Pericardial repair after extensive resection: another use for the pedicled diaphragmatic flap

Left upper lobectomy in a patient with congenital pericardial defect

Congenital pericardial defect is an uncommon anomaly due to the congenital absence of the pericardium. In this case, it was associated with diaphragmatic hernia and incidentally discovered during thoracoscopic left upper lobectomy for lung cancer. The thoracoscopic dissection of the hilar structures was complicated with arrhythmia and hypotension. Thus, we converted thoracoscopy to thoracotomy, and the lobectomy was successfully performed. The pericardial defect and diaphragmatic hernia were not repaired, but the vessels and bronchial stump were covered to avoid heart injury. Postoperative course was unremarkable and at six-month follow-up patient did not have any problems.

Diaphragmatic and pericardial reconstruction after surgery for malignant pleural mesothelioma

Extrapleural pneumonectomy (EPP) and pleurectomy-decortication (P/D) are both recognised surgical procedures for selected cases affected by malignant pleural mesothelioma (MPM). Surgical techniques have ameliorated over the last years, remaining the complete macroscopic resection of the disease the main surgical principle. EPP is defined as an en-bloc resection of the visceral pleura, parietal pleura, pericardium and diaphragm alongside the pneumonectomy. The thoracic domain of the International Association for Study of Lung Cancer (IASLC) recently clarified the, previously confused, surgical terminology. "Extended P/D" is considered as parietal and visceral pleurectomy, diaphragmatic and pericardial resection with the purpose to remove all macroscopic disease. The term "radical" was replaced by "extended" to underline that this procedure does not have oncologic radicality aims. Both operations above are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. The technical aspects of resection and reconstruction are described and the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

Is video-assisted thoracoscopic diaphragmatic plication a widespread technique for diaphragmatic hernia in adults? Review of the literature and results of a national survey

Diaphragmatic plication is the most accepted treatment for symptomatic diaphragmatic hernia in adults. The fact that this pathology is infrequent and this procedure not been widespread means that this is an exceptional technique in our field. To estimate its use in the literature, we carried out a review in English and Spanish, to which we added our series. We found only six series that contribute 59 video-assisted mini-thoractomy for diaphragmatic plications in adults, and none in Spanish. Our series will be the second largest with 18 cases. Finally, we conducted a survey in all the Spanish Thoracic Surgery units in Spain: none reported more than 10 cases operated by thoracoscopy in the last 8 years (except our series) and most continue employing thoracotomy as the main approach. We believe that many patients with symptomatic diaphragmatic hernia could benefit from the use of such techniques.

Complete left-sided pericardial defect in a lung cancer patient undergoing pneumonectomy without closure of the defect

A 61-year-old asymptomatic man underwent a left pneumonectomy for Stage IIIA lung cancer. At thoracotomy, the pericardium was found to be completely absent; however, we did not close the defect. Although the heart was rotated toward the left pleural cavity in the postoperative chest computed tomography (CT), the postoperative course was uneventful, and the patient has remained asymptomatic for 7 months, since the resection. We reviewed the preoperative chest CT, which showed the heart extending unusually to the left, but the pericardial defect was not evident. Complete pericardial defects usually do not endanger the lives of patients, and if the patient is asymptomatic, surgical repair of the defect may be unnecessary even during a left pneumonectomy.

Pericardial reconstruction using a pedicle flap of the diaphragmatic central tendon

A 46-year-old woman was referred to our hospital for further evaluation of an abnormal shadow on a chest X-ray. Chest computed tomography and magnetic resonance imaging revealed a lobulated tumor arising from the left lower lobe. At operation, the tumor tissue was found to have invaded the lingula and pericardium, involving the left phrenic nerve. Resection of the left lower lobe, lingula and pericardium including the phrenic nerve was performed for extended pulmonary malignancy. A pedicle flap of the diaphragmatic central tendon was used as a pericardial patch for pericardial reconstruction with satisfactory results. The patient's postoperative course was uneventful. The postoperative histological diagnosis was pulmonary adenocarcinoma with sarcomatous elements [pT3N2M0]. At present, 43 months after the operation, the patient is receiving chemotherapy after having undergone cyberknife radiotherapy for brain metastasis of the tumor. The use of a pedicle diaphragmatic flap was effective in repairing a pericardial defect after extensive resection of pulmonary malignancy.

Cardiac displacement after lobectomy in a patient with a congenital complete left-sided pericardial defect

A 74-year-old man underwent left upper lobectomy for a suspected lung cancer. At thoracotomy, the pericardium was found to be completely absent. The heart was fixed in a central position with an artificial patch to prevent displacement. However, the heart became displaced just after closure of the thoracotomy. The thoracotomy was immediately reopened. The anchor points of the patch on the adventitia of the descending aorta had pulled through. The heart was fixed to the surrounding mediastinal tissues with a larger patch using pledget-reinforced mattress sutures. Because simple closure may result in cardiac herniation due to the cardiac pulsations, congenital pericardial defects should be securely repaired when encountered.

Cardiac dislocation after extended pneumonectomy with pericardioplasty

Two cases of cardiac dislocation occurred after intrapericardial right pneumonectomy with extended pericardiectomy and radical nodal dissection in spite of proper reconstruction with a pericardial fat flap in one case and with a Gore-tex prosthesis in the other. In the case of major pericardial excision resulting in extensive mobilisation of the SVC a complete reconstruction of pericardium and mediastinal pleura is recommended in order to prevent cardiac dislocation.

The diaphragmatic flap: A multiuse material in thoracic surgery

BACKGROUND

The use of diaphragmatic pedicle flaps for reconstructive procedures in thoracic surgery is not very popular. Nevertheless, it provides considerable advantages.

METHODS

Our experience covers 10 years (1987-1997) with a total of 25 patients in whom the diaphragmatic flap was used for different purposes. In 6 patients we used the diaphragmatic flap to protect the bronchopleural fistula at its early onset, which was not beyond 12 hours from the clinical diagnosis. We performed prophylactic suture protection after neoadjuvant therapy in 9 high-risk patients who underwent pneumonectomy and in 2 who underwent sleeve lobectomy. Postpneumonectomy pericardial defect repair was performed in 4 patients. In another 4 patients the diaphragmatic flap was used after spontaneous (n = 2) and iatrogenic (n = 2) lesions of the esophagus after 24 to 72 hours.

RESULTS

No perioperative mortality was recorded. Complications were mainly related to the severe preoperative conditions of the patients: arrhythmia, respiratory insufficiency, and empyema. We report only 2 cases of minimal persistent bleeding from the chest tube, which spontaneously ceased. For those patients who survived for more than 1 year (n = 11), no diaphragmatic hernias were recorded. Bronchopleural fistulas and pericardial defects healed in all instances. The diaphragmatic flap was also effective in bronchopleural fistula. A late fistula caused by cancer relapse at the bronchial stump developed in only one patient. Excellent repair was achieved in all patients with esophageal lesions.

CONCLUSIONS

We conclude that the diaphragmatic flap can be considered a practical, safe, and redundant material particularly indicated for defect or fistula closure and for suture line protection in the thoracic cavity.