Intercostal Flap Research Articles

醸膿胸膜剥皮と有茎肋間筋弁被覆により治癒した非結核性抗酸菌症（<i>Mycobacterium intracellulare</i>）に合併した難治性膿気胸の1例

醸膿胸膜剥皮と有茎肋間筋弁被覆により治癒した非結核性抗酸菌症（<i>Mycobacterium intracellulare</i>）に合併した難治性膿気胸の1例

腫瘍核出術と肋間筋弁被覆にて食道切除を回避した食道神経鞘腫の1例

腫瘍核出術と肋間筋弁被覆にて食道切除を回避した食道神経鞘腫の1例

Wrapping of the Bronchial Stump or Anastomosis with a Pedicled Intercostal Muscle Flap in Operations for Primary Lung Cancer

Wrapping of the Bronchial Stump or Anastomosis with a Pedicled Intercostal Muscle Flap in Operations for Primary Lung Cancer

Salvage Endotherapy (Stent and Suture) for Failed Thoracotomy Repair of Boerhaave Syndrome

Introduction: Transmural esophageal perforation, or Boerhaave syndrome, is a life threatening emergency. Urgent surgical repair of the defect using a left thoracotomy is the standard of care. Occasionally surgical repair doesn't completely fix the injury, especially in cases with delayed presentation when tissues are friable. Endotherapy using temporary covered esophageal stent (ES) is often successful in healing such defects, but stent migration can occur. Case description: A 59 year old male with history of intermittent solid food dysphagia presented with epigastric pain after a violent retching episode. He developed odynophagia, dyspnea and fever. A thoraco-abdominal CT scan showed pneumomediastinum, bilateral pleural effusions and pneumoperitoneum within the lesser sac (Fig 1). Gastrograffin upper GI series showed a distal esophageal perforation. Esophagoscopy revealed a impacted food bolus in distal esophagus. Utilizing a left thoracotomy, a large purulent fluid collection was evacuated. The paraesophageal tissue was friable and the perforation was located immediately above the GE junction. It was repaired in 2 layers and buttressed with an intercostal muscle flap. Postoperatively the patient was intermittently febrile. Repeat CT scan showed a small residual left pleural effusion, fluid collection in the lesser sac and esophago-pleural fistula. The lesser sac collection was drained percutaneously. Esophagoscopy confirmed the esophago-pleural fistula, and a fully covered ES was deployed to cover the defect (Fig 2). Repeat imaging showed distal migration of the ES. The stent was repositioned during esophagoscopy, and its proximal end was anchored to the esophageal wall by endoscopic suturing, overstitch (Fig 3). The patient gradually improved with resolution of fluid collections in the chest and abdomen and was discharged. The ES was retrieved 6 weeks later and the fistula had completely healed.Figure 1Figure 2Figure 3Discussion: Our patient presented >48 hrs after onset of symptoms and had developed an empyema and fluid collection in the lesser sac for which surgical exploration was warranted. In cases that present early and tissue contamination is minimal, a covered ES may be sufficient in repairing the esophageal tear. When used in a non-obstructed esophageal lumen, a covered ES tends to displace and migrate distally necessitating some form of anchoring. While endoclips are likely to displace easily, endoscopic suturing appears to offer a better alternative.

Results of surgical closure of bronchopleural fistula with vascularized tissues

BackgroundBronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree or lung parenchyma resulting in air leak in the chest tubes. Chronic BPF is a serious complication of several pulmonary and postoperative conditions, as it carries a high morbidity and mortality and is associated with prolonged hospital stay and thus high resource consumption. Till date surgical intervention has been the main stay of management of chronic BPF.This study was carried out to assess the efficacy of surgical closure of the chronic BPF using vascularized tissue transfer into the pleural cavity. Patients and methods28 patients were operated upon primarily due to chronic BPF with or without empyema. All patients were selected and subjected to surgical intervention using vascularized tissue transfer into the pleural cavity. The vascularized tissues had been used were: Intercostal muscle flap, Latissmus dorsi muscle transposition, Omental flap, and Pericardial pad of fat. ResultsThe mean hospital stay postoperatively was 4 ± 1 day. There was immediate or early stoppage of air leak after the intervention in all patients. No patient had prolonged postoperative air leak (≥5 days). One patient required negative suction for 2 days to help stoppage of the leak. No patient required instillation of sealants through the tubes. ConclusionOnce the BPF has developed, early recognition, drainage of the pleural space and control of the inflammatory process are critical. Surgical closure of BPFs with proper vascularized tissues is an effective technique associated with low cost and lower hospital stay.

