for the reconstruction of soft tissue defects of the hand; improve the quality of life of patients with soft tissue defects of the hand Materials and methods: the results of reconstruction of soft tissue defects of the hands with the posterior intercostal flap of the forearm in 6 patients (5 men and 1 woman) aged 31 to 67 years were analysed. In all 6 cases, reconstruction of the posterior interosseus flap was performed during the phased treatment of the patient with severe post-traumatic defects in the soft tissues of the hand. In all 6 cases, the reconstruction of soft tissue defects of the hands was combined with complex traumatic and orthopedic operations (autocost plasty with a cortical-spongiotic graft, removal or resection of one of the rays of the hand with the formalion of narrow – fingered hand, osteosynthesis and rheosynthesis by spokes, microscrews and microplates, necrectomy and amputations). Preoperative preparations included ultrasound Doppler of the forearm with visualization of posterior interosseus vessels. In all cases, reconstructive operations were performed using binocular optics with an increase of 30–35 times. In the postoperative period, the condition of vascularization of flaps was monitored by thermal imaging. Results: the flaps has taken root in all 6 cases. Postoperative complication in the form of marginal flap necrosis in it’s local venosus insufficiency was determined in one patient, which indicates the variability of vascular anatomy of the flap. Conclusion: 1 year after operation, all patients were satisfied with the function of the hand the aesthetic appearance of the hand and donor area on the forearm. Survey Disabilities of the Arm, Shoulders, and Hand (DASH) was used to assess postoperative results in all patients after 1 year.

Abstract 15867: A Swimming Heart: A Unique Complication of Gastropericardial Fistula

Background: Gastropericardial fistula is a rare clinical entity associated with gastroesophageal operations. Case: 63-year-old female with medical history of hypertension, GERD, and hiatal hernia status post Nissen fundoplication presented to the ER with one week of chest pain and dyspnea. Six months prior to presentation, she was found with ischemic colitis, candida esophagitis and slipped Nissen. In the ER, she was febrile and hypoxic. Chest x-ray showed a large hydropneumopericardium with air-fluid level. CT chest showed pneumomediastinum. Upon arrival to our facility, an echocardiogram showed normal EF 65% and a large complex pericardial effusion with presence of gas, liquid, and organized material without evidence of tamponade. Repeat CT abdomen showed a thin-walled collection of gas and fluid projecting from the area of the Nissen through the diaphragmatic hiatus in contact with the pericardium suspicious for a gastropericardial fistula. She went to the OR for pericardial window with drainage of 700 cc of purulent fluid and findings of chronic-appearing granulation of the pericardium. Intraoperative endoscopy noted a perforation near the GE junction that was stented with a 155 x 23 mm covered esophageal stent. Cultures grew Candida and gramnegative bacilli. She then underwent staged right thoracotomy with repair of fistula with intercostal muscle flap. Postoperative course was complicated with posterior wall hemorrhage requiring embolization of the left eight intercostal artery. The esophageal stent was removed three months post insertion due to distal migration causing superficial ulceration and esophagitis. Patient has since recovered gradually without further complications. Discussion: Gastropericardial fistula is associated with high morbidity and mortality. The treatment is surgical with early pericardial drainage usually by pericardial window and de-functioning esophagostomy or gastrostomy plus repair of the defect.

S2384 The First Case of Water Immersion Endoscopy in the Definitive Diagnosis of Atrio: Esophageal Fistula

