Serratus Anterior Transposition Muscle Flaps for Bronchial Coverage: Technique and Functional Outcomes

Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study

OBJECTIVE

To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy.

METHODS

Patients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality.

RESULTS

During the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts.

CONCLUSIONS

Empiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.

Middle lobe preserving right lower lobectomy with a serratus anterior hammock flap in a patient with previous right upper lobectomy

Increasingly, many patients are diagnosed with a second lung cancer after curative thoracotomy. It is very difficult to manage such patients surgically due to the significant loss of pulmonary function. Especially on the right side, avoiding a completion pneumonectomy may contribute to reducing postoperative functional loss and surgical complications as well as the morbidity of post-pneumonectomy syndrome. A technique is needed to prevent torsion of the preserved middle lobe. Following recently published cases utilizing a latissimus dorsi muscle flap, in this case report, we describe the use of the serratus anterior muscle flap as an alternative.

Pneumonectomy: The final cut in a rare incidence of persistent bronchopleural fistula following empyema

The incidence of necrotizing pneumonia and empyema complicated by bronchopleural fistula is rising. We describe the case of a 2-year-old boy who presented with empyema thoracis and necrotizing pneumonia who developed a bronchopleural fistula. At initial thoracotomy for decortication, necrotic lung was found and resected. He subsequently underwent further thoracotomy, prolonged chest tube drainage and endobronchial glue application attempts to close a bronchopleural fistula. The fistula was only sealed at third thoracotomy and completion pneumonectomy. This case highlights the potential challenges faced when dealing with air leaks in the setting of infection and we discuss the treatment options available.