Management of early bronchopleural fistula after pneumonectomy

To investigate the management of early bronchopleural fistula(BPF) within one month after pneumonectomy. A total of 30 cases developed BPF within one month after pneumonectomy in recent 30 years were reviewed from First Hospital of Jilin University. All patients were treated by reoperation, closed drainage with or without open thoracic window, or endobronchial glue. Seventeen patients were returned to the operating room for reclosure of BPF, one patients died of BPF and 16 reoperations were successful.Twelve cases were treated by closed drainage with or without followed open thoracic window. In 6 patients who were managed by closed drainage alone, 2 cases died of BPF and 4 bronchopleural fistulas closed spontaneously. In 6 patients treated with closed drainage and later with open thoracic window, one case died of BPF. One patient successfully underwent endoscopic glue to close BPF with injection three times. Within one month postoperatively, BPF without established empyema with pus should be reoperated if the patient had enough cardiopulmonary reserve and could there fore tolerate reoperation. Contamination of pleural space is not the contraindication to reoperation. Reclosure via original thoracotomy and repair the fistula with pedicled intercostal muscle flap are convenient and efficient. Drainage with or without followed open thoracic window is appropriate for the patients with limited cardiopulmonary reserve, impaired general condition, secondary to empyema with pus, early recurred cancer, or some small fistulas.

Does a Multimodal No-Compression Suture Technique of the Intercostal Space Reduce Chronic Postthoracotomy Pain? A Prospective Randomized Study

IntroductionChronic postthoracotomy pain is a significant adverse outcome of thoracic surgery. We evaluated with a prospective randomized trial the effect of a multimodal no-compression suture technique of the intercostal space on postoperative pain occurrence in patients undergoing minithoracotomy. MethodsPatients undergoing a muscle-sparing lateral minithoracotomy for different thoracic diseases were randomly divided into two groups: 146 patients received intercostal muscle flap harvesting and pericostal no-compression “edge” suture (the IMF group), and 151 patients received a standard suture technique associated with an intrapleural intercostal nerve block (the IINB group). Pain scores and interference of pain with daily activities were assessed by using the Italian version of the Brief Pain Inventory on day 1, and at 1 to 6 months postoperatively. The results of pulmonary function tests (spirometry and the 6-minute walking test ) were evaluated preoperatively and at 1 and 6 months postoperatively. ResultsPostthoracotomy pain scores throughout the first postoperative day were significantly lower in the IMF group. After 1 and 6 months, patients in the IMF group had a significantly lower average pain score (p = 0.001). There were no significant differences in pain interference scores at each evaluation time point in either group. However, differences were shown in lung function test results at 1 and 6 months postoperatively (the forced expiratory volume in 1 second in the IINB group averaged 68.8 ± 17.4% of predicted value and 72.8 ± 10.5%, respectively, and in the IMF group it averaged 83.1 ± 7.4% and 86.4 ± 12.8%, respectively [p = 0.023 and 0.013, respectively]; the 6-minute walking test results in the IINB group averaged 311.1 ± 51.0 and 329.9 ± 54.8 m, respectively, and those in the IMF group averaged 371.2 ± 54.8 and 395.7 ± 56.4 m, respectively [p = 0.0001]). ConclusionsThe multimodal no-compression suture technique is a rapid and feasible procedure that reduces the intensity of early and chronic postthoracotomy pain.

