Pediculated Intercostal Muscle Flaps in Bronchiactasis Resectional Surgery for Bronchial Stump Reinforcement.

OBJECTIVE: To determine the outcome of muscle flap to cover the bronchial stump in the resectional surgery for bronchiectasis for prevention of bronchopleural fistula. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Combined Military Hospitals of Quetta, Lahore, and Rawalpindi from January 2006 to August 2017. METHODOLOGY: Patients with localised bronchiectatic changes were included. Patients with carcinoma and without flap resection were excluded. Resectional surgery was performed through posterolateral thoracotomy approach, under general anesthesia with one lung ventilation. Pediculated or bipediculated intercostal muscle flap (ICM) was used to reinforce the bronchial stump. Pediculated ICM flaps were utilised for reinforcement of bronchial stump and bipediculated flaps were used over lesser. RESULTS: Three hundred and ninety-eight cases of bronchiectasis with average age of patients 38.5 ±19.8 years and male to female ratio of 2:1 were included. Bronchiectasis was unilateral in 377 cases. Tuberculous was found in 278 of the cases. Thirty-five had poor lung function tests (FEV1 <1.5%). Eighty-two patients underwent pneumonectomy, 228 patients had lobectomy and 88 patients underwent segmentectomy. Posterior-based pediculated ICM flap was used in 365 patients, and bipediculated ICM flaps in 30 cases. The most common complication was post-thoracotomy neuralgia 53. Bronchopleural fistula, despite transposition of intercostal muscle flap on bronchial stump, was present in 4 patients. CONCLUSION: Application of muscle flap over bronchial stump after resection surgery for bronchiectasis, is simple, safe and effective surgical option to avoid complication of bronchopleural fistula.

Trachea Reconstruction with Single-Stage Composite Flaps in a Rabbit Model.

BACKGROUND: Trachea reconstruction requires creation of a functional lining, semirigid support, and vascularity. We aimed to design composite flaps with these three components in a rabbit model. METHODS: Circumferential (n = 9) and partial anterior (n = 8) tracheal defects were created in rabbits. A circumferential defect was reconstructed with a tubed ear flap incorporating cartilage for support and skin for lining. This was pedicled on the posterior auricular vessels and tunneled into the neck to bridge the defect. In the second experiment, a longitudinal anterior trachea defect was patched with a pedicled rib cartilage and intercostal muscle flap based on the internal mammary vessels. The vascularized fascia over the intercostal muscles replaced the lining while the cartilage provided support. Postoperatively, the rabbits were monitored clinically and endoscopically. The tracheal constructs were examined histologically after the animals were sacrificed. RESULTS: Rabbits with circumferential defects reconstructed with the ear flap survived up to 6 months. Histology demonstrated vascularized cartilage with good integration of the flap with native trachea. However, hair growth and skin desquamation resulted in airway obstruction in the long term. In the second experiment, all the rabbits survived without respiratory distress, and the intercostal muscle fascia was completely covered by native respiratory epithelium. CONCLUSION: We described two experimental techniques using autologous composite flaps for single-stage trachea reconstruction in a rabbit model. Skin was a poor lining replacement, whereas vascularized muscle fascia became covered with respiratory epithelium. A rib cartilage and muscle flap could potentially be used for reconstruction of partial defects in humans.

Pleural Dural Fistula After Anterior Excision of Thoracic Disc Hernia: Suggested Repair Procedure.

A young woman displayed a dural tear during thoracic spine surgery. The corpectomy was by anterior approach, after thoracotomy. The dural defect was plastered by a fatty flap and a pleural layer. One month later, she exhibited a right pleural effusion. No consensual intervention is available for this complication. This dural fistula was sealed by a triple patch comprising a flap of intercostal muscles. The incidence of dural leaks following an anterior thoracic spinal surgery is infrequent but not rare. A long delay from the index surgery is unusual. Three years after the repair, the patient is free from complaints.

Video-Assisted Intercostal Muscle Flaps for Bronchial Stump Coverage.

This article describes the surgical technique for performing an intercostal muscle flap for bronchial stump coverage using a video-assisted thoracic surgery approach.

Tracheoplasty With Use of an Intercostal Muscle Flap for Caustic Necrosis.

We report a case of intercostal muscle flap used in tracheobronchial reconstruction for extensive necrosis after burn lesions of the posterior wall. A 32-year-old man attempted suicide by ingestion of caustic material. He underwent emergency total esogastrectomy, tracheostomy, and feeding jejunostomy. Ten days later, endoscopy showed complete destruction of the membranous trachea, extending from the tracheostomy to the carina. Reconstruction was conducted with the patient under venovenous extracorporeal membrane oxygenation by use of a pedicled intercostal muscle flap. The patient was weaned from respiratory support on the 14th postoperative day. Examination of a biopsy specimen from the flap 7 months after tracheoplasty showed ciliated neoepithelium.

