Pedicled myocutaneous flap transplantation for a large chest wall defect with infection in a 72-year-old female.

Background: In the realm of thoracic surgery, addressing chest wall defects accompanied by infections remains a formidable task. Despite the availability of a spectrum of surgical options, attaining clinical resolution is particularly challenging in intricate cases involving extensive chest wall defects in elderly patients. Thorough debridement followed by the utilization of autologous tissue for repair and reconstruction has emerged as a prevalent approach in current clinical practice. Case presentation: Herein, we present a 72-year-old female patient with a large chest wall defect and infection. She has experienced left breast cancer surgery, multi cycle radiotherapy and chemotherapy. Nine months ago, there was yellow purulent fluid in the left chest wall. She had undergone debridement in other hospital, and the treatment effect was poor. At our hospital, Chest computed tomography (CT) imaging revealed a soft tissue anomaly on the left side of the chest wall, along with partial rib bone deterioration. Considering the patient's clinical presentation and radiological findings, a tentative diagnosis of an infected chest wall defect and chronic osteomyelitis was established. Consequently, daily dressing changes were deemed necessary for the patient's infected chest wound. Surgery for chest wall repair and reconstruction was scheduled once the wound area exhibited cleanliness with emerging granulation tissue. Preoperatively, a myocutaneous flap of an appropriate size was meticulously planned. During the surgical procedure, initial debridement of the infected chest wall area was conducted, followed by the strategic placement of a harvested pedicled latissimus dorsi myocutaneous flap to rectify the defect. Postoperative care involved stringent anti-infective measures, anti-spasmodic treatment, and preventive anticoagulation, accompanied by vigilant monitoring of the myocutaneous flap's viability and the healing progress of the defect site. Conclusions: Utilizing the pedicled latissimus dorsi myocutaneous flap for repairing extensive defects in the chest wall presents a viable and efficient strategy. This technique preserves cardiopulmonary functionality and maintains the thoracic contour. The outcomes observed in the short to medium term postoperatively have been consistently gratifying.

Salvage treatment of acute respiratory failure after autogenous tissue flap transplantation for chronic empyema with chest wall sinus: a case report and literature review.

BACKGROUND: Chronic empyema with chest wall sinus is a difficult and complex disease caused by multiple causative factors. It is difficult to control local infection due to its possible combination of bronchopleural fistula (BPF) and residual bone.The relevant literature emphasizes some risk factors for empyema progression after pneumonectomy, while the correlation between empyema and BPF after pneumonectomy increases mortality by infecting the remaining lungs. After pneumonectomy, the lung function of the contralateral side is particularly important. CASE PRESENTATION: This paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 12 years ago and began to develop empyema with anterior chest wall sinus 3 years ago. After admission, chest computed tomography (CT) showed right pleural effusion and formation of chest wall sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the huge residual cavity of the patient,the clinical effect of using free vastus lateralis myocutaneous flap combined with pedicled pectoralis major muscle flap to fill the abscess cavity was satisfactory,but acute respiratory failure occurred due to left lung aspiration pneumonia after operation. CONCLUSIONS: After a series of treatment measures such as tracheal cannula, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, the patient was ultimately rescued and cured. Postoperative follow-up showed that the muscle flaps survived and empyema was eliminated.

Autologous myocutaneous flap implantation for chronic refractory chest wall sinus with infection: a case report.

BACKGROUND: Chest wall sinus with infection is a refractory disease caused by a variety of susceptible factors, and the treatment is still challenging. For clinically complex cases, although there are various surgical methods to choose from, it is still very difficult to achieve clinical cure, especially for patients with older age and many underlying diseases. Complete resection of chest wall sinus and application of repair and reconstruction technology may bring hope to refractory cases. CASE PRESENTATION: Herein, we report a case of a 67 year-old woman who had undergone breast cancer surgery and a history of multiple cycles of radiotherapy and chemotherapy. One year ago, she had a fistula in the left chest wall with yellow purulent fluid. After admission to our hospital, chest computed tomography (CT) showed the formation of the left chest wall sinus, accompanied by high-density images of the left clavicle, part of the ribs and part of the sternu. According to the patient's symptoms, signs and imaging examination, we preliminarily diagnosed the patient as chest wall sinus with infection and chronic osteomyelitis. Therefore, in the first-stage operation, the patient underwent left chest wall sinus resection, left partial rib resection, left partial clavicular resection and left partial sternal resection, After surgery, the wound surface was changed with gauze dressing with sensitive antibiotic solution every day until the wound surface was clean and new granulation was formed. In the second-stage operation, the wound surface was appropriately expanded, and the pedicled latissimus dorsi myocutaneous flap was transferred to the chest wall defect. Finally, the skin paddle was sutured without tension to the normal skin around the chest, and two drainage tubes were placed. Anti-infection, anti-spasm, anti-coagulation and other treatments were given after operation, and the survival of myocutaneous flap, wound healing and sinus disappearance were observed. CONCLUSION: The application of pedicled latissimus dorsi myocutaneous flap in the treatment of intractable chronic chest wall sinus is an effective method. It does not change the shape of the thorax. The clinical effect is satisfactory in the near and medium term, which is worthy of clinical promotion.

