Intercostal Pedicle Research Articles

Far-lateral Vascularized Rib Graft for Cervical and Lumbar Spinal Arthrodesis: Cadaveric Technique Description

Background:Rotational vascularized autografts are ideal for achieving spinal arthrodesis because they maintain bony vascularization while avoiding the morbidity and challenges of free-tissue transfer. Although proximal ribs are ideal candidates for vascularized bone grafts, their use is restricted to the thoracic spine. This study describes a novel technique for harvesting lateral rib grafts on an intercostal pedicle for use in cervical and lumbar posterolateral arthrodesis.Methods:Six cadaveric dissections were performed (2 included upper and all 6 included lower rib dissections). Measurements included graft width and thickness, distance reached from harvest level to the top of the graft, and ipsilateral and contralateral spine levels reached by the graft.Results:Overall, 60 lateral rib grafts were harvested. Intercostal vessel pedicles were torn during harvest in 4/48 (8.3%) of the lower rib and 5/12 (41.7%) of the upper rib grafts. Mean measurements of successful upper rib grafts were 1.4 ± 0.12 cm × 0.5 ± 0.15 cm (width × thickness), 14.1 ± 2.79 cm (distance) reached, and C2 (occiput–C4) reached ipsilaterally and C3 (occiput–C5) reached contralaterally. Mean lower rib graft measurements were 1.4 ± 0.26 cm × 0.4 ± 0.15 cm (width × thickness), 18.0 ± 6.19 cm (distance), S1 (L1–S2) reached ipsilaterally, and L4 (L1–S1) reached contralaterally.Conclusions:It is technically feasible to rotate a far-lateral rib graft on an intercostal pedicle into the posterolateral cervical or lumbar spine for the augmentation of arthrodesis. Upper ribs seem to be more difficult to harvest and rotate while keeping the intercostal pedicle intact than lower ribs.

The triangles of Grynfeltt and Petit and the lumbar tunnel: an anatomo-radiologic study.

Lumbar hernias are protrusions of intra-abdominal contents classically through the superior (Grynfeltt) and inferior (Petit) lumbar triangles. The anatomy of the triangles is variable and quantitative data are few. No radiological data on the anatomy of the triangles are available. Fifty computed tomography angiography of the upper abdomen (M25, F25, mean age 72.5-year-old) were analyzed. The dimensions and the contents of the lumbar triangles were analyzed. The characteristics of the space between the two triangles were also documented. The superior lumbar triangle showed a mean surface area of 5.10±2.6cm2. In the area of the triangle, the 12th intercostal pedicle and the 1st lumbar branches of the iliolumbar vessels were found in 42 and 46%, respectively. The inferior lumbar triangle had a mean surface of area 18.7±8.4cm2. In this area, the 2nd, 3rd, and 4th lumbar branches were found in 9, 67, and 8%, respectively. On oblique coronal images, a direct tunnel between the superior and the inferior lumbar triangles was found, showing an oblique course, with a postero-anterior direction (mean length 36.5±5.8mm, mean caliber 7.4±3.1mm). Among the anatomical factors of weakening of the abdominal wall, the course of branches of the lumbar vessels was documented not only in the superior but also in the inferior lumbar triangle. A real musculoaponeurotic tunnel between the superior and the inferior lumbar triangles located in the oblique coronal plane was found, that could play a role in the development of incarceration or strangulation of lumbar hernias.

Face Reconstruction Using Lateral Intercostal Artery Perforator-Based Adipofascial Free Flap

BackgroundThe aim of this study was to determine the efficacy of lateral intercostal artery perforator-based adipofascial free flaps for facial reconstruction in patients with facial soft tissue deficiency.MethodsWe conducted a retrospective study of five consecutive patients diagnosed with facial soft tissue deficiency who underwent operations between July 2006 and November 2011. Flap design included the area containing the perforators. A linear incision was made along the rib, which had the main intercostal pedicle. First, we dissected below Scarpa's fascia as the dorsal limit of the flap. Then, the adipofascial flap was elevated from the medial to the lateral side, including the perforator that pierces the serratus anterior muscle after emerging from the lateral intercostal artery. After confirming the location of the perforator, pedicle dissection was performed dorsally.ResultsDominant perforators were located on the sixth to eighth intercostal space, and more than four perforators were found in fresh-cadaver angiography. In the clinical case series, the seventh or eighth intercostal artery perforators were used for the free flaps. The mean diameter of the pedicle artery was 1.36 mm, and the mean pedicle length was 61.4 mm. There was one case of partial fat necrosis. No severe complications occurred.ConclusionsThis is the first study of facial contour reconstruction using lateral intercostal artery perforator-based adipofascial free flaps. The use of this type of flap was effective and can be considered a good alternative for restoring facial symmetry in patients with severe facial soft tissue deficiency.

