Intercostal Flap Research Articles

Indocyanine green fluorescence in the assessment of the quality of the pedicled intercostal muscle flap: a pilot study†

The pedicled intercostal muscle flap (IMF) is a high quality vascularized tissue commonly used to buttress the bronchial stump after pneumonectomy or bronchial anastomosis after sleeve lobectomy in order to prevent bronchopleural fistula formation. The evaluation of the viability of the muscle flap is difficult. The aim of this study was the assessment of the application of indicyanine green fluorescence for the evaluation of IMF perfusion. The study included 27 patients (10 males and 17 females), mean age 62.6 years (47-77 years). Indocyanine green fluorescence (ICG) was used for objective assessment of the IMF quality by a near-infrared camera system (Photodynamic Eye(®), Hamamatsu Photonics, Japan). The following factors that may have an impact on the quality of the IMF were assessed: age, gender, body mass index, comorbidities, IMF length and thickness and timing of the harvesting during the procedure. The following surgical pulmonary resections with IMF harvesting were performed: 12 pneumonectomies, 2 sleeve lobectomies and 13 lobectomies. Intercostal muscle flap (IMF) was harvested before rib spreader insertion in 23 patients (85%) and at the end of the surgery in 4 patients (15%). The mean length and thickness of the harvested intercostal muscle were 19.9 ± 2.9 cm (range 13-24 cm) and 2.4 cm ± 0.7 cm (range 1.0-3.5 cm), respectively. Indocyanine green angiography showed ischaemia in the distal part of the muscle in all cases, despite the lack of obvious macroscopic signs. Median length of the ischaemic part was 4 cm (range 0.5-20 cm). The IMF length and thickness had a significant impact on the length of the ischaemic segment. In 24 patients, the ischaemic part of the muscle flap was severed. In 3 patients with the longest ischaemic segment (11, 13 and 20 cm), an alternative tissue was used to cover the bronchial stump. No major complications occurred. Our preliminary results confirmed the simplicity and high efficacy of ICG in the assessment of intercostal muscle blood perfusion. ICG was superior to macroscopic evaluation and influenced surgical proceeding.

Early and late outcome after surgical treatment of acquired non-malignant tracheo-oesophageal fistulae

Tracheo-oesophageal fistula (TOF) is a rare, life-threatening condition. We report our results of surgical treatment and evaluation of the outcome of acquired non-malignant TOF. Twenty-five patients (aged 49 ± 21 years) with TOF were operated on between 2001 and 2011. Tracheo-oesophageal fistula was due to prolonged intubation/tracheostomy (84%), was secondary to other surgery (8%) or trauma (4%) or was idiopathic (4%). The tracheal defect was 2.4 ± 1.3 cm long and was associated with tracheal stenosis in seven (28%) patients. Surgical treatment consisted of direct suturing of the oesophageal defect in two layers (or end-to-end oesophageal resection and anastomosis in one case) associated with tracheal suturing (n = 15; 60%), tracheal resection and anastomosis (n = 8; 32%) or covering of a large tracheal defect by an intercostal muscle flap or by a resorbable patch with muscle apposition (n = 2; 8%). The surgical approach was cervicotomy (n = 14; 56%), cervicotomy plus median sternotomy or split (n = 6; 24%), thoracotomy (n = 4; 16%) or cervicotomy plus sternal spit plus thoracotomy (n = 1; 4%). In 18 (72%) cases a muscular flap was used and in six (24%) a protective tracheostomy was performed. No perioperative deaths occurred. Morbidity occurred in eight (32%) patients; none of them required a second surgical look. At median follow-up of 41 months, the outcome was excellent or good for 22 patients (88%), two (8%) are still dependent on jejunostomy and tracheostomy for neurological diseases and one (4%) is under mechanical ventilation for end-stage respiratory failure. Surgical treatment of TOF is associated with good results in terms of control of acute symptoms and long-term outcome, particularly concerning oral intake and spontaneous breathing.

