Chest Wall Flaps

DOI: 10.1016/S0003-4975(10)63596-5 1978;25:491-499 Ann Thorac Surg

John R. Hankins, John E. Miller and Joseph S. McLaughlin Experience with 21 Patients

The Use of Chest Wall Muscle Flaps to Close Bronchopleural Fistulas:

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ORIGINAL ARTICLES

The Use of Chest Wall Muscle Flaps to Close Bronchopleural Fistulas: Experience with 21 Patients John R. Hankins, M.D., John E. Miller, M.D., and Joseph S . McLaughlin, M.D.

ABSTRACT Nineteen patients with bronchopleural fistulas associated with tuberculosis and 2 patients with fistulas following resection for bronchiectasis underwent closure of the fistulas with pedicled flaps of chest wall muscle. The muscle grafting was com- bined with a limited thoracoplasty in 13 patients. The initial myoplasty produced prompt fistula closure in 15 patients and delayed closure in 2 others. A repeat myoplasty was successful in 2 patients in whom the initial myoplasty failed. Compared with other methods of treating bronchopleural fistulas used during the same period, muscle grafting carried a higher rate of successful fistula closure and a lower mortality rate.

A number of techniques have been advocated to control persistent bronchopleural fistulas. Scarifying agents, radium implants, cauteriza- tion, packing, and inversion with pursestring suture have all been used with varying degrees of success [5,7]. Pedicled flaps or grafts of chest wall muscle (myoplasties) were introduced by Abrashanoff [ll in 1911 and have proved to be an effective means of closing such fistulas. This report describes our experience over a 13-year period with the treatment of persistent bronchopleural fistulas by myoplasty.

Material and Methods

Twenty-one patients with bronchopleural fistulas underwent a total of 23 muscle flap procedures at the Thoracic Surgical Services of the Mt. Wilson State Hospital for Pulmonary Dis- ease and the University of Maryland Hospital from 1963 to 1976. These patients ranged from 19 to 64 years old with a median age of 48 years. Thirteen were white and 8 were black; there were 12 men and 9 women.

From the Division of Thoracic and Cardiovascular Surgery, University of Maryland School of Medicine, Baltimore, MD.

Presented at the Twenty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Nov 3-5, 1977, Marco Island, FL.

Address reprint requests to Dr. Hankins, University of Maryland Hospital, Baltimore, MD 21201.

Nineteen patients had active pulmonary tuberculosis (Table 1). A fistula developed following pulmonary resection in 15 of these 19 patients. The following types of resection were employed: pneumonectomy in 1 patient, lobectomy in 4, bilobectomy in 1, lobectomy plus segmental or wedge resection in 6, segmental resection in 2, and subsegmental resection in 1. For 7 of these patients, sputum cultures were positive for Mycobacterium tuberculosis at the time of resection. Bronchopleural fistula and empyema from spontaneous rupture of tuberculous cavities into the pleural space developed in 2 patients. Initial treatment, consisting of pleuropneumonectomy in 1 of these patients and decortication in the other, failed to resolve these fistulas. One patient was admitted with a fistula after having undergone rib resection and later decortication at another hospital for an empyema in which the underlying tuberculous cause was not suspected. In the remaining patient a fistula developed that was accompanied by sputum positive for M . tuberculosis 21 years after a Lucite sphere plombage. She had been asymptomatic for more than 20 years.

In 2 patients who formerly had had tuberculosis but in whom the disease was no longer active, the fistula occurred following pulmonary resection for posttuberculosis bronchiectasis. These resections were lobectomy plus segmental resection in 1 patient and segmental resection in the other.

Among the 17 patients in whom the time of onset of the fistula could be determined accurately, the interval between onset and myoplasty ranged from just under 3 months to 10 years, with the median interval being 6 months. The time interval was difficult to de- termine in 4 patients in whom fistulas developed before they were admitted to our in- stitutions.