Intercostal Artery–Based Rectus Abdominis Transposition Flap for Sternal Wound Reconstruction

The rectus abdominis transposition (RAT) flap is a well-accepted alternative to pectoralis muscle flaps for sternal reconstruction after debridement in poststernotomy mediastinitis. Use of this flap based on an intercostal artery pedicle, after division of the ipsilateral internal mammary artery (IMA), is a less-recognized option for reconstruction, given its less substantial vascular supply. The authors present 15 cases where intercostal artery-based RAT flaps were used for sternal reconstruction over a span of 15 years. They describe patient demographic data, management approaches, surgical techniques, and clinical outcomes. Perioperative flap survival and wound healing was optimal in all cases. One morbidity and 1 mortality were encountered in patients with multiple chronic medical problems. Follow-up demonstrated optimal surgical results and satisfied patients. Our observations suggest that the intercostal artery-based RAT flap is a safe treatment option for sternal reconstruction when pectoralis muscle flaps have failed or do not adequately provide coverage of sternal defects after debridement of the poststernotomy wound.

Advantages of Using Intercostal Vessels as the Recipients for Free Flaps Covering Lumbar Defects

Anatomic conditions in the lumbar region can complicate procedures for covering defects. In particular, a free flap is often required when the defect is large, in which case suitable recipient vessels must be found to insure revascularization. This report concerns a 50-year-old woman with multiple basal-cell carcinomas in the lumbar radiodermatitis zone, who underwent a large resection from D10 to S2. The defect was repaired using a free latissimus dorsi flap revascularized by microvascular anastomosis to the 8(th) intercostal pedicle. The advantages of using these recipient vessels are then considered relative to reports in the literature.

Pneumonectomy for nontuberculous mycobacterial infections

Background Pneumonectomy is considered in the treatment of nontuberculous mycobacterial infections when an entire lung is affected. However, this procedure carries high morbidity. We report on our experience in using pneumonectomy for treating patients with nontuberculous mycobacterial infections. Methods Between 1983 and 2002, 53 patients infected with nontuberculous mycobacteria underwent 55 pulmonary resections. Of these patients, 11 (3 men, 8 women) underwent pneumonectomy (5 right, 6 left). Median age was 57 years (range, 43 to 69 years). Mycobacterium avium complex disease occurred in 10 patients and Mycobacterium abscessus disease in 1. Indications for pneumonectomy included multiple cavities in one lung and destruction of an entire lung. The bronchial stump was covered with a latissimus dorsi muscle flap in 7 patients and with an intercostal pedicle flap in 2. Results Operating time ranged from 142 to 477 minutes (median, 360 minutes). The median intraoperative blood loss was 555 mL (range, 130 to 1,245 mL). There was no operative mortality. Bronchopleural fistula occurred in 3 patients. All fistulas were observed after right pneumonectomy, and were treated by reclosure of the bronchus. Empyema occurred in 1 patient, who was treated with irrigation. All patients achieved sputum-negative status after surgery. Two late deaths occurred. One patient died of respiratory failure 11 months after surgery. A second patient, the only patient who had recurrent disease, died of respiratory failure 4 years postoperatively. Conclusions Despite bronchial stump protection, right pneumonectomy carries a risk for bronchopleural fistula. Nonetheless, pneumonectomy can result in high cure rates in patients with nontuberculous mycobacterial infections.

Control of post-resection gastro-esophageal reflux by intercostal pedicle esophagogastropexy

Control of post-resection gastro-esophageal reflux by intercostal pedicle esophagogastropexy

Protection and revascularization of bronchial anastomoses by the intercostal pedicle flap

We used an improved method for preparation of the intercostal pedicle flap for encircling bronchial anastomoses, and we studied its vascular supply after the operation. The flap was used in 56 patients undergoing various types of sleeve resection and in three patients undergoing single lung transplantation. The technique is simple, fast, and causes neither extra surgical trauma nor complications. It allows satisfactory isolation and sealing of the bronchial anastomosis. Even if complete anastomotic dehiscence occurs (one case), the flap preserves the continuity of the airway, thus avoiding bronchopleural fistulas or other complications. The postoperative arteriographic study of the intercostal artery supplying the flap (performed in 14 patients) demonstrated the full patency of the vessel in all cases. It also showed that a fine vascular network develops around the anastomosis early in the postoperative period.

Lung resection after high doses of mediastinal radiotherapy (sixty grays or more)

Mediastinal radiotherapy of more than 60 Gy highly compromises bronchial and wound healing after lung resection. Nine patients with primary lung cancers underwent radical resection after high radiation doses. Eight patients had primary lung cancer previously treated by radiotherapy alone (n = 2) or associated with chemotherapy (n = 6). One patient had a tracheal cancer involving the carina that was previously treated by radiotherapy. Seven patients underwent pneumonectomy and one patient underwent lobectomy with reinforcement of bronchial stump closure with use of the serratus anterior muscle. One patient underwent a sleeve lobectomy with bronchial reconstruction wrapped with an intercostal pedicle flap. Five patients had no postoperative complications and four patients had empyema, one associated with a small bronchial fistula. All except one patient were successfully treated by thoracostomy and immediate or secondary transposition of the pectoralis major muscle and the omentum to fill the cavity. These results show that lung resections can be done after high doses of radiotherapy without a high rate of bronchial fistula by using thoracic muscle flaps to reinforce bronchial stumps and anastomoses. In this procedure, surgical dissection is more time-consuming and increases the postoperative empyema rate (4/9). However, the higher long-term survival may justify this choice in selected cases.