Repair of a Complex Bronchogastric Fistula After Esophagectomy With Biologic Mesh

Bronchogastric conduit fistula is a rare and potentially fatal complication after esophagectomy for esophageal cancer. We report a case of a patient transferred to our institution with a complex bronchogastric conduit fistula after a thoracoscopic three-hole esophagectomy for midesophageal squamous cell carcinoma. The defect involved the entire membranous airway of the bronchus intermedius, with a 15-cm dehiscence of the gastric conduit staple line. This was successfully reconstructed with a single-stage repair by use of an Alloderm patch reinforced with an intercostal muscle flap. At postoperative follow-up the patient is doing well and tolerating a regular diet without dysphagia.

Prophylactic flap coverage and the incidence of bronchopleural fistulae after pneumonectomy

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'In pneumonectomy patients, is buttressing the bronchial stump associated with a reduced incidence of bronchopleural fistula?'. Fifty-seven papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. One prospective randomized controlled trial was identified, which found significantly lower rates of bronchopleural fistula and empyema after pneumonectomy with the use of pedicled intercostal flap buttressing. Intercostal muscle flaps and pericardial flaps have been used in case series of high-risk patients, e.g. those with neoadjuvant therapy or extended resections, with low rates of subsequent bronchopleural fistulae. There is the least-reported evidence for thoracodorsal artery perforator and omental flaps. There is relatively little published evidence beyond the single randomized trial identified, with only a few comparison studies to guide clinicians. We conclude that there is evidence for flap buttressing in reducing the risk of bronchopleural fistulae after pneumonectomy in diabetic patients. Flap coverage in other high-risk situations, such as extrapleural or completion pneumonectomy, has been reported in case series with good results. Of the reported techniques, the evidence is strongest for the pedicled inter-costal flap.

Successful Use of Intercostal Muscle Flap in Cavitary Lung Lesions

Background: Lung cavities sometimes result from a number of pathological processes including suppurative necrosis, caseous necrosis, ischemic necrosis and cystic dilatation of lung structures. The aim of this study is to evaluate the use of intercostals muscle flap as a successful method to fill the lung cavity for reduction of symptoms and treatment of patients presented with symptomatic pulmonary cavity and to avoid the risk of pulmonary resection. Methods: This is a prospective study conducted between 2009 to 2012, in department of cardiothoracic surgery, Zagazig University Hospital. The study included 32 patients suffering from cavitary lung lesions divided into two groups, group (A): 14 patients treated by using intercostal muscle flap to fill the defect after Cavernostomy without lung resection; and group (B): 18 patients treated by traditional methods by lung resection. Patients with high risk of lung resection, suspicion of dense adhesion, symptomatic chronic lung abscess and patients with bad pulmonary function tests were included in group (A). Results: 20 patients were male and 12 were females in both groups, the large numbers of cases were lung abscess in group A (4 cases 28.5%) followed by Aspergilloma and TB cavity (3 cases 21.4%). Hemoptysis, persistent cough and expectoration were the main presentation of our patients. Poor pulmonary function was significant finding in group A (7 cases 50%). Complications reported in our study were bleeding, recurrent symptoms and one case mortality in group B after Pneuomenectomy. Conclusion: Using the intercostal muscle flap implanted inside the lung cavity after cavernostomy is a successful alternative curative method especially in cases with high risk of lung resection.

Successful Anesthetic Management for Surgical Repair of Atrio-Esophageal Fistula Following Radiofrequency Ablation for Atrial Fibrillation

Introduction: Atrio-esophageal fistula is a rare but often fatal complication of radiofrequency ablation for atrial fibrillation. Here we report a successful case in anesthetic management of surgical repair of atrio-esophageal fistula. Case Report: The patient was a 56-year-old man status post radiofrequency ablation for atrial fibrillation one month before presenting with fever and symptoms and signs of cerebral emboli. He was diagnosed as having atrio-esophageal fistula, which required emergent surgical repair. In the operating room, rapid sequence induction was performed with avoidance of positive pressure ventilation before securing airway. Double lumen tube was used for lung isolation for left thoracotomy. Upon exploration, a small fistula was identified. Both atrial and esophageal defects were ligated and an intercostal muscle flap was placed. The patient’s heart rhythm was atrial flutter/atrial fibrillation with marginal hemodynamics during the procedure, but cardioversion was delayed until the fistula was repaired and no remaining air, blood clot or gastric content in the heart was confirmed by epicardial ultrasound. The patient tolerated the surgery and was transferred to ICU, intubated and ventilated. He recovered from surgery and was transferred to a rehabilitation hospital with residual expressive aphasia. Conclusion: We had a successful case in anesthetic management for surgical repair of atrio-esophageal fistula by preventing massive bleeding as well as multiple air embolization through the fistula.