Introduction: Atrial fibrillation (AF) is the most common heart rhythm disorder with estimated global prevalence of 33.5 million. Catheter ablation is the treatment modality of choice for refractory AF. Atrio-esophageal fistula (AEF) is a serious complication of catheter ablation. Diagnosis is critical to the management of AEF, and includes computed tomography of the chest, esophagram and esophagogastroduodenoscopy (EGD). Prompt diagnosis of AEF is essential for survival. Case Description/Methods: A 56-year-old male with AF presented with fever, fatigue and bilateral leg weakness. Twenty days prior to presentation he underwent pulmonary vein isolation radiofrequency ablation and discharged the following day. Upon re-presentation his vitals were notable for fever and tachycardia. Labs revealed a normal white count and hemoglobin, and elevated lactate and troponin. One hour after arrival he developed complex focal seizure and AF with rapid ventricular rate followed by respiratory decompensation requiring intubation. His blood cultures revealed Streptococcus mitis and Gemella haemolysans. His MRI disclosed numerous bilateral emboli concerning for endocarditis, however TEE did not reveal any valvular vegetation, thus proposing AEF as a possible complication accounting for the emboli. CT chest angiogram revealed subtle irregularity along the posterior wall of the left atrium (figure A), but did not provide conclusive evidence to warrant high-risk cardiothoracic surgery. Water immersion EGD was performed to diagnose and localize the fistula, revealing esophageal defect in the proximal esophagus with movement of non-bloody debris through the tract (figure B). One hemostatic clip was placed near the tract to assist with localization for surgical closure. The following day the patient underwent right thoracotomy with placement of intercostal muscle flap to fistula (Figure C). Discussion: AEF is a rare complication of radiofrequency ablation therapy for AF. High mortality rate is primarily attributed to major cerebrovascular morbidity from septic thrombi. Currently there is no effective modality to visualize AEF safely and reliably. Water immersion colonoscopy allows for completion of difficult colonoscopies, decreased insertion pain, and increased adenoma-detection rates. This technique was applied to identify the AEF. Water immersion EGD is an important modality that can confidently be considered within the diagnostic armamentarium of gastroenterologists to ensure safe and rapid diagnosis and treatment of AEF.Figure 1.: 1: (A) Illustrates a subtle contour abnormality involving the posterior wall of the left atrium (arrow) concerning for AEF (B) Water immersion endoscopy illustrating 3mm defect (arrow) in the wall of the esophagus (C) Underwent right thoracotomy to access AEF. This image highlights 3mm fistula site (arrow) that is approximated to be at the midpoint of the atrium.

409. RECONSTRUCTION OF A SEGMENTAL OESOPHAGEAL DEFECT WITH A TUBED RADIAL ARTERY FOREARM FREE FLAP GUIDED BY 3-DIMENSIONAL MODELLING

Abstract Segmental defects of the oesophagus are rare but complex. If the patient survives the initial insult, reconstructive techniques most commonly involve gastric pull-up or colonic interposition (1) however alternative techniques such as free flap reconstruction can be utilised if the former are unsuitable (2). The surgical field often is quite hostile in these cases, making pre-operative visualisation and planning critical in achieving a successful outcome. We describe our approach after a surgical complication in a 49-year-old man. cT3N2M0 GOJ adenocarcinoma, pre-operative FLOT4, three-stage oesophagectomy complicated by anastomotic leak and tracheo-gastric fistula. Cervical oesophagostomy and venting gastrostomy (via laparotomy) was performed (severe illness precluded one-lung ventilation). He improved and was discharged, but a persistent fistula from the gastric conduit to his trachea remained. Reconstruction was planned by a multidisciplinary team using detailed 3D modelling. Via right thoracotomy, the gastric conduit was reduced into the abdomen and the tracheal defect was repaired with an intercostal muscle flap. A retrosternal colonic interposition restored gastrointestinal continuity. The superior 2 cm infarcted and was replaced by a dual-paddled tubular radial forearm free flap. This complex surgical situation demonstrates how 3D visualisation of a segmental oesophageal defect can be extremely helpful in pre-operative planning. In particular, the precise anatomical location of the gastro-tracheal fistula and its relationship to the bony landmarks and surrounding vascular anatomy were critical in considering surgical access and reconstruction options. Whilst the literature describes applications of 3D visualisation for surgical planning in alternative contexts, there is minimal information of its use in upper gastrointestinal reconstruction. The use of 3D modelling and printing within the surgical context has frequently been associated with reduced operating times and improved medical outcomes (3). This case adds to the previously documented advantages of 3D modelling in surgical planning but applies them to an area not well covered in the literature. Additionally, it demonstrates the utility of an infrequently used technique (RAFF) for reconstructing a segmental oesophageal defect. Further research into quantifying the outcomes following the implementation of 3D modelling in visualisation and surgical planning would be useful in encouraging its integration into mainstream surgical practice.

The technique of stump closure has no impact on post-pneumonectomy bronchopleural fistula in the non-small cell lung cancer-a cross-sectional study.