Preliminary experience of autologous free myocutaneous flap combined with free dermal graft in the treatment of refractory empyema with bronchopleural fistula.

Objectives: To explore the effects of autologous free dermal graft combined with free myocutaneous flap on bronchopleural fistula (BPF) with empyema, we summarized and analyzed two cases. Methods: Two patients with refractory empyema and BPF were treated with autologous free dermal graft combined with free myocutaneous flap. The treatment included debridement of empyema, rib resection drainage, repair of bronchopleural fistula, and free vastus lateralis myocutaneous flap transplantation to eliminate the empyema. After the free dermal graft was harvested from the healthy skin around the incision, it was inserted into the fistula and sutured with the surrounding pleural tissue. The keys to the operation lies in the anastomosis of the lateral circumflex femoral artery (LCFA), vein and nerve that supply the vastus lateralis muscle flap to the thoracodorsal vessels and nerves. After surgery, the empyema, air leakage, and the survival of the myocutaneous flap were observed. Results: There was no disease recurrence after follow-up for seven and six months, respectively. Re-examination of the chest computed tomography (CT) or magnetic resonance imaging (MRI) indicated that the abscess cavity had disappeared. No necrosis of the myocutaneous flap was observed after surgery. Conclusion: The application of autologous free dermal graft combined with free vastus lateralis myocutaneous flap transplantation is effective in the treatment of patients with bronchopleural fistula with refractory chronic empyema, and the clinical effect is satisfactory.

Surgical operation combined with bronchoscopy in the treatment of fungal empyema: 5 cases report.

RATIONALE: Fungal empyema is a chronic refractory disease. It is difficult to control thoracic infection, and it is faced with the problem of recurrence. How to control the infection and reduce the probability of recurrence is a difficult problem. Surgical operation combined with endobronchial therapy was used to control infection, seal the fistula and eliminate residual cavity and achieved good results. PATIENT CONCERNS: A total of 5 patients with fungal empyema were treated from 2019 to 2021, aged 27 to 72 years, with an average age of 54.8 ±â€…7.6 years. Two cases were on the left side and 3 cases on the right side. DIAGNOSIS: While meeting the diagnostic criteria of empyema, the diagnosis of fungus in pus culture or the discovery of fungus in deep tissue pathology confirmed the diagnosis of fungal empyema in the 5 cases. INTERVENTIONS: Through surgical operations combined with bronchoscopy and individualized treatment, the infection was controlled, the fistulas were blocked, and the pus cavity was filled. OUTCOMES: After 11 to 30 months of follow-up, the muscle flap in the abscess cavity was mildly atrophied, and there was no recurrence of empyema. Three patients who completed the second-stage operation had their chest tubes removed and returned to normal life. The 2 patients who did not complete the second-stage operation had no recurrence of thoracic infection and no recurrence of cough or fever, and their quality of life was greatly improved. LESSONS: Surgical operation combined with bronchoscopy is a reliable method for the treatment of fungal empyema, which can find and plug the fistula more efficiently and eliminate the residual cavity by surgery to avoid recurrence. Therefore, it is a recommended treatment method.

Video-assisted thoracoscopic surgery lobectomy for giant intralobar pulmonary sequestration: A case report.

