Intrathoracic Defects Research Articles

Robotically-harvested, thoracoscopically-tunneled transdiaphragmatic omental pedicle flap for obliteration of radiated empyema cavity

Intra-thoracic defects continue to pose a challenge for the reconstructive surgeon. Stable soft tissue coverage and obliteration of dead space can be particularly challenging when complicated by infection or previous radiation. These cases may require a less conventional method of reconstruction. We describe a case in which vacuum-assisted closure followed by pedicled omental flap transposition was successfully used to reconstruct a complicated intra-thoracic wound following pneumonectomy, radiation therapy, and recurrent wound dehiscences secondary to chronic infection.

Muscle flaps in pulmonary infections: a case series from Northeast India

Treatment of complications due to pulmonary infections usually involves lung resection with or without debridement. Managing residual intrathoracic defects, chronic empyema, and bronchopleural fistulae after such resections poses unique challenges. We retrospectively reviewed the data of all 9 patients referred to us with complications due to pulmonary infections, including the surgical procedures, flaps used, and their outcomes between 2018 and 2019. The mean age of the patients was 30 years (range 9?48 years). The primary disease was tuberculosis in 6 (66%) patients. Complications of primary infections were pneumothorax (n = 3), auto-pneumonectomy (n = 2), organized empyema (n = 3), and recurrent hemoptysis (n = 1). Initial interventions included lobectomy (n = 2), tracheoesophageal repair (n = 1), bronchial artery embolization (n = 1), intercostal tube drainage (n = 4), and decortication(n = 1). Complications after primary interventions included bronchopleural fistula (n = 4, 45%), recurrent empyema (n = 3, 33%), tracheal stump dehiscence (n = 1, 11%) and non-resolving hemoptysis (n = 1, 11%). Pathological microorganisms were isolated in 8 (88%) patients. Secondary corrective surgical interventions along with pedicled muscle flap interposition and reinforcement were undertaken. Nine flap procedures with or without thoracoplasty were performed. There was no open thoracostomy conversion. There was one death postoperatively. A locoregional pedicled flap with or without thoracoplasty is an effective option to manage complications of pulmonary infections. The cardiothoracic surgeon should have a knowledge of the locoregional flaps of the thorax and abdomen to address such complications.

Adult-Type Intrathoracic Xanthogranuloma: Excision and Reconstruction Using a Latissimus Dorsi Muscle Flap

Adult-Type Intrathoracic Xanthogranuloma: Excision and Reconstruction Using a Latissimus Dorsi Muscle Flap

Management of Intrathoracic Defects

Intrathoracic defects continue to provide one of the most challenging problems faced by the reconstructive surgeon, particularly in the presence of bronchopleural fistula. We review the principles of management of bronchopleural fistulae and empyema, with an emphasis on the Clagett principle, pedicled and free muscle flaps, and the concept of a "designed air fistula" in bronchopleural fistula management. Although the importance of muscle flap closure in intrathoracic defects is undisputed, the timing and relative superiority of muscle flap closure versus conventional thoracic-surgical techniques remains an unanswered question.

Thoracodorsal versus reversed mobilisation of the latissimus dorsi muscle for intrathoracic transposition☆

The objective of our study is to perform a comparative analysis of the mobilisation of latissimus dorsi (LD) muscle flap using the primary versus secondary blood supply. Between 1 January 2003 and 1 March 2009 we used the LD muscle flap in 57 patients with different intrathoracic suppurations; these patients were divided according to the blood supply used for flap mobilisation. Group A consists of 26 patients in whom the LD was mobilised based on the thoracodorsal vessels (alone in eight patients, in combination with other flaps in 18 patients). Group B consists of 31 patients in whom the LD was mobilised based on the perforator branches from the last intercostals and lumbar vessels (alone in nine patients, in combination with other flaps in 22 patients). Statistical analysis was performed using the GraphPad Prism 5 and EpiInfo 3.5.1 for Windows software. The two groups were similar in age, sex distribution, incidence of tuberculosis, bronchial fistula, postoperative empyema and co-morbidities (p>0.05). We found no statistically significant difference between group A and group B in terms of operative time group (176 ± 33 min vs group B 170 ± 40 min), mortality (4% vs 3%), infection recurrence (8% vs 3%), incidence of minor local complications (8% vs 6%) or hospitalisation 39 ± 16 days versus 41 ± 16 days (p>0.05 for all the parameters). We encountered no significant functional sequelae in any of the 57 patients. Both modalities of mobilisation of the LD muscle flap are safe and allow easy transposition in any part of the chest; the choice of how to use this flap should be made based only on the location of the intrathoracic defect.