Surgical Repair with a Pedicled Intercostal Muscle Flap for Intraoperative Injury of the Trachea During Esophagectomy

Surgical Repair with a Pedicled Intercostal Muscle Flap for Intraoperative Injury of the Trachea During Esophagectomy

Successful lung lobectomy for a lung cancer following thoracic endovascular aortic repair for a thoracic aortic aneurysm: report of a case

Lung cancer and a thoracic aortic aneurysm were detected simultaneously in a 79-year-old male patient with diabetes. The aneurysm was first treated by thoracic endovascular aortic repair. A right lower lobectomy was subsequently performed after the blood flow of the bronchial and intercostal arteries was confirmed by computed tomographic angiography. The bronchial stump was covered with an intercostal muscle flap. The patient's postoperative course was uneventful. Thoracic endovascular aortic repair is a useful and less invasive treatment for such cases, but a blood flow evaluation of the aortic branches should be done following this procedure before a lung resection is considered.

Comparison of non-divided intercostal muscle flap and intercostal nerve cryoanalgesia treatments for post-oesophagectomy neuropathic pain control

Oesophagectomy is at present considered to be the optimal curative treatment for patients with severe oesophageal disease. Postoperative pain, both acute and chronic, plays a significant role in the quality of life for post-oesophagectomy patients. The present study compared the effects of two methods-application of a non-divided intercostal muscle flap (NIMF) and intercostal nerve cryoanalgesia (INC) treatment-in reducing neuropathic pain in post-oesophagectomy patients. From June 2009 to June 2010, a total of 160 patients who underwent posterolateral thoracotomy and oesophagectomy were subsequently recruited to our study and divided into NIMF groups and INC groups at random. Patient follow-up studies were conducted for one year on all the subjects and the resultant postoperative pain, chronic pain, rehabilitation and complication scored were measured and documented. INC treatment was more time-intensive than NIMF treatment (P < 0.05). Also, additional chest tube drainage and subsequent extubation were often necessary in the INC group (P < 0.001). No statistically significant differences were found between the two groups regarding the number of subjects who required oral medication one month postoperative with respect to pain score. The chronic pain level, as well as the number of patients requiring oral pain medication, increased significantly by the sixth month following operation and notably increased until the 12th postoperative month in the INC group (P < 0.05). Both NIMF and INC treatments were effective and safe for the treatment of acute pain after oesophagectomy. NIMF was the better technique in reducing chronic postoperative pain.

Intramural bronchogenic cyst of the oesophagus.

Bronchogenic cysts are relatively common mediastinal cysts. Here, we report removal of a rare paraoesophageal-type bronchogenic cyst by video-assisted thoracoscopic surgery in a 52-year-old male patient. The defect of the oesophageal wall was successfully reinforced with an intercostal muscle flap.

The role of intercostal nerve preservation in pain control after thoracotomy†

Pain control after thoracotomy is an important issue that affects the outcome in thoracic surgery. Intercostal nerve preservation (ICNP) has increased interest in the outcomes of conventional thoracotomy. The current study critically evaluates the role of preservation of the intercostal nerve in early and late pain control and its benefit in patients undergoing thoracotomy. Data obtained prospectively between January 2006 and December 2010 by a study colleague at our division of General Thoracic Surgery were retrospectively analysed. There were 491 patients who underwent thoracotomy. Eighty-one patients were excluded from the study due to incompatible data. Patients were divided into two groups according to the intercostal nerve state: Group I consisted of patients with ICNP and Group II consisted of patients with intercostal nerve sacrifice. Group I consisted of 288 patients [206 male (71%), P < 0.001, mean age 66 years]. Group II consisted of 122 patients [79 male (64%), P = 0.001, mean age 66 years]. There was less use of opiate in Group I (P = 0.019). Early mobilization of the patients was significantly higher in Group I (P = 0.031). The rate of pneumonia and re-admission to the intensive care unit was higher in Group II (P = 0.017 and 0.023, respectively). The rate of pain-free patients at discharge was significantly higher in Group I (P = 0.028). A 2-week follow-up after hospital discharge showed parasternal hypoesthesia to be more in Group II (P = 0.034). Significant patient contentment in Group I was noticed (P = 0.014). Chronic post-thoracotomy pain (CPTP) was higher in Group II (P = 0.016). ICNP without harvesting an intercostal muscle flap achieves excellent outcomes in controlling acute post-thoracotomy pain and CPTP. ICNP is an effective, simple method to perform, and it should be considered as standard in performing thoracotomy.