Use of Intercostal Flap for Conservative Surgical Management of Complex Lower Esophageal Fistula.

Lower esophageal fistula is a rare complication after upper digestive tract surgery, but it is associated with high morbi-mortality. There is no consensus on therapeutic care, however when reoperation is necessary, a pedicled inter-costal flap from the thoracotomy can be easily harvested to patch a large defect or buttress a direct suture, saving -digestive reconstruction. This technique should be mastered by thoracic and general surgeons. We present here two cases of lower esophagus fistulas cured thanks to this intercostal flap, in which we avoided fistula recurrence with maintenance of digestive continuity.

Cervicothoracic airway injury repair using double-wide intercostal muscle flap.

We present a useful technique for the surgical management of long-segment cervicothoracic tracheobronchial injury using a double-wide intercostal muscle flap. This flap is a modification of a previously endorsed technique extending the ability to reinforce repairs of tracheobronchial injuries not adequately covered by a single intercostal muscle flap.

Reconstruction of a complex tracheal injury using an intercostal muscle flap.

Blunt tracheobronchial injuries occur rarely but can be life threatening. These injuries require accurate preoperative diagnosis and potentially complex reconstruction. We present the case of a 15-year-old boy who was transferred to the University of Washington with a complex tracheobronchial injury after rolling over in a sand-rail dune buggy. The injury was repaired successfully using an intercostal muscle flap and cardiopulmonary bypass.

Successful repair of an atrioesophageal fistula after catheter ablation for atrial fibrillation.

Catheter ablation of arrhythmias can result in the rare but devastating complication of an atrioesophageal fistula. This complication can be associated with significant neurologic morbidity and high mortality and requires a high index of suspicion to facilitate life-saving surgical intervention. Herein, we report the successful repair of an atrioesophageal fistula after catheter ablation for atrial fibrillation.

Successful management of a large bronchopleural fistula after lobectomy: report of a case.

The development of bronchopleural fistula after pulmonary resection is a well-known complication associated with a high mortality rate. We herein describe the successful management of a bronchopleural fistula using a rib and intercostal muscle in a patient with a large stump opening of 25 mm in diameter. A flap with rib and intercostal muscle is useful for large bronchopleural fistulas to avoid airway stenosis.

Bucket-handle repair of a tear in the bronchus intermedius with an intercostal muscle flap.

As previously well described in the literature, the intercostal muscle (ICM) flap can be used to buttress bronchial stumps following lung resection. We describe a harvesting technique of ICM flap which enabled a bi-lobectomy to be avoided in a patient with poor pulmonary function. The Key to this technique is the preservation of the neurovascular bundle. Therefore the flap is not divided anteriorly thereby differentiating it from any previous technique described.We have called it the 'bucket handle' technique, which was used to repair an intra-operative tear in bronchus intermedius. Its efficacy was tested to the full when the patient developed severe adult respiratory distress syndrome (ARDS) secondary to pseudomonas pneumonia and required high-pressure mechanical ventilation. This case demonstrates that ICM flap is an effective buttress to bronchial stumps or repairs and offers reassurance for optimal outcome due to its intact vascular pedicle.

Intercostal muscle flap for decreasing pain after thoracotomy: a prospective randomized trial.

BACKGROUND: Intercostal nerve damage is often suggested to be the cause of pain after thoracotomy. METHODS: This was a prospective randomized study of 120 patients who had posterolateral thoracotomy. They were equally divided into two groups, the first in which intercostal muscle flap and intracostal sutures were used, and the other group in which the usual pericostal sutures were used. These two groups were compared regarding operative time, rib fracture, postoperative pulmonary functions, time to ambulation, pain score in the first week, doses of analgesics injected in the epidural catheter, postoperative complications, chest tube drainage, hospital stay, return to daily activities, and pain score and use of analgesics at 1, 3, and 6 months. RESULTS: Postoperative pain score throughout the first week was significantly lower in the patients in the intercostal muscle flap group, who had also a significantly earlier postoperative ambulation and return to normal daily activities, and received significantly lower doses of postoperative analgesics. After 1 month, patients in the intercostal muscle flap group had a significantly lower pain score and use of analgesics. After 3 months, pain score was not significantly different between both groups, but the use of analgesics was significantly lower in the intercostal muscle flap group. After 6 months, no significant difference was present between both groups with regard to pain score or the use of analgesics. CONCLUSIONS: Intercostals muscle flap and intracostal sutures are rapid, safe, and effective procedures in decreasing early pain after thoracotomy with subsequent earlier return to normal daily activities and lesser use of analgesics.