Preoperative Evaluation and Preparation Specimens were taken from the empyema space, and cultures for M . tuberculosis, fungi,

491 0003-497517810025-0602$1.25 @ 1978 by John R. Hankins


492 The Annals of Thoracic Surgery Vol25 No 6 June 1978

Table 1 . Underlying Disease or Condition Associated with Bronchopleural Fistula in 21 Patients

Disorder No. of Patients

Tuberculosis Resection Decortica tion Plombage Intrapleural cavity

rupture Bronchiectasis

Resection

19 15a 1 1 2

2b

"The following types of resection were performed in these patients: pneumonectomy in 1, lobectomy in 4, bilobectomy in 1, lobectomy plus segmental or wedge resection in 6, segmental resection in 2, and subsegmental resection in 1.

patient underwent lobectomy plus segmental resection and the other, segmental resection.

and pyogenic organisms were grown. In 3 patients M. tuberculosis was grown from the empyema fluid. Sensitivity studies indicated the need for a change in the antimicrobial regimen before an attempt was made to close the fistula. Sensitivity to antibiotics also was determined for the pyogenic organisms found in the cavities, and appropriate antimicrobial agents instituted. Pseudomonas aeruginosa, Proteus, and Staphylococcus were among the more frequent organisms encountered.

Bronchoscopy was routinely performed to rule out tuberculous endobronchitis and to check for excessive length of the bronchial stump.

Sinograms were made for the majority of the patients to confirm the diagnosis of fistula, to identify the offending bronchus, and to deter- mine the size and adequacy of dependent drainage of the empyema cavity.

Bronchography was not routine. At times it provided useful information about the length and condition of the bronchus giving rise to the fistula or about the remainder of the bronchial tree in the affected lobe or lung.

Pulmonary function tests were carried out when possible. At times it was necessary to temporarily occlude the cutaneous opening of the fistula to obtain accurate spirometry. Poor

pulmonary function was an indication to avoid thoracoplasty if possible or at least to limit the number of ribs that were removed in conjunction with the myoplasty.

Myoplasty was not considered an emergency procedure. It was performed only when the active infection in the cavity was under control and the patient was in optimal nutritional condition.

Operative Management The presence of a fistula creates special prob- lems for the anesthesiologist. The loss of anes- thetic gases and oxygen through the fistula and drainage of infected material from the empyema cavity through the fistula into the dependent part of the tracheobronchial tree con- stitute real hazards. Although there are some advantages in the use of double-lumen endotracheal tubes, these have the disadvantages of being difficult to position accurately and of having such narrow lumens that thick secretions cannot be readily removed through them. We prefer to occlude the fistula by tight gauze packing of the sinus tract during the initial stages of the procedure. After the sinus tract has been dissected down to the bronchus, the latter can be occluded by temporary sutures. In this way a single-lumen endotracheal tube can be used with impunity in most instances.

In the majority of patients in this series, the operative approach was simply a reopening of the previously made posterolateral thoracotomy. When a thoracoplasty was to be included with the myoplasty, the posterior end of the incision was extended cephalad almost to the level of the first rib. If it was anticipated that the pectoralis major or pectoralis minor muscle would be used, the incision was extended anteriorly.

The incision was developed through the extracostal muscles down to the ribs. The fistula tract was excised from the skin opening down to the point where the tract passed through an intercostal space. When a thoracoplasty was performed, the upper 3, 4, or 5 ribs were resected subperiosteally, the number being determined by the size of the empyema space as shown on the sinogram (Table 2). A thoracoplasty concomitant with myoplasty was per-


493 Hankins, Miller, and McLaughlin: Chest Wall Muscle Flaps to Close Bronchopleural Fistulas

Table 2 . lndications for Myoplasty in 21 Patients I ) , I '

Indication No. of Patients

Failure of previous thoracoplasty

Anticipated thoracoplasty failure

To obviate thoracoplasty

5

11

5

Table 3 . Thoracoplasty or Unroofing of Empyema Performed in Conjunction with 23 Myoplasties