BackgroundPneumonectomy is a high-risk radical resection procedure, with bronchopleural fistula (BPF) being its most challenging and severe complication. This study aimed to assess the surgical risk factors and the impact of the bronchial stump closure technique on the incidence of the BPF.MethodsThis is a single-center, cross-sectional study of the medical records of 455 post-pneumonectomy patients operated due to non-small cell lung cancer (NSCLC) in 2006–2017. We analyzed the following variables and their influence on the occurrence of the BPF: operation side, surgical techniques (i.e., manual suture or the stapler), stump buttressing, the extension of pneumonectomy, comorbidities, and postoperative complications.ResultsBPF occurred in 7.47% of post-pneumonectomy patients. BPF was more prevalent in right-sided pneumonectomy versus left-sided (10.98% vs. 5.32%; P=0.026). The use of a stapler or manual suture was not associated with the incidence of the BPF (7.96% vs.7.09%, P=0.72). There were no significant differences in the occurrence of BPF among bronchial stump buttressing with the parietal pleura (P=0.80), intercostal muscle flap (IMF) (P=0.46), and pericardial fat pad (P=0.88). When comparing data from 2006–2012 with those from 2013–2017, we found a steady decrease in the number of performed stump reinforcements, but this was not associated with a higher risk of BPF.ConclusionsThe method used for stump closure, additional tissue buttressing of the bronchial stump and year of the surgery had no significant impact on the occurrence of BPF. Only right-sided pneumonectomy was associated with higher BPF occurrence.

Posterior intercostal flap: an anatomical study and best flap design

BackgroundPosterior intercostal arteries perforators (PICAPs) and lateral intercostal arteries perforators (LICAPs) are great vascular pedicles. Between the 4th and 11th spaces, they arise from the thoracic aorta. These are large perforators that can be the basis of many flaps. Yet, these perforators are underrated as they are poorly studied and scarcely utilized in plastic reconstructions.MethodsTwenty (ten males and ten females) adult cadaveric dissections were done on both sides to study the types, locations, and sizes of posterior intercostal perforators to help design flaps based on them in the best possible way. Perforators were assigned into one of 3 topographical zones of the back (medial, intermediate, and lateral).ResultsThe skin of the back was divided into 3 vertical zones: medial, intermediate, and lateral. Posterior intercostal arteries perforators (PICAPs) were found in the medial and intermediate zones. Medial zone PICAPs were large and appeared at the medial border of erector spinae (Es). Intermediate zone PICAPs appeared at the lateral border of Es and passed through latissimus dorsi (Ld) before reaching the skin. Lateral zone perforators were branches of lateral intercostal arteries and were divided into 2 types: (1) posterior branches of lateral intercostal perforators: simply named posterior lateral perforators (PLs); they were small and present in most of the spaces, and (2) anterior branches of lateral intercostal perforators (LICAPs): they were large, dominant pedicles and were found mainly in the 4th to the 7th spaces.ConclusionPICAPs and LICAPs are constant and of enormous size and run for a great distance in the skin. They can be utilized as any type of flap.

Intraoperative methods for wrapping anastomoses after airway reconstruction: a case series.

BackgroundAnastomosis management is the main challenge of airway resection and reconstruction, and postoperative anastomotic complications, including ischemia, stenosis, dehiscence, and separation may lead to severe outcomes and a poor prognosis. The anastomotic buttress is vital in airway reconstruction, but the selection of surgical buttress and reinforcement remains controversial. We aimed to demonstrate and evaluate the buttress options of anastomosis, including their preoperative characteristics, the intraoperative process, and the incidence of postoperative complications to help address the controversy regarding anastomosis management.MethodsThis retrospective study was conducted at a single institution. Patients who underwent airway reconstruction with anastomotic wrapping from Jan. 2019 to Sep. 2021 were enrolled in this study and preoperative characteristics and operational features were collected. All patients were carefully followed up by telephone and outpatient. Their postoperative complications and postoperative status after 6 months were recorded. The surgical procedures and clinical characteristics of the buttress options of anastomosis were assessed.ResultsA total of 62 patients undergoing either cervical tracheal, thoracic tracheal, carinal, or secondary carinal and main bronchus resection and reconstruction were evaluated. The anastomotic buttress used included mediastinal pleural flap (24/62, 38.7%), anterior cervical muscle (14/62, 22.6%), sternocleidomastoid (2/62, 3.2%), thymus flap (12/62, 19.4%), intercostal muscle flap (2/62, 3.2%), biological patch (2/62, 3.2%), prepericardial fat (1/62, 1.6%), thyroid gland (1/62, 1.6%), pectoralis major flap (2/62, 3.2%), and omental flap (2/62, 3.2%). All procedures produced satisfactory results without short-term anastomotic complications. A follow-up for 6 months was conducted and all patients were alive postoperatively. Tracheomalacia stenosis postoperatively occurred in 3 patients and they were subsequently treated with an endotracheal stent. One patient had tumor recurrence 3 months after surgery and received adjuvant chemotherapy.ConclusionsVarious anastomotic wrapping materials are used in airway reconstruction. Different utilizations of buttress are selected according to the anatomic characteristics and the reconstruction method used. This study indicated that appropriate surgical buttresses for wrapping anastomoses are legitimate alternatives to reduce the risk of anastomotic complications.