Thoracic reconstruction with the omentum: indications, complications, and results.

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.

Intrathoracic Free Flaps

The utility of pedicled muscle flaps transposed into the thoracic cavity to reconstruct complex intrathoracic defects has been well documented. However, in some patients, local chest-wall muscles have already been either sacrificed or transected by previous thoracotomies and are not available for reconstruction. In these patients, we have successfully employed microvascular techniques to transfer distant muscle flaps into the thoracic cavity. Seven patients with complex intrathoracic defects were reconstructed with three latissimus dorsi, one omental, and three rectus abdominis free flaps. In each case, the microvascular anastomosis was extrathoracic, with the flap transposed into the thoracic cavity. Each of the flaps was revascularized successfully. Four of the five bronchopleural fistulas were sealed, with the remaining patient continuing to demonstrate a reduced but persistent air leak. No infections were encountered, and each flap transfer resulted in a healed wound. When local muscle flaps are not available to reconstruct complex intrathoracic wounds, microvascular transfer of distant muscle flaps can provide abundant well-vascularized tissue for reconstruction of any portion of the thoracic cavity. Versatility is afforded in flap selection and recipient vessel site location, making this technique an important option in the treatment of these difficult wounds.

Pectoralis Major Muscle-Musculocutaneous Flap for Chest-Wall Reconstruction

Pectoralis major muscle and musculocutaneous flaps are the most frequently selected for the ventral chest wall, sternum, and anterior mediastinum because of their proximity, reliability, and versatility. These advantages are derived from consistent anatomic features that allow knowledgeable surgeons to use a variety of flap designs tailored to defect needs. The flaps can be transferred on either thoracoacromial or internal mammary vascular pedicles and can be segmentally split to achieve defect closure while retaining portions of the muscle in situ to preserve donor motor function and surface form. The musculocutaneous paddles can be placed in a variety of locations and extended beyond the muscle borders to meet specific defect needs. This anatomic versatility gives pectoralis major muscle and musculocutaneous flaps a most useful role in the reconstruction of defects of the sternum and anterior mediastinum, defects of the ventral and lateral chest wall, and intrathoracic defects such as empyema cavities and bronchopleural fistula. A detailed knowledge of surgical anatomy is essential for optimal application of these flaps in the full spectrum of clinical needs.

Reconstruction of complex thoracic defects with myocutaneous and muscle flaps: Applications of new flap refinements

This report describes reconstructions of complex thoracic defects with myocutaneous and muscle flaps that were modified by several recent refinements of flap design. These refinements comprise a second generation of myocutaneous and muscle flaps, which have substantially increased versatility and extended applications, as compared with the originally described flaps. These refinements include the following: (1) segmentally split latissimus dorsi and pectoralis major flaps, which transfer only one muscle segment as the flap and leave other segments of the same muscle in situ to preserve motor function; (2) pectoralis major fasciocutaneous flaps, which are extended by abdominal skin and fascia to provide longer, larger flaps; (3) reversed pectoralis major and latissimus dorsi flaps, which are supplied by secondary, distal vascular pedicles that permit flap use when the primary vascular supply is interrupted; and (4) island vascular pedicle muscle flaps, which allow intercostal passage for reconstruction of intrathoracic defects and cavities. The anatomic bases for these flap refinements are described, and the advantages provided are discussed.