Bronchoesophageal Fistula Repair with Intercostal Muscle Flap Followed by Occlusion of Residual Diverticula with N-butyl Cyanoacrylate (NBCA) Glue: A Case Report

The incidence of bronchoesophageal fistula in presence of benign pathology of tracheal tree or oesophagus is rare. It is encountered in thoracic diseases like tuberculosis, syphilis or histoplasmosis due to erosion by infected lymph node or abscess to adjoining structures. The source of primary pathology has to be eliminated followed by appropriate steps of fistula tract closure is essential for optimal result. We report a 25-year-old patient with left sided bronchoesophageal fistula. He had a past history of pulmonary tuberculosis. A left lower lobectomy followed by repair of oesophageal fistula opening was performed by primary closure and reinforcement with an intercostal muscle flap based on posterior intercostal artery. Postoperative oesophagogram showed short diverticula, which was occluded with n-butyl cyanoacrylate (NBCA) glue under radiological guidance. Feeding was started one week after application of glue without further complication. Reports on intercostals muscle flap repair and intervention of residual oesophageal diverticula with n-butyl cyanoacrylate (NBCA) glue under radiological guidance are scanty.

Iatrogenic injuries to the trachea and main bronchi.

IntroductionIatrogenic tracheobronchial injuries are rare.AimTo analyse the mechanism of injury, symptoms and treatment of these patients.Material and methodsRetrospective analysis of hospital records of all patients treated for main airway injuries between 1990 and 2012 was performed.ResultsThere were 24 patients, including 21 women and 3 men. Mean time between injury and initiation of treatment was 12 hours (range: 2-48). In 16 patients the injury occurred during tracheal intubation, in 1 during rigid bronchoscopy, in 1 during rigid oesophagoscopy, in 1 during mediastinoscopy and in 5 during open surgery. Mean length of airway tear was 3.8 cm (range: 1.5-8). In 1 patient there was an injury to the cervical trachea and in the remaining 23 in the thoracic part of the airway. The treatment included repair of the membranous part of the trachea performed via right thoracotomy in 10 patients (in 1 patient additionally coverage with a pedicled intercostal muscle flap was used), a self-expanding metallic stent in 1 patient, suture of the right main bronchus and the oesophagus in 1, left upper sleeve lobectomy in 1, right upper lobectomy in 1, implantation of a silicone Y stent in 3, mini-tracheostomy in 1, and conservative treatment in 5 patients.ConclusionsIntubation is the most frequent cause of iatrogenic main airway injuries. Patients with these life-threatening complications require an individualised approach and treatment in a reference centre.

Does addition of a pericardial drain in patients undergoing isolated aortic valve replacement reduce post-operative complication: A comparative study of single versus two drains in the early post-operative period?

Does addition of a pericardial drain in patients undergoing isolated aortic valve replacement reduce post-operative complication: A comparative study of single versus two drains in the early post-operative period?

Tubercular esophago-pleural fistula—a rare case report and review of literature

Esophago-pleural fistula is a rare entity. A young patient presented with chest discomfort after taking food and occasional cough. Computed tomography scan of thorax revealed esophago-pleural fistula. Intraoperatively, there was a BPF in the right lower lobe. The fistulous diverticulum was excised followed by primary repair of the esophagus and reinforced with intercostal muscle flap with buttressing of BPF by soft tissue flap. Patient was discharged uneventfully under coverage of ATT. Primary repair and reinforcement by myoplasty have superadded advantage over endoscopic procedures where recurrence rate is high. So, proper evaluation and timely management are required to prevent morbidity and mortality.

Tracheoesophageal fistula in adults due to corrosive ingestion: challenges in management.