Procedure No. of Procedures

Limited, first-stage 11

Second-stage thoracoplasty 3

Unroofing (removal of short 9a

thoracoplasty

(after previous thoracoplasty)

segments, 1 to 3 ribs) ~ ~~ ~

"Performed because of thoracoplasty failure in 4 instances and to obviate thoracoplasty in 5 instances.

formed in 11 patients (Table 3). In resecting these ribs, great care was taken to preserve at least two intercostal muscles and their associated intercostal vessels for use as pedicled grafts (Fig 1). The periosteum from the ribs on either side and the underlying parietal pleura were left on the muscles to help ensure integrity of the intercostal vessels. Each muscle was di- vided anteriorly near the costochondral junc- tion and thus remained based on a posterior pedicle. In patients in whom a thoracoplasty had been performed previously and in those in whom a thoracoplasty was to be avoided, short segments of 1 to 3 ribs overlying the empyema cavity were resected to unroof it. In these situa- tions the intercostal muscles on either side of the resected ribs were again preserved for use as grafts.

The empyema cavity was thoroughly exposed and unroofed, but extensive mobilization of the surrounding lung was avoided to prevent seri- ous air leakage. The cavity was cleansed of any necrotic or purulent material and the infected granulation tissue lining was removed by curet- tage.

Fig I. Method of developing and transferring to the bronchus an intercostal muscle graft.

The bronchus from which the fistula originated was dissected away from the wall of the empyema cavity and, where possible, up to the main airway from which it originated-that is, to the trachea in the case of a postpneumonectomy fistula or to the main bronchus for a post- lobectomy fistula. An excessively long bronchial stump, even though securely sutured, predisposes to recurrence. After reamputation, the bronchus was closed with interrupted nonabsorbable sutures.

The muscle flap was tacked over the stump using the ends of the bronchial closure sutures passed through the flap, plus additional tacking sutures around the edges as indicated (Fig 2). Finally, the muscle graft was sutured to the walls of the empyema cavity to ensure that it would remain in place and fill the cavity as completely as possible.

It was possible to carry out the foregoing technique-that is, dissection of the bronchus with or without reamputation, followed by suture closure and muscle flap reinforcement of the closure-in 14 of the 23 myoplasties, or in 12 of the 21 patients (Table 4). In 3 patients it was not possible to dissect the bronchus sufficiently to allow suture closure, either because too short a stump remained or because of dense scarring. In these instances, the muscle graft was sutured to the stoma of the bronchus with


494 The Annals of Thoracic Surgery Vol 25 No 6 June 1978

Fig 2 . Technique of suture closure and muscle f l a p coverage used when the bronchial stump can be dissected. lnset shows cross-sectional view.

interrupted sutures in such a way as to occlude it (Fig 3).

In 4 other patients the bronchial fistulas were multiple, in some instances resembling a sieve. Here a combination of the two methods was used. The larger openings were closed by suture and then covered by the muscle flap, while the smaller ones were occluded by tacking the same flap over them. In 1 patient who had had a prolonged air leak in association with an empyema, the fistula could not be found after the empyema cavity was opened. The fistula also could not be located in a patient with postpneumonectomy empyema, although the preoperative bronchogram had clearly demon- strated one. The cavity in both patients was simply filled with the muscle flap.

Table 4 . Method of Management of Bronchus in 23 Myoplasties

No. of Method Procedures

Suture closure plus covering 14 with muscle flap

bronchus Flap sutured over open 3

Combination procedurea 4 Fistulous opening not 2

located (muscle used to fill empyema cavity)

~ ~

aMultiple fistulas present: some sutured closed then covered with flap, others simply covered with flap.