原発性肺癌手術における有茎肋間筋弁による予防的気管支断端被覆

原発性肺癌手術における有茎肋間筋弁による予防的気管支断端被覆

Myo-osseous intercostal pedicle flaps for tracheal reconstruction in puppies

We evaluated a myo-osseous intercostal pedicle flap for distal tracheal reconstruction. Mongrel puppies, 6 to 10 weeks old, underwent tracheal repair, 12 for primary defects and seven for stenotic lesions created in the distal trachea. A composite flap was constructed from the anterior portion of the fourth rib with the overlying pleura and periosteum and a posteriorly based intercostal muscle/neurovascular pedicle. The animals did well following tracheal reconstruction without evidence of airway obstruction. Bronchoscopy documented normal tracheal diameter and the repair site could not be discerned from the surrounding mucosa. Histologically, there was complete respiratory epithelial ingrowth with no inflammatory changes. The rib graft had active hematopoietic marrow. This work suggests that the myo-osseous intercostal pedicle flap provides a surface for normal epithelial ingrowth of tracheal mucosa without stimulating granulation tissue, interposes a stent capable of growth, therefore minimizing anastomotic stricture, and is an effective alternative in the management of distal tracheal stenosis.

Revascularization of ischemic bronchial anastomoses by an intercostal pedicle flap

Ischemia of the donor bronchus, perfused solely by retrograde collaterals from the pulmonary circulation, is an important factor in the impaired healing of the bronchial anastomosis of transplanted lungs. The healing of two experimental models of bronchial anastomotic ischemia, the bronchial segmental autograft and the postpneumonectomy bronchial autograft, was assessed in dogs. The application of a polytetrafluoroethylene wrap to the bronchial segmental autograft and the application of an intercostal pedicle flap to the postpneumonectomy bronchial autograft, with and without concomitant administration of corticosteroids, were also studied to elucidate factors that affect bronchial anastomotic healing. The bronchial segmental autograft healed normally without stricture, but isolation of this autograft from the mediastinum and lung by the polytetrafluoroethylene wrap resulted in necrosis of the autograft. All dogs that had a postpneumonectomy bronchial autograft died of bronchopleural fistulas due to autograft necrosis. Application of an intercostal pedicle flap to the autograft resulted in healing in all animals. Arteriography and Microfil injection demonstrated revascularization of the postpneumonectomy bronchial autograft by the pedicled intercostal artery. Several conclusions can be drawn: With the lung in situ the bronchial segmental autograft survives, probably as a free composite graft. In contrast, the postpneumonectomy bronchial autograft is an excellent model of bronchial anastomotic ischemia. The intercostal pedicle flap is a reliable method for providing neovascularity and mechanical reinforcement to an ischemic bronchial anastomosis. Its effect on bronchial anastomotic healing was not diminished by administration of corticosteroids. The intercostal pedicle flap may be useful in preventing bronchial anastomotic complications in clinical lung transplantation.

Intercostal pedicle method for control of postresection esophagitis: Thirteen-year clinical study

In attempting to solve the problem of gastroesophageal reflux esophagitis, we tested an experimental technique in 1967. In the past 13 years we have applied that intercostal pedicle method to prevent reflux in 43 patients. Thirty-four patients had esophagogastrectomy and esophagogastrostomy for cancer. Six additional patients underwent palliative, nonresective esophagogastrostomy. In another two patients the lower esophagus was resected for complete full-wall thickness fibrous stricture. One patient had severely symptomatic reflux. Six patients treated by resection for cancer are long-term survivors. The two patients with benign stricture were followed for 2 years and the last patient with severe reflux symptoms was followed for 13 years. History, esophagography, fluoroscopy, and fiberoptic esophagoscopy were used for follow-up in 40 of 43 patients. Motility and pH studies were used for follow-up in 21 instances. There have been no symptoms of regurgitation and reflux. No stricture has been seen though one patient needed a few dilatations for the first 2 years and none in the last 2 years. The esophagogram shows a typical slinglike appearance. The lower esophageal sphincter-like pressure has been as high as 26 mm Hg in the immediate postoperative period, settling to 12 to 15 mm Hg in the long-term follow-up. The pH is definitely alkaline in the esophagus. Competence has also been observed in the only two patients who had an ephemeral anastomotic leak. We recommend the intercostal pedicle technique in all cases of esophagogastrostomy performed in the chest.

Experimental evaluation of intercostal pedicle grafts in esophageal repair

Experimental evaluation of intercostal pedicle grafts in esophageal repair