Benign esophagorespiratory fistula: a case series and a novel technique of definitive management

Benign esophagorespiratory fistula is a relatively rare condition in adults that poses a technical challenge to manage. This case series describes our experience in the treatment of benign esophagorespiratory fistula in 12 adults. A retrospective review of case records of 12 patients with benign esophagorespiratory fistula was done. There were eight tracheoesophageal fistulae and four bronchoesophageal fistulae. Among them, four fistulae were congenital, one was secondary to corrosive injury, three were due to foreign body (dentures), one was secondary to erosion because of prolonged endotracheal intubation, one was secondary to penetrating trauma, and two were infective in etiology. Of the 12 patients, there were nine males and three females. The mean age of presentation was 30.16 years (range 15-53 years). Nine patients had a definitive surgical intervention. The esophageal end of the fistula was managed by primary closure of the esophageal defect and reinforcement with pleural or intercostal muscle flap or a subtotal esophagectomy. The respiratory end of the fistula was dealt with by primary closure of the defect or by a novel technique of neomembranous airway formation, whereby the tracheal defect was closed with the help of a vascularized patch of the esophageal wall. The technique of this neomembranous airway formation is described in detail, and to our knowledge, this is the first time that this technique is being reported in the English literature. This technique is a novel method for definitive repair and can be considered as an option for repair of esophagorespiratory fistula with large defects.

EComment. Post-pneumonectomy bronchopleural fistula

We read with interest the article by Andreetti et al. regarding the treatment of post-pneumonectomy bronchopleural fistula (PPBPF) by self-expandable stent and we agree that this modality can be in the armamentarium of cardiothoracic surgeons [1]. PPBPF is one of the most serious and lethal complications in thoracic surgery. There are well-known predisposing factors related to this devastating postoperative complication such as extensive bronchial devascularization, right-sided pneumonectomy, long residual bronchial stump, neoadjuvant or adjuvant chemotherapy, regional radiotherapy, diabetes mellitus, steroid therapy, prolonged mechanical ventilation, history of smoking, pre-existing empyema, incomplete resection of cancer at the bronchial margins, decreased albumin levels (less than 3.5 mg/dL), male gender, and technique of bronchial stump closure [2, 3]. From the beginning of thoracic surgery, many different methods have been used to prevent the development of PPBPF [2, 3]. Pedicled pericardial flap or pericardial fat pad, pleura, intercostal muscle, diaphragm, and azygos vein (for right pneumonectomy) have been used as an additional coverage of bronchial stub wound with very good results [2, 3]. Brewer et al. in 1953 were the first ones who reported on their experimental and clinical work on the use of pedicled pericardial fat graft for reinforcement of bronchial closure in patients with pulmonary resection [4]. Taghavi et al. in 2005, in their retrospective study of 96 patients who underwent pneumonectomy (89.2% for primary lung cancer) and had covered bronchial stump with a pedicled pericardial flap, did not notice any evidence of PPBPF during the perioperative and postoperative period (mean follow up 15 ± 21.2 months) [2]. Sfyridis et al. in 2007, in their prospective randomised trial of 70 patients with diabetes mellitus who underwent pneumonectomy and were randomised to have their bronchial stump covered with an intercostal muscle flap or not; found that the group with the covered bronchial stump had a lower incidence of PPBPF (0% versus 8.8%; p = 0.02) and of empyema (0% versus 7.4%; p = 0.05) compared with the group not covered, at a mean follow-up of 18 ± 9.2 months [3]. Endobronchial valves have also been used to good effect in patients with persistent pulmonary air leaks (refractory to other therapy) secondary to alveolopleural fistula and to bronchopleural fistula as well [5]. In conclusion, in high risk patients the consideration of an effective method for covered bronchial stump for the prevention of the development of PPBLF is very important. Therefore, the multidisciplinary approach for the ideal treatment of patients with PBPF should be on an individual basis and is of paramount importance. Conflict of Interest: None declared