It is essential that the muscle flap completely fill the empyema cavity. If one or two intercostal muscle grafts did not suffice, then other muscles in the vicinity of the thoracotomy, such as serratus anterior, latissimus dorsi, or sacro- spinalis, were used (Table 5). The muscle that is



Fig 3 . Technique of occluding the open bronchus wi th the muscle f lap , used when the bronchus cannot be dissected sufficiently for direct suture closure. Inset shows cross-sectional v i e w .

used must have an adequate blood supply and sufficient length to reach the fistula without tension. To allow for a certain amount of shrink- age and contracture, we believe that the length of the flap should be at least four times its width. In this series intercostal muscle alone was used in 14 operations and a combination of intercostal and extracostal muscles in 5 others. In 4 myoplasties the intercostal muscles could not be used because of excessive scarring, and extracostal muscles alone were used. One drainage tube was left within the empyema cavity but superficial to the graft. If a thoracoplasty was performed in conjunction with the myoplasty, the second tube was left in the subscapu-

I

(,

Table 5 . Types of Muscle Used in 23 Myoplasties ~~

Type of Muscle Used No. of Procedures

Intercostal muscles only 14

Both intercostal and 5 Extracostal muscles only 4

extracostal muscles

lar space. If extensive dissection of the lung was required, the second tube was left intrapleu- rally. Air leakage from the chest tubes continued for at least several days postoperatively in nearly all patients and was assumed to be due to superficial tears in the lung resulting from the dissection. In 1 patient the air leak continued for more than 3 months but eventually ceased. Drainage of exudate from the tube that had been left in the empyema cavity declined



Table 6 . Results of 23 Myoplasties in 21 Patients

Outcome No. of Patients

Successful closure Partial successa Failure

15 2 4 b

aEmpyema cavity and fistula reduced in size; ultimate closure occurred after hospital discharge. "Includes 1 hospital death; 2 patients whose fistulas were successfully closed by subsequent myoplasties; and 1 closed by second stage thoracoplasty.

more gradually. Generally, this tube was han- dled as an empyema tube. It was cut off after approximately three weeks and the space was allowed to fill with granulation tissue. This required usually 1 to 3 months, but in 2 patients 4 and 6 months, respectively, were required before final tube removal.

Results Myoplasty was considered successful if the fistula was obliterated and chest tubes could be removed without further operative interven- tion. By these criteria the myoplasty was successful initially in 15 of the 21 patients (Table 6, Fig 4).

In 2 patients myoplasty was only partially successful. Although the fistulas eventually closed without reoperation, the closure took an inordinately long time. Myoplasty reduced the size of both the empyema space and the fistula, allowing the patients to be discharged with empyema tubes in place. In 1, the air leak ceased after 4 years and the tube was removed 3 months later. The other patient was readmitted 4% months postoperatively with a severe head injury which proved rapidly fatal. At the time of readmission the chest tube was still in place but there was no mention of air leakage.

In 4 patients the myoplasty failed to close the fistula. In 2, repeat myoplasties after intervals of 2 and 13 months, respectively, brought about closure. The reason for primary failure in 1 of these patients was probably an excessively long bronchial stump, but there was no apparent cause in the other. The third patient was admitted with a destroyed right lung accompanied by positive sputum cultures and a bronchopleural

fistula. A pleuropneumonectomy was performed but a fistula again followed. Although the sputum was still positive, a myoplasty com- bined with a 5-rib thoracoplasty was performed, but this again was followed by recurrence. Two weeks later a second thoracoplasty with removal of an additional 3% ribs was carried out and resulted in prompt closure of the fistula. The fourth patient had severe chronic lung disease, which led to respiratory failure after the myoplasty. Tracheal intubation with mechanical ventilation was required, and this undoubtedly contributed to reopening of the fistula and recurrence of the empyema. Ulti- mately, renal failure supervened and led to the patient's death 1 month after the operation.