Rupture diaphragmatique et hernie intercostale droites homolatérales sur toux aiguë

We are reporting the case of a 64-year-old patient with chronic cough who has been diagnosed with an intercostal hernia with pleural and hepatic content associated with a diaphragmatic hernia of non-traumatic origin. The patient was treated for an acutely febrile cough with signs of respiratory distress. Thoracic scan showed an intercostal hernia containing an encysted hematoma and a right anterior diaphragmatic hernia with epiploic content. The COVID PCR was negative. This is one of the rare reported cases of intercostal hernia associated with a homolateral diaphragmatic rupture. Visceral and thoracic surgery enabled treatment of the two hernial orifices by raphy as well as omentectomy of the necrotic omentum ascending to the right pulmonary hilum. These two parietal complications of chronic cough should be considered in case of intercostal flap or acute respiratory distress. Surgery must then be carried out as a matter of urgency to reduce the content of the hernias and treat the musculoaponeurotic dehiscent orifices.

Iatrogenic Tracheal Rupture After Successful LVAD-Explantation

<h3>Introduction</h3> Cardiac recovery followed by LVAD-explantation is rare and happens only in 1-2% of the cases. Tracheal rupture during tracheotomy is an even more rare but dreaded complication. <h3>Case Report</h3> We report the case of a 60 year old female patient who had received LVAD therapy (HeartWare) six years ago for DCM caused by myocarditis. She had an uncomplicated course for four years, had one medically treated episode of systemic infection after five years and recently sepsis together with minor cerebral bleeding. After recovery, a CT-scan showed infection of the LVAD including the outflow graft. As echocardiography and right heart catheterization revealed sufficiently recovered cardiac function, the decision for LVAD-explantation was made. The device was successfully explanted via a median re-sternotomy and the complete outflow graft was removed. The patient was stable and extubated on the 1. POD, but needed to be re-intubated on the 4. POD due to pneumonia. As prolonged weaning from the respirator was expected, the patient underwent a tracheotomy. Shortly after, she developed a severe emphysema, could not be sufficiently ventilated and received an emergency implantation of a VV-ECMO. Bronchoscopy showed a large laceration of the back wall of the trachea. This was repaired surgically by direct suture and two days later a re-operation to cover the tracheal laceration with an intercostal muscle flap was required. After this, the patient developed recurrent bleedings with hemothorax and the need for multiple re-thoracotomies. The patient was on VV-ECMO for two weeks without ventilation or blockage of the tube-cuff to allow the trachea to heal. After bronchoscopic confirmation of good tracheal healing, careful ventilation was initiated. The pulmonary function recovered and the ECMO could be explanted after 36 days. Further along the patient was discharged to a pulmonary weaning clinic. She further recovered and is currently in good shape with NYHA class I-II. Interestingly, during the course of this dramatic complication, the patient was always in good cardiac function without any need of inotropic support. <h3>Summary</h3> After complete cardiac recovery and successful LVAD-explantation even a close to fatal complication like a tracheal rupture can be survived with good clinical outcome. Avoiding mechanical stress to the lacerated trachea under VV-ECMO might be a promising strategy.