Are intracostal sutures better than pericostal sutures for closing a thoracotomy?

A best evidence topic was written according to a structured protocol. The question addressed was to identify which thoracotomy closure method lends itself to the least postoperative pain. Altogether 109 papers were found using the reported search; of which, seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the closure by intracostal sutures with intercostal nerve sparing offers a superior postoperative pain profile for thoracotomy patients when compared with conventional techniques. Up to 1-year follow-up has shown that this technique (avoiding strangulation of the intercostal nerve) leads to lower postoperative pain and analgesic use, better ambulation and a quicker return to daily activities. Three papers (including two randomized trials) found intracostal sutures with intercostal nerve sparing techniques to be superior to conventional methods such as pericostal suture closure. Rib approximation with intercostal nerve sparing was found to be superior to rib approximation without nerve sparing in one study. Two studies associated with the creation of an intercostal muscle flap prior to the insertion of a rib retractor to be associated with significantly reduced postoperative pain. One study described a novel 'edge-closure' technique, comparable to the closure with intracostal sutures without drilling, to be superior to conventional closure with pericostal sutures. Postoperative pain is a significant issue faced by thoracic surgeons both in-hospital and in the longer term where patients may complain of chronic thoracotomy pain. We would therefore recommend that some form of intercostal nerve protection be implemented during thoracotomy opening and closure.

Bronchopleural fistula after lower lobectomy of the right lung following thoracic endovascular aortic repair

A 77-year old male patient was admitted for the treatment of a thoracic aortic aneurysm (TAA) and primary lung cancer. A saccular aneurysm, 4.8 cm in diameter, located in the proximal segment of the descending thoracic aorta and a pulmonary tumour, 3 cm in diameter, located at the right lower lobe, with lymph node swelling, were detected simultaneously. First, a thoracic endovascular aortic repair (TEVAR) was performed for TAA, and then 45 days later, a lobectomy and radical lymph node dissection by open thoracotomy were performed safely for primary lung cancer. The postoperative course was complicated by a bronchopleural fistula (BPF). Massive necrotic changes to the bronchial stump and the intercostal muscle flap were observed during an open window thoracotomy. Both the chronic use of corticosteroids and TEVAR may have been among the predisposing factors for the occurrence of the fistula. The patient died as a result of respiratory failure 68 days after the lobectomy. This is a first case report of a BPF after a staged operation of TEVAR and major lung surgery. We reviewed and discussed the surgical strategy and timing for both the primary lung cancer and the thoracic aortic aneurysm.

A Bronchial Patch-closure Using a Pericardium and Intercostal Muscle Flap for a Patient with Lung Cancer

A Bronchial Patch-closure Using a Pericardium and Intercostal Muscle Flap for a Patient with Lung Cancer