Two-stage safe repair of aortobronchial fistula.

Aortobronchial fistulas are a rare and frequently misdiagnosed cause of massive hemoptysis, which is often fatal. Aortic stent grafts now allow for a safer emergency repair. However, there is a high (40% to 50%) recurrence risk, with a high fatality rate. A patient with an aortobronchial fistula due to a ruptured thoracic aortic aneurysm underwent a two-stage repair. An aortic stent graft was deployed as an emergency, and a second surgical durable repair was performed 4 months later. The patient recovered well. The best management of aortobronchial fistula may be emergency use of stent graft, followed by a delayed durable open repair when the patient has achieved stability.

A prospective, single-blind randomised study on the effect of intercostal nerve protection on early post-thoracotomy pain relief.

OBJECTIVES: Intracostal suture or intercostal muscle flap can reduce post-thoracotomy pain through the preservation of intercostal nerves below or above the incision. This study aims to test whether combining intracostal suture with intercostal muscle flap might achieve better pain relief than intracostal suture alone. METHODS: This study included 144 consecutive patients who underwent pulmonary resection. Eighty patients entered the trial but eight were excluded. Seventy-two patients were randomly assigned to a muscle flap group, in which the fifth intercostal muscle and neurovascular bundle were raised and intracostal suture on the sixth rib was applied. For the control group, only intracostal suturing on the sixth rib was done. All patients had a functional epidural placed, which were removed 24h after surgery. Differences on average numeric rating scale (aNRS) scores were assessed in an early post-operative period from day 1 to day 7 and a later period from week 2 to week 12, when patients were resting or coughing. The doses of oxycodone demand and hyperalgesia-related intercostal dermatomes (HIDs) were recorded for analysis. RESULTS: No differences were noted between the two groups in terms of length and width of the incision, or duration of rib retraction. Neither in different time periods (early or late) nor the activity status (while resting or coughing) yielded a statistical difference on aNRS scores between the muscle flap group and the control group (muscle flap group vs control group: mean (95% confidence intervals) from d ay 1 to day 7, 4.42 (1.56-7.28) vs 4.79 (2.03-7.55) on coughing (p=0.282); median (inter-quartile range, IQR) from day 1 to day 7, 1.71 (0.86-3) vs 2.50 (1.16-3.12) while resting (p=0.279); median (IQR) from week 2 to week 12, 0.43 (0-0.86) vs 0.48 (0.06-1.20) on coughing (p=0.595); median (IQR) from week 2 to week 12, 0 (0-0.14) vs 0.05 (0-0.14) while resting (p=0.856)). No differences were found in total oxycodone consumption from day 1 to day 7 between the two groups (Z=-1.821, p=0.069). The rate of HIDs in each intercostal space and median number of HIDs were similar between the two groups on day 1 (p>0.05) and day 7 (p>0.05). CONCLUSIONS: The combination of intracostal suture with intercostal muscle flap may not necessarily achieve better post-thoracotomy pain control than using intracostal suture alone.

Lesão complexa da traqueia: correção com retalho pediculado de músculo intercostal / Complex tracheal lesion: correction with an intercostal muscle pedicle flap

A reconstrução esofágica é uma das mais complexas cirurgias do aparelho digestivo, principalmente quando realizada por técnicas minimamente invasivas. Esse procedimento está associado a inúmeras complicações, como deiscência de anastomose, quilotórax, necrose do tubo gástrico e fistulas. Relatamos o caso de um paciente com o diagnóstico de carcinoma epidermoide no terço distal do esôfago que foi submetido à uma esofagectomia por videotoracoscopia e laparoscopia. Durante o ato operatório, houve lesão do brônquio principal esquerdo, sendo necessária a correção cirúrgica imediata da lesão. No pós-operatório, o paciente evoluiu com insuficiência respiratória aguda e grande escape aéreo pelos drenos de tórax e pela ferida operatória cervical. Foi submetido à nova intervenção cirúrgica, através da qual se observou uma grande lesão na parede membranosa da traqueia, que foi corrigida com um retalho de músculo intercostal.

Esophageal reconstruction is one of the most complex types of gastrointestinal surgery, principally when it is performed using minimally invasive techniques. The procedure is associated with various complications, such as anastomotic dehiscence, chylothorax, esophageal necrosis and fistulae. We report the case of a patient diagnosed with epidermoid carcinoma in the distal third of the esophagus. The patient was submitted to esophagectomy by video-assisted thoracoscopy and laparoscopy. During the operation, the left main bronchus was injured, and this required immediate surgical correction. In the postoperative period, the patient presented with acute respiratory failure and profuse air leak through the thoracic drains and through the cervical surgical wound. The patient underwent a second surgical procedure, during which a large lesion was discovered in the membranous wall of the trachea. The lesion was corrected with an intercostal muscle pedicle flap.