Esophagorespiratory fistula in adults as a result of corrosive ingestion is a rare occurrence and is a difficult problem to manage. Three young (15-19 years) patients (2F, 1M) out of 115 (incidence 2.6%) of corrosive ingestion who had tracheoesophageal fistula (TEF) were reviewed retrospectively. After initial management, enteral route of nutrition was established. Based on the extent of concomitant esophageal stricture, the fistulae were classified as: type I (short) and type II (long segment). Fistula was repaired through thoracotomy and formation of a neomembranous trachea. Esophageal stricture could be managed either short-segment resection (type I) or resection and replacement (type II). The etiology was aluminum phosphide in two and caustic soda in one. All the patients were operated beyond 9 weeks of ingestion. Tracheal defect was 5, 9 and 30 mm. Fistula could be repaired by neomembranous trachea in all the patients and defect reinforced with pleural flap in two and intercostal muscle flap in one patient. Two patients required colon interposition, while one could be managed with short-segment resection. All the patients are well at follow-up. TEF due to corrosive ingestion is a rare entity in adults. Formation of a neomembranous trachea is feasible in all patients. Management of esophageal stricture depends upon the pattern of involvement of the esophagus.

Use of Intercostal Flap for Conservative Surgical Management of Complex Lower Esophageal Fistula

Lower esophageal fistula is a rare complication after upper digestive tract surgery, but it is associated with high morbi-mortality. There is no consensus on therapeutic care, however when reoperation is necessary, a pedicled intercostal flap from the thoracotomy can be easily harvested to patch a large defect or buttress a direct suture, saving digestive reconstruction. This technique should be mastered by thoracic and general surgeons.We present here two cases of lower esophagus fistulas cured thanks to this intercostal flap, in which we avoided fistula recurrence with maintenance of digestive continuity.

Intercostal muscle flap for repair of bronchopleural fistula.

A 50-year-old male patient, a known case of chronic obstructive pulmonary disease (COPD), presented with the features of bronchopleural fistula (BPF) on the right side for 1 month. The patient was a chronic smoker and did not give any history suggestive of pulmonary Koch's. The patient had sudden-onset breathlessness and chest pain 1 month before, which was diagnosed to be due to spontaneous pneumothorax. An intercostal drain was inserted but even after 1 month of all conservative measures, the lung remained collapsed and there was large air leak in the intercostal drain. Computed tomogram (CT) of the chest revealed collapsed and entrapped lung with surgical emphysema of the subcutaneous tissues due to rupture of the emphysematous bulla on the right side along with the presence of emphysematous bullae on the left upper lobe also. Surgical intervention in the form of decortication of entrapped lung and repair of the BPF with intercostal muscle flap was performed. The patient recovered well and was discharged after 10 days.

Current Results of a Combined Endovascular and Open Approach for the Treatment of Aortoesophageal and Aortobronchial Fistulae

Aortoesophageal (AEF) and aortobronchial (ABF) fistulae are uncommon but invariably fatal if left untreated. Mortality rates of open surgery remain prohibitive. Thoracic endovascular aortic repair (TEVAR) was shown to be a valid alternative to control bleeding in emergency, allowing a reduction of perioperative mortality. However, it entails a significant risk of late sequelae, namely endograft contamination and sepsis, related to the untreated esophageal leak. The aim of this study is to present initial results of a combined "hybrid" (endovascular and open) strategy to treat AEF and ABF. From 2006 to 2013, 8 patients (6 men, mean age 63±13years) were operated at our institution for primary and secondary AEF (7 patients) or ABF (1 patient) by means of a combined approach: emergent endovascular exclusion of the aortic rupture, followed by staged open surgical repair of the esophageal or bronchial lesion with associatedintercostal muscle flap interposition. Follow-up was available in all patients (mean 34±26months). TEVAR was successfully performed in all cases in emergency because of active bleeding or hemodynamic instability. Stabilization of hemodynamic parameters was obtained in all patients. Open surgical stage was performed either directly after TEVAR (n=1) or after a mean delay of 6.9±3.5days (n=7). No perioperative sepsis, bleeding, or death was observed. At follow-up, 7 patients were alive (87.5%). One patient died 1year after the procedure because of sudden cardiocirculatory arrest of unknown origin. Another patient experienced 2 hospitalizations, at 3 and 8months after the procedure, for recurrent fever requiring prolonged intravenous antibiotic therapy. No conversion or aortic bleeding was recorded during follow-up. Immediate TEVAR followed by staged open repair of the esophageal or bronchial defect with intercostal muscle flap interposition appears to be a feasible treatment of AEF and ABF. Despite the fact that initial results are encouraging, further data on wider cohorts with longer follow-up are necessary to confirm the efficacy and durability of this strategy.