Diagnostic and Therapeutic Challenges in Treating an Esophago-Pleural Fistula Following Lung Transplantation

Introduction Esophago-pleural fistula (EPF) is a rare surgical complication with important morbidity and mortality. Generally, EPFs present as a recurrent or chronic respiratory infection, empyema, or hemorrhage. Diverse diagnostic and multimodal treatment strategies can be considered including stenting, endoluminal clipping, as well as surgical repair. We present the diagnostic and therapeutic challenges of a unique case of EPF after bilateral lung transplantation (BLTx). Case Report A 62-year-old male with scleroderma and secondary pulmonary arterial hypertension underwent BLTx under VA-ECMO for acute deterioration of his underlying lung fibrosis. Early recovery was uncomplicated with weaning from ECMO on post-operative day (POD) 2, successful extubation on POD 3 and discharge to the ward on POD 13. However, 2 days later he developed acute respiratory distress due to a right-sided pneumothorax. Chest drainage did not suffice and on POD 18 a thoracoscopic exploration for empyema was performed. On POD 26, semi-digested food was seen in the chest tube. Esophagogastroscopy with methylene blue confirmed leakage and two separate EPFs. Nil per os policy was started. On POD 32 endoluminal clipping was attempted and esophagogastroscopy showed healing of the upper fistula, though persistence of the lower one. Additional clipping of the distal EPF was performed. Despite clinical improvement, a new esophagogastroscopy on POD 71 revealed a new fistula between the endoluminal clips. Ultimately, the EPF was primarily closed and covered with an intercostal muscle flap trough right-sided thoracotomy on POD 105. Nine days after surgical closure, a contrast esophagogram showed no residual leakage. The patient experienced a slow but gradual recovery and oral intake was started successfully. At 2.5 years post-BLTx, the patient has a normal oral intake and spirometry shows a good pulmonary function without signs of rejection or chronic lung allograft dysfunction. Summary Post-operative EPF is a life-threatening situation, especially in immunocompromised patients. A low threshold of clinical suspicion and esophagogastroscopy are warranted to impede the diagnosis of EPF. In our experience, minimal invasive endoscopic strategies should be considered first, however, surgical treatment with primary suture and muscle coverage has the highest chance to be effective. Esophago-pleural fistula (EPF) is a rare surgical complication with important morbidity and mortality. Generally, EPFs present as a recurrent or chronic respiratory infection, empyema, or hemorrhage. Diverse diagnostic and multimodal treatment strategies can be considered including stenting, endoluminal clipping, as well as surgical repair. We present the diagnostic and therapeutic challenges of a unique case of EPF after bilateral lung transplantation (BLTx). A 62-year-old male with scleroderma and secondary pulmonary arterial hypertension underwent BLTx under VA-ECMO for acute deterioration of his underlying lung fibrosis. Early recovery was uncomplicated with weaning from ECMO on post-operative day (POD) 2, successful extubation on POD 3 and discharge to the ward on POD 13. However, 2 days later he developed acute respiratory distress due to a right-sided pneumothorax. Chest drainage did not suffice and on POD 18 a thoracoscopic exploration for empyema was performed. On POD 26, semi-digested food was seen in the chest tube. Esophagogastroscopy with methylene blue confirmed leakage and two separate EPFs. Nil per os policy was started. On POD 32 endoluminal clipping was attempted and esophagogastroscopy showed healing of the upper fistula, though persistence of the lower one. Additional clipping of the distal EPF was performed. Despite clinical improvement, a new esophagogastroscopy on POD 71 revealed a new fistula between the endoluminal clips. Ultimately, the EPF was primarily closed and covered with an intercostal muscle flap trough right-sided thoracotomy on POD 105. Nine days after surgical closure, a contrast esophagogram showed no residual leakage. The patient experienced a slow but gradual recovery and oral intake was started successfully. At 2.5 years post-BLTx, the patient has a normal oral intake and spirometry shows a good pulmonary function without signs of rejection or chronic lung allograft dysfunction. Post-operative EPF is a life-threatening situation, especially in immunocompromised patients. A low threshold of clinical suspicion and esophagogastroscopy are warranted to impede the diagnosis of EPF. In our experience, minimal invasive endoscopic strategies should be considered first, however, surgical treatment with primary suture and muscle coverage has the highest chance to be effective.