The sensate medial dorsal intercostal artery perforator flap for closure of cervicothoracic midline defects after spinal surgery: an anatomic study and case reports.

Complex cervicothoracic midline defects after spinal surgery are traditionally treated with the use of muscle and myocutaneous flaps. The authors introduce the sensate medial dorsal intercostal artery perforator flap as an alternative treatment for these defects. Following an anatomic study, the use of the flap is illustrated with 3 case reports. This well-vascularized flap is easy to harvest and causes minimal donor site morbidity. It can provide enough volume to obliterate dead space. Inclusion of the cutaneous nerve gives protective sensibility to the reconstructed area.

The island anterior intercostal artery perforator flap as another option for the difficult epigastric abdominal wound.

Closure of the epigastric or upper abdominal wound can be challenging even with traditional flap options. If those are unavailable due to prior surgical or anatomic constraints, a local muscle perforator flap based on the anterior intercostal artery (AICA) may be another available option if a vascularized flap is mandatory. Caution must be observed as the perforators of the AICA are diminutive, and the dissection can be tedious. Nevertheless, in 2 clinical cases, the anterior intercostal artery perforator (AICAP) flap was successfully used as an island pedicled flap to close a difficult subxiphoid wound, proving a secondary role for this donor site as a potential alternative selection.

Anatomical study of pectoral intercostal perforators and clinical study of the pectoral intercostal perforator flap for hand reconstruction.

BACKGROUND: The authors have used pectoral intercostal perforator flaps to reconstruct burned or injured hands by staged transfer. This flap is designed with a narrow skin pedicle that includes intercostal perforators from the fifth to eighth intercostal spaces, with a wide flap area that lies on the upper abdomen. The distal area is thinned down to the subdermal vascular network level; thus, such flaps are called "superthin flaps" or subdermal vascular network flaps. In this article, the authors discuss the arterial networks associated with this flap and present clinical cases. METHODS: The authors performed an anatomical study using 13 cadavers to obtain angiograms and dissect the anterior chest and abdominal region. Clinically, the authors retrospectively analyzed 21 cases over 13 years. RESULTS: Anatomically, the anterior intercostal regions could be divided into three segments with regard to vascular supply to the skin and subcutaneous layer. In particular, in the fifth to eighth intercostal spaces, perforators communicated with one another to form a "latticework" pattern. In addition, the vascular territories participating in the pectoral intercostal perforator flap, that is, the intercostal perforators, the superior epigastric artery system, and the deep inferior epigastric artery system, linked with each other through choke vessels. In the authors' clinical cases, functional and aesthetic results were satisfactory. CONCLUSIONS: The pectoral intercostal perforator flap was supported by the arterial networks among perforators in the intercostal spaces and in the upper abdomen. This flap is one useful method for reconstruction of the hand region, providing good quality in terms of thinness and texture.

Management of a complicated pulmonary fistula caused by lung cancer using a fibrin glue-soaked polyglycolic acid sheet covered with an intercostal muscle flap.

Pulmonary fistulas caused by tumours are very fragile and difficult to suture directly. It is impossible to close pulmonary fistulas with tissue sealants when massive air leakage occurs in the low pressure of the respiratory tract. A 73-year-old man with a pneumothorax caused by lung cancer had suffered a persistent massive air leakage for more than one month. We used a fibrin glue-soaked polyglycolic acid (PGA) sheet for sealing the complicated fistula. In addition, the visceral pleura of the fistula was wrapped with the pedicle of an intercostal muscle (ICM) flap to prevent massive air leakage. The pneumothorax did not reappear after surgery. Thus, a fibrin glue-soaked PGA sheet covered with an ICM flap was effective for sealing an intractable air-leaking fistula caused by lung cancer.

Complex tracheal lesion: correction with an intercostal muscle pedicle flap.

Esophageal reconstruction is one of the most complex types of gastrointestinal surgery, principally when it is performed using minimally invasive techniques. The procedure is associated with various complications, such as anastomotic dehiscence, chylothorax, esophageal necrosis and fistulae. We report the case of a patient diagnosed with epidermoid carcinoma in the distal third of the esophagus. The patient was submitted to esophagectomy by video-assisted thoracoscopy and laparoscopy. During the operation, the left main bronchus was injured, and this required immediate surgical correction. In the postoperative period, the patient presented with acute respiratory failure and profuse air leak through the thoracic drains and through the cervical surgical wound. The patient underwent a second surgical procedure, during which a large lesion was discovered in the membranous wall of the trachea. The lesion was corrected with an intercostal muscle pedicle flap.