Comment The development of improved chemotherapy and better suture techniques and materials, as well as use of the automatic stapler, have low- ered the incidence of bronchopleural fistula following pulmonary resection from 28% two or three decades ago [6] to 3% or less in recent years [8, 101. Nevertheless, postresection fistula remains an important problem for the thoracic surgeon. Also, there is a not-insignificant incidence of nonsurgical spontaneously occurring bronchopleural fistula associated with such diseases as lung abscess or empyema [2,10,121. Patients with nonsurgical fistulas comprised 14 (27%) of the 52 patients with fistulas reported by Malave and associates [lo]. Further, the mortality rate from bronchopleural fistula remains high. Twelve, or 23.1%, of those 52 patients died [lo].

Adequate dependent surgical drainage is the sine qua non of the treatment of bronchopleural fistula. But drainage alone results in closure of less than 20% of fistulas [8, 10, 121. In the remainder, further surgical procedures are required. Decortication with revision of the empyema space may at times succeed [lo, 121. For patients with postpneumonectomy fistulas, reamputation of a long bronchial remnant will often effect closure [ll]. But traditionally, the secondary procedures advocated when drainage alone fails have included thoracoplasty first, and if this does not succeed, then either a further thoracoplasty or a further pulmonary re-



C D

Fig 4. Serial chest roentgenograms in a 41-year-old man who underwent right upper and middle lobectomy for cavitary tuberculosis. (A ) On admission. (B) Three weeks postresection, showing a large apical space. (C) Three months postoperatively. Despite adequate tube drainage, the sinogram shows a bronchopleural fistula. ( D ) Seven months after myoplasty and a 4-rib thoracoplasty, the fistula and empyema have both become o blitera ted.



section. However, both of these latter operations sacrifice potentially salvageable lung tissue. Many patients with fistulas have impaired cardiopulmonary function and either fail to survive such operations or become pulmonary cripples. Myoplasty offers the possibility of closing the fistula without excision of additional lung tissue and with the removal of few, if any, additional ribs.

Abrashanoff [l] with his report in 1911 described the use of muscle flaps to close bronchopleural fistulas. In the United States, Eggers [5] in 1920 provided early impetus toward this use, as did Pool and Garlock [13]. The latter authors showed through animal experiments that muscle grafts implanted into bronchial fistulas unite firmly with the interior of the bronchus and become covered by bronchial epi- thelium. Maier and Luomanen [9] in 1949 reported their experience using the pectoralis major muscle after the method of Berry. In 1971, Barker and associates [2] described their mod- ification of this technique. Shenstone [14] in 1936 popularized the use of intercostal muscles as grafts. Demos and Timmes [4] reported in 1973 their use of this muscle, as did Delarue and Gale a year later 131.

We believe that myoplasty is indicated when a fistula persists despite adequate drainage and an adequate thoracoplasty (see Table 2) [21. This was the indication in 5 patients with postresection fistulas in our series, 4 of whom had undergone a thoracoplasty before resection and 1, a thoracoplasty concomitant with resection.

We believe a second indication for muscle grafting is anticipated failure of a thoracoplasty. An additional surgical procedure can be avoided if those patients in whom thoracoplasty alone is likely to fail are identified and undergo myoplasty as a supplement to the thoracoplasty. Experience has shown that a conventional 5-rib thoracoplasty is unlikely to obliterate a fistula that follows a pneumonectomy or a large Lucite sphere plombage or, in certain instances, an upper lobectomy and superior segmentectomy. The addition of myoplasty to the thoracoplasty in patients with such large empyema cavities usually makes it possible to obliterate both the cavity and the fistula by resection of fewer ribs than would

otherwise have been necessary. Thus pulmonary function is conserved. Because of the anticipated failure of thoracoplasty alone, myoplasty concomitant with limited, first-stage thoracoplasty was performed in 11 patients.

In 11 of the 17 patients reported by Barker and co-workers [21 a thoracoplasty preceded the myoplasty. The initial myoplasty was successful in 14 of the 17 patients. One patient died. But the average interval between the onset of the fistula and myoplasty was 40 months. Whereas the two series are not entirely similar in other respects, we think the results in our 11 patients who underwent concomitant. myoplasty and limited, first-stage thoracoplasty compare favorably with those of Barkers series. If the 2 patients who were admitted with fistulas of 6 and 10 years duration, respectively, are excluded, the average interval from onset of fistula to myoplasty in our patients was only 6 months. None of the patients died, and although myoplasty failed initially in 3 patients, all 3 subsequently achieved successful closure through other operations after intervals rang- ing from 1 to 17 months.