RATIONALE: Pulmonary sequestration, which can be divided into 2 main types: intralobar pulmonary sequestration (IPS) and extralobar pulmonary sequestration, is an uncommon congenital condition for which surgical resection is usually indicated. Video-assisted thoracoscopic surgery, as compared with open thoracotomy, has increasingly become the preferred operative procedure in the treatment of PS, owing to less postoperative pain and faster recovery. This report describes a rare and challenging case with a giant IPS undergoing video-assisted thoracic lobectomy. PATIENT CONCERNS: A 39-year old woman suffered from recurrent pneumonia for nearly 3 years. An enhanced computed tomography scan performed in our hospital revealed a 12.0 cm × 10.0 cm-sized IPS in the left lower lobe, supplied by an 8-mm aberrant artery originating from the descending thoracic aorta. DIAGNOSIS: Histology of the resected lobe confirmed the diagnosis of giant intralobar pulmonary sequestration associated with infection. INTERVENTIONS: Thoracoscopic left lower lobectomy was performed. OUTCOMES: The patient has been discharged from the hospital on the ninth day after surgery with an uneventful recovery, she was in good health after a 1-year follow-up. LESSONS: Although full of challenges, thoracoscopic lobectomy for giant IPS is a safe and feasible surgical procedure associated with reduced surgical trauma and postoperative pain as well as improved cosmetic results compared with traditional thoracotomy.

Limited thoracoplasty and free musculocutaneous flap transposition for postpneumonectomy empyema: A case report.

BACKGROUND: Empyema is a severe complication following pneumonectomy that is associated with high morbidity and mortality rates. Although there are a wide variety of treatment options, successful management remains challenging when this condition is combined with a large cavity in very thin patients who had previously undergone a posterolateral thoracotomy. CASE SUMMARY: We reported the case of a thin, 63-year-old man with a progressive pulmonary cyst who underwent left pneumonectomy via posterolateral thoracotomy 23 years ago. After an initially uneventful postoperative course, he was readmitted with empyema and a large cavity 21 years after surgery. He was successfully treated with limited thoracoplasty, followed by free vastus lateralis musculocutaneous flap transposition. CONCLUSION: This case highlights that the treatment mode of limited thoracoplasty and free vastus lateralis musculocutaneous flap transposition is safe and effective for the management of postpneumonectomy empyema with a large cavity in thin patients who had previously undergone a posterolateral thoracotomy.

Thoracoscopic diagnosis of traumatic pericardial rupture with cardiac hernia: A case report.

BACKGROUND: Pericardial rupture caused by blunt chest trauma is rare in clinical practice. Because of its atypical clinical symptoms, and because surgeons are often unfamiliar with the clinical and radiological manifestations of the injury, preoperative diagnosis is difficult; it is easily misdiagnosed and causes serious consequences. CASE SUMMARY: A 60-year-old man, previously healthy, was transported to the emergency room after falling from a great height. Upon arrival, his vital signs were stable. Electrocardiography and echocardiography were performed, and there was no sign of cardiac injury or ischemia. Chest and abdomen computerized tomography revealed pneumopericardium, hemopneumothorax, lung contusion, multiple rib fractures on the right side (Figure 1), and right scapula and clavicle fractures. He was admitted to the inpatient department for further observation after tube thoracostomy. The next day, the patient suddenly experienced rapid arrhythmia (the ventricular rate reached 150-180 beats/min) when turning onto his right side, accompanied by a blood pressure drop to 70/45 mm Hg and a chief complaint of palpitation. Thoracoscopy was performed urgently, and a large vertical tear (8 cm × 6 cm) was found in the pericardium. The defect was successfully repaired using a heart Dacron patch. His postoperative condition was uneventful without any fluctuations in vital signs, and he was transferred to the orthopedics department for further surgery on postoperative day 8. CONCLUSION: Although the possibility of pericardial rupture combined with cardiac hernia is extremely low, it is one of the causes of cardiogenic shock following blunt trauma. Therefore, clinicians need to be more familiar with its characteristic manifestations and maintain a high degree of vigilance against such injuries to avoid disastrous consequences.

Free vastus lateralis muscle flap transplantation for postoperative chronic empyema: retrospective analysis of eight case series.

BACKGROUND: Postoperative chronic empyema (PPE) remains a complex challenge for thoracic surgeons. We retrospectively investigated patients with PPE who were treated with free vastus lateralis muscle flap transplantation, and report our results. METHODS: Eight patients with PPE and persistent bronchopleural fistula (BPF) treated in our hospital from January 2015 to June 2019 were retrospectively analyzed, the time since onset of empyema ranged from 5 to 72 months. The operation was performed in two stages, stage I surgery included empyema debridement, rib resection drainage or open-window thoracostomy (OWT), meanwhile, BPF was treated under bronchoscope. Stage II surgery included obliteration of the pleural space by free muscle flap transplantation. The keys to the operation are thorough debridement, closure of the BPF, and complete obliteration of the residual pleural space. The challenge lies in the anastomosis of the lateral femoral circumflex artery and vein that supply the vastus lateralis muscle flap to the thoracodorsal vessels. RESULTS: The free muscle flaps survived in all eight patients. The abscess cavity was completely obliterated with the muscle flap. Good efficacy was achieved with primary wound healing. No serious perioperative complications were reported. No empyema recurrence, atrophy, infection, or necrosis of the muscle flap was seen during the 18- to 72-month follow-up. CONCLUSIONS: The vastus lateralis muscle flap has a large volume with good blood supply and strong antibacterial ability. It can be used for effective obliteration of a large residual cavity caused by empyema and maintains a good thoracic shape. It is an ideal choice for the treatment of postoperative chronic refractory empyema.

