Intercostal pedicle flap for thoracic oesophageal perforations

Aorto-esophageal fistula: successful open surgical management of two cases

An aorto-esophageal fistula (AEF) is a rare yet life-threatening cause of upper gastrointestinal bleeding. We report our experience with open surgical management of two cases of AEF. Both cases presented with almost identical presentations: hematemesis and hemodynamic instability. The aorta in the first patient was normal; the defect was small and was repaired with a Dacron patch. The second patient had an aneurysmal aorta, which was replaced with a Dacron graft. Both cases were performed under partial bypass. The esophageal rent in both patients was debrided, primarily closed and buttressed with a vascularized intercostal pedicle. Nonavailability of endovascular personnel and equipment along with hemodynamic instability of the patient influenced our surgical strategy. Long-term follow-up of these patients is necessary to analyze the outcomes of our surgical repair.

An unusual case of intercostal muscle flap ossification mimicking an intrathoracic rib

We present a unique case of intercostal muscle flap (ICMF) ossification mimicking an intrathoracic rib diagnosed 3 years after oesophageal perforation repair. A 58-year-old male presented with complaints of mild chest discomfort. Three years ago he had undergone left thoracotomy and primary repair of post-emetic oesophageal perforation. An ICMF had been used to strengthen the repair. Chest X-ray identified a linear calcific density within the left hemithorax. Subsequent thoracic CT characterized the anomaly as ossification of the ICMF. The lesion had the appearance of a well-differentiated intrathoracic rib coursing through the left lower lobe. We discuss the typical appearances of ossified ICMFs and the potential complications resulting from this ossification.

Pedicle Muscle Flaps in Intrathoracic Cancer Resection: Imaging Appearance and Evolution

Pedicle muscle flaps that are used to enhance surgical site integrity after thoracic cancer resections may simulate a recurrent mass at postoperative imaging. However, such flaps have a characteristic appearance and location that should allow their differentiation from a solid mass or fluid collection. The location and appearance of a flap depend on the type of muscle used (whether intercostal, serratus anterior, or latissimus dorsi) and the extent of resection. The appearance also varies according to the presence and amount of fat and calcification in the flap. Most flaps have fat strands along the flap axis that increase in size over time. Linear areas of calcification also may occur because of the inclusion of periosteum in a flap, or more extensive calcification may lead to ossification over time. Uncomplicated flaps do not show substantial radionuclide uptake at positron emission tomography (PET), but areas of extensive calcification may show increased uptake similar to that in bone. Vessels also may be seen within a flap, particularly if the flap has a high fat content; and enhancing vessels frequently are evident at contrast material-enhanced computed tomography (CT). The magnetic resonance (MR) imaging characteristics of flaps are similar to those of normal fat and muscle. Although CT is the modality most often used for follow-up imaging, PET or MR imaging may be helpful in cases in which the CT findings are questionable.

The radiologic appearance of intercostal muscle flap

BACKGROUND

The intercostal muscle flap (ICMF) is commonly used in airway and esophageal surgery to reinforce an anastomosis or site of closure. These flaps undergo heterotopic ossification that may result in stenosis of adjacent airways or the esophagus. We evaluated the computer tomography (CT) scan, technetium-99m-methylene diphosphonate bone scan and positron emission tomography with 2-[18F]-fluoro-2-deoxy-D-glucose (FDG-PET) findings of ICMF and the frequency of airway or esophageal stenosis.

METHODS

A retrospective review was made of the radiologic records of 23 patients (9 women, 14 men) who underwent ICMF. The CT scans were obtained a mean of 36 months (range, 1 week to 58 months) after surgery and the size, morphology, and density of the ICMFs were recorded. Correlative bone scan in 13 patients and FDG-PET scans in 11 patients were reviewed.

RESULTS

A discontinuous, thin, linear calcified stripe or parallel stripes (mean thickness, 4 mm; mean density, 430 Houndsfield unit [HU]) were present in all patients on CT. The flap contained fat density (mean, -59 HU) in 18 patients and soft tissue density (mean, 41 HU) in 8 patients and measured about 1 cm in thickness. The appearance of ICMF is characteristic when the ossification extends from the posterolateral chest wall to an adjacent bronchial stump. There was no increased uptake on bone scan or FDG-PET scan. None of the patients had airway or esophageal stenosis.

CONCLUSIONS

The ICMF manifests on CT as a thin, linear calcified stripe or parallel stripes with central fat or soft tissue density. Airway stenosis due to ICMF is likely quite rare. We did not detect any airway stenosis.

Closure of bronchopleural fistula after pneumonectomy with a pedicled intercostal muscle flap

OBJECTIVES

The value of the pedicled intercostal muscle flap for the closure of postpneumonectomy bronchopleural fistulas was studied retrospectively.

METHODS

Bronchopleural fistula was suspected in case of fever, cough, putrid or haemorrhagic expectoration, in combination with a rise of WBC and CRP. Fistula diagnosis was established bronchoscopically. Two patients underwent an initial trial of bronchoscopic sealing, the rest were reoperated immediately after fistula diagnosis. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection, WBC and CRP were controlled. Age, side, sex, histology, TNM-stage, duration of hospital stay after fistula diagnosis (days), duration of treatment (defined as the duration of chest tube drainage in days after operation), total hospital stay (including the initial hospital stay for primary resection and the hospital stay for fistula treatment in case of readmission), fistula size (mm), interval (days) between primary operation and fistula formation, and bacteriology were recorded.

RESULTS

Eight patients (seven male) were treated. Age ranged from 46 to 70 years (mean 57.86). Six fistulas were located on the right side. All patients had non small cell lung cancer. Interval ranged from 2 to 72 days (mean 26.9 days). Fistula size ranged from 1 to 7 mm (mean 3.43). Seven fistulas were successfully closed. Duration of treatment lasted from 15 to 28 days in those patients treated successfully (mean 17). Hospital stay ranged from 15 to 31 days (mean 24.4). In one patient the flap became necrotic, he was successfully treated with total thoracoplasty. One patient died on the 38th day after rethoracotomy due to aspiration pneumonia. At postmortem examination the bronchial stump was closed.

CONCLUSION

The use of the pedicled intercostal muscular flap is an efficient method for the closure of bronchopleural fistula after pneumonectomy.

Median sternotomy and use of a pedicled sternocleidomastoid muscle flap in the management of recurrent tracheoesophageal fistula

Recurrent tracheoesophageal fistula may complicate primary repair of congenital tracheoesophageal fistula. Standard treatment involves repair via a right lateral thoracotomy and use of adjacent soft tissues to separate the suture lines of the fistulous openings. The authors describe an alternative approach via a median sternotomy, which improves access, reduces the operating time required to identify the recurrent fistula, and enables the use of a pedicled sternocleidomastoid muscle flap to decrease the risk of refistulization.