It could be argued that in some of these 11 patients, fistula obliteration would have occurred with thoracoplasty alone. This will remain a moot point. Nevertheless, the addition of myoplasty to thoracoplasty did not increase the operative mortality. It appears to have saved at least some of the 11 patients an additional operation. And it considerably reduced hospital stay.

A third indication for myoplasty is the situa- tion in which a myoplasty would likely obviate the need for a thoracoplasty altogether. In patients with a fistula associated with a small empyema space below the level of the posterior end of the fifth rib, such as may occur after a lower lobectomy, myoplasty alone will often successfully obliterate the fistula and the space. Moreover, it will do so with far less com- promise of pulmonary function than would occur if enough ribs were removed to collapse such a space. Five of the myoplasties in the present series were performed for this indication.

It is interesting to assess the results in the 21 patients treated by myoplasty in relation to those in 52 other patients with bronchopleural



fistula treated by other methods during the same period. The two groups are not necessar- ily comparable to the point of statistical valid- ity, and some-selection of the more favorable cases may have occurred in the myoplasty group. Conversely, the nonmyoplasty group contained 9 patients whose fistulas healed after surgical drainage alone. Ultimate fistula obliteration occurred in 17 of the 21 patients in the myoplasty group, but in only 27 of the 52 patients in the other group. One of the myoplasty group and 15 of the other group died. The high rate of fistula closure and the low mortality rate associated with myoplasty encourage us to con- tinue using the procedure in patients in whom it is indicated.

References

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11. Abrashanoff: Plastische Methode zur Schlieszung von Fistelgangen Welche von inneren Organen Kommen. Zentralbl Chir 38:186, -1911 Barker WL, Faber LP, Ostermiller WE Jr, et al: Management of persistent bronchopleural fistulas. J Thorac Cardiovasc Surg 62:393, 1971 Delarue NC, Gale G: Surgical salvage in pulmonary tuberculosis. Ann Thorac Surg 18:38, 1974

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Demos NJ, Timmes JJ: Myoplasty for closure of tracheobronchial fistula. Ann Thorac Surg 15:88, 1973 Eggers C: The treatment of bronchial fistulae. JAMA 72:345, 1920 Floyd RD, Hollister WF, Sealy WC: Complica- tions in 430 consecutive pulmonary resections for tuberculosis. Surg Gynecol Obstet 109:467, 1959 Keller WL: The treatment of bronchial fistulas. JAMA 81:1006, 1923 Kirsh MM, Rotman H, Behrendt DM, et al: Com- plications of pulmonary resection. Ann Thorac Surg 20:215, 1975 Maier HC, Luomanen RKJ: Pectoral myoplasty for closure of residual empyema cavity and bronchial fistula. Surgery 25:621, 1949 Malave G, Foster E, Wilson JA, et al: Broncho- pleural fistula-present-day study of an old problem. Ann Thorac Surg 11:1, 1971 McLaughlin JS: Discussion of Barker et a1 [2] McLaughlin JS, Hankins JR: Current aspects of surgery for pulmonary tuberculosis. Ann Thorac Surg 17:513, 1974 Pool EH, Garlock JH: A treatment of persistent bronchial fistula. Ann Surg 90:213, 1929 Shenstone NS: The use of intercostal muscle in the closure of bronchial fistulae. Ann Surg 104:560, 1936


DOI: 10.1016/S0003-4975(10)63596-5 1978;25:491-499 Ann Thorac Surg

John R. Hankins, John E. Miller and Joseph S. McLaughlin Experience with 21 Patients

The Use of Chest Wall Muscle Flaps to Close Bronchopleural Fistulas:

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