Cervicothoracic Airway Injury Repair Using Double-Wide Intercostal Muscle Flap

We present a useful technique for the surgical management of long-segment cervicothoracic tracheobronchial injury using a double-wide intercostal muscle flap. This flap is a modification of a previously endorsed technique extending the ability to reinforce repairs of tracheobronchial injuries not adequately covered by a single intercostal muscle flap.

Left atrial-esophageal fistula repair after radiofrequency catheter ablation for atrial fibrillation.

Left atrial-esophageal fistula (LAEF) is a rare complication of radiofrequency ablation (RFA) procedures undertaken for atrial fibrillation (AF). This complication is associated with significant morbidity and mortality. Currently, there is no clear consensus on the appropriate management strategy. We report a case of a LAEF that developed in a patient 2 weeks after RFA for medication refractory AF. The patient underwent successful repair of the fistula through a left posterolateral thoracotomy, wherein the esophageal and atrial lesions were repaired primarily with an intercostal muscle flap and bovine pericardial patch to reinforce and prevent recurrence.

Thorascopic Resection of Esophageal Heterotopic Pancreas

Heterotopic pancreas is normal pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Heterotopic pancreatic tissue is a rare congenital anomaly found usually in the stomach, duodenum, or jejunum and is rarely seen in the esophagus. This is a case of heterotopic pancreas found in the esophagus that was removed thorascopically.

Open Surgical Secondary Procedures after Thoracic Endovascular Aortic Repair

Improved outcomes of thoracic endovascular aortic repair (TEVAR) compared with open repair have changed the therapeutic paradigm of thoracic aortic lesions. As the number of TEVAR survivors has grown, reports of complications have similarly increased. Although secondary endovascular rescue measures are often undertaken, patients with serious complications are often converted, ultimately, to open repair. The aim of this study was to assess causes and midterm results of open surgical secondary procedures after thoracic endovascular aortic repair. A total of 236 patients underwent TEVAR. Fourteen of these patients required open repair because of six aortobronchial fistulas, four retrograde type A dissections, two aneurysm enlargement without endoleak, one thoracic stent-graft collapse, and one aortoesophageal fistula. Eight (57.1%) patients underwent surgical repair using cardiopulmonary bypass. Six stent-grafts were totally removed, and eight stent-grafts were left in situ. Four patients underwent supracoronary ascending aorta replacement, and one an extensive replacement of the aortic arch through sternotomy. Three patients had descending aortic replacement through left thoracotomy combined with a total esophagectomy in one case. One patient was treated by ligation of the aortic arch, ascending to supraceliac abdominal aorta bypass and stent-graft explantation. One patient was treated by exclusion bypass of the descending thoracic aorta. Pulmonary resection and large pleural or intercostal muscle flap interposition to wrap the stent-graft left in situ was done in four cases of aortobronchial fistula. All patients survived the surgical procedure. Ten patients (71%) had an uneventful postoperative course. There were two in-hospital deaths (14.3%). Both died from multi-organ failure in the early postoperative course after surgical repair of a stent-graft infection and an aortoesophageal fistula. One patient suffered a definitive paraplegia and a secondary aortoesophageal fistula requiring reoperation for esophageal repair. One patient, treated by pulmonary resection and flap interposition to wrap the stent-graft, underwent stent-graft explantation and in situ descending aortic replacement because of stent-graft reinfection. Actuarial survival was 87.7% after a mean follow-up of 26.3 months (range 9-72 months). Complications or prevention of complications after TEVAR either due to device failure or adverse events may require conversion to open repair or additional open surgical procedure. Open repair can be performed by a team experienced in management of diseases of the thoracic aorta and a low mortality rate achieved despite the precarious preoperative conditions and complex aortic pathologies of patients.

Robotic harvest of intercostal muscle flap

Robotic harvest of intercostal muscle flap