Intercostal Muscle Flap in Post Tuberculous Pneumonectomy: A New Technique

Objective: There are many risk factors for postoperative bronchopleural fistula (BPF), including extensive resection, diabetes, chronic infection, perioperative steroid therapy, preoperative chemotherapy, and radiotherapy, the risk of bronchopleural fistula increases with resection for inflammatory diseases, especially Mycobacterium tuberculosis (MTB). The aim of this study is to evaluate the efficacy and safety of using double pedicled intercostal muscle flaps with dual blood supply to buttress the bronchial stump after pneumonectomy for tuberculous lesions as a prophylactic new technique from post-pneumonectomy BPF. Methods: Between 2007 and 2011, 47 patients with pneumonectomy for post tuberculous lesions in the department of cardiothoracic surgery, Zagazig University Hospital were divided into two groups. Group A: 28 patients with single pedicled intercostal muscle flap used and applied on the bronchial stump after pneumonectomy. Group B: 19 patients with double pedicled intercostal muscle flaps used and applied on the bronchial stump. The mean age of the patients was 42.9 years (range 27 - 67 years) in Group A, 44.8 years (range 36 - 71 years) in Group B. Results: Bleeding in one patient in Group A (3.5%) and two patients in Group B (10.5%); empyema in two patients (7.1%) in Group A only one of them developed bronchopleural fistula; arrhythmias in one patients (3.5%) in Group A and one patient in Group B (5.2%); chylothorax in one patients (3.5%); Chronic chest pain in one patient in Group A (3.5%) and two patients in Group B (10.5%). The mean follow up period was 32.7 ± 12.9 months (range between 3 and 48 months). All patients remained symptom free with no evidence of late bronchopleural fistula in Group B. Conclusions: Double pedicled intercostal muscle flaps with dual blood supply buttressing the bronchial stump is new prophylactic technique from BPF after pneumonectomy for pulmonary tuberculous lesions in high risk patients.

The philosophy of a nerve-sparing thoracotomy closure

We read with interest Bayram and colleagues’ recent article [1] on the randomized trial evaluating a modified thoracotomy closure technique to reduce compression of the intercostal nerve and thereby reduce post-thoracotomy pain. The authors’ report a statistically significant reduction in postoperative pain using this technique. The described procedure is a modification of a technique proposed by Cerfolio and colleagues [2, 3], who harvest the intercostal muscle flap at the beginning of surgery, retract the flap outside the thoracotomy field using a soft Penrose drain, and, at closure, drill holes in the lower rib to avoid compressing the nerve. This approach is theoretically a more attractive concept as it avoids nerve entrapment both by the chest retractor during surgery and the pericostal sutures after closure. Bayram’s technique, on the other hand, does not avoid nerve compression intraoperatively by the chest retractor, and nerve compression at this stage could still cause postoperative neuropathic pain. We have seen Cerfolio’s group perform their procedure with impressive results and are halfway through a randomized trial to evaluate the technique in our unit. Similar to Cerfolio’s group, we retract the harvested flap with a soft drain and this gives unrestricted intrathoracic access.

Unilateral Pulmonary Artery Agenesia Complicated by Massive Haemoptysis in An Adult Female

Isolated unilateral pulmonary artery agenesis is a rare congenital abnormality. We report a case of right pulmonary artery agenesis in an adult female without other cardiovascular anomalies. The patient presented with massive haemoptysis four years after the original diagnosis. The patient underwent right pneumonectomy with stapled suture of the main bronchus covered by an intercostal muscle flap. The clinical course was complicated by a bronchopleural fistula one month after the first operation. The fistula was successfully treated with a videothoracoscopic omentoplasty and serratus muscle flap. In these patients the surgical approach can be particularly complex because of the high risk of bleeding from the highly vascularised and extensive adhesions between the lung and the chest wall, associated with hyperplasia of the bronchial and intercostal arterial trees. In spite of these difficulties, access to the pulmonary veins and the main bronchus during pneumonectomy is not challenging.

Chest Wall Reconstruction of Severe Mediastinitis With Intercostal Artery–Based Pedicled Vertical Rectus Abdominis Muscle Flap With Oblique-Designed Skin Pedicle

Recurrent poststernotomy mediastinitis has significant morbidity and mortality. Reconstructive treatment begins with pectoral muscle or omental flaps. When these options are unavailable or inadequate, surgeons resort to internal mammary artery-based vertical rectus abdominis muscle flap. If the internal mammary artery is harvested for coronary artery bypass grafting, surgeons are reluctant to use the muscle for pedicled flap because of the elevated risks. However, recent reports suggest that if enough time passes for intercostal artery collaterals to develop, they would support the viability of the flap. Moreover, recent improvements in defining flap microvasculature and proposed surgical techniques have enabled us to further refine the procedure. Although it appears that the intercostal artery-based pedicled vertical rectus abdominis muscle flap with oblique-designed skin pedicle is safe and effective for chest wall reconstruction, potential for failure remains elevated until sample size accumulates.