The Amplatzer device and pedicle muscle flap transposition for the treatment of bronchopleural fistula with chronic empyema after lobectomy: two case reports.

BACKGROUND: Bronchopleural fistula (BPF) refers to an abnormal channel between the pleural space and the bronchial tree. It is a potentially fatal postoperative complication after pulmonary resection and a complex challenge for thoracic surgeons because many patients with BPF ultimately develop refractory empyema, which is difficult to manage and has a major impact on quality of life and survival. Therefore, an operative intervention combined with conservative and endoscopic therapies may be required to control infection completely, to occlude BPF, and to obliterate the empyema cavity during treatment periods. CASE PRESENTATION: Two patients who suffered from BPF complicated with chronic empyema after lobectomy were treated in other hospitals for a long time and did not recover. In our department, we performed staged surgery and creatively combined an Amplatzer Septal Occluder (ASO) device (AGA Medical Corp, Golden Valley, MN, USA) with pedicled muscle flap transposition. First, open-window thoracostomy (OWT), or effective drainage, was performed according to the degree of contamination in the empyema cavity after the local infection was controlled. Second, Amplatzer device implantation and pedicled muscle flap transposition was performed at the same time, which achieved the purpose of obliterating the infection, closing the fistula, and tamponading the residual cavity. The patients recovered without complications and were discharged with short hospitalization stays. CONCLUSIONS: We believe that the union of the Amplatzer device and pedicle muscle flap transposition seems to be a safe and effective treatment for BPF with chronic empyema and can shorten the length of the related hospital stay.

An 83-year-old-male with bronchopleural fistula and empyema successfully treated with multidisciplinary management of thoracostomy, endoscopic, and surgical treatment: a case report.

Bronchopleural fistula (BPF) with empyema is a severe complication in patients undergoing lobectomy or pneumonectomy and is associated with high morbidity and mortality rates. Although a wide variety of treatment options exist, refractory cases with larger fistulas are still difficult to cure, especially in elderly patients. Here, we report a case of an 83-year-old man with stage I squamous cell lung carcinoma who underwent minimally invasive right lower lobectomy. After an initially uneventful postoperative course, he was readmitted to our hospital due to the progression of severe cough with fever after lung resection. Chest computed tomography (CT) showed an empyema cavity containing pleural effusion and a drainage tube in the right lower thorax. Bronchoscopy confirmed the presence of a fistula between the right lower bronchial stump and the pleural cavity. On the basis of his clinical symptoms and these imaging findings, the patient was diagnosed with BPF with empyema after lobectomy. He was successfully treated with multidisciplinary management including adequate pleural drainage by open-window thoracostomy, closure of the BPF by endoscopic therapy using an Amplatzer device, and complete obliteration of the empyema cavity with pedicled muscle flap. Multidisciplinary management combining thoracostomy, endoscopic therapy, and pedicled muscle flap transfer is a safe and effective treatment for elderly patients with larger fistulas and empyema.

Effective treatment of bronchopleural fistula with empyema by pedicled latissimus dorsi muscle flap transfer: Two case report.

RATIONALE: Bronchopleural fistula (BPF) is a dreaded complication after lobectomy or pneumonectomy and is associated with high morbidity and mortality. Successful management remains challenging when this condition is combined with empyema, and the initial treatment is usually conservative and endoscopic, but operative intervention may be required in refractory cases. PATIENT CONCERNS: Two patients diagnosed with BPF with empyema were selected to undergo surgery in our hospital because they could not be cured by conservative and endoscopic therapy for 1 or more years. One was a 70-year-old man who had a 1-year history of fever and cough after he received a minimally invasive right lower lobectomy for intermediate lung adenocarcinoma and chemotherapy 2 years ago; the other was a 73-year-old man who had a 2-year history of cough and fever after he underwent a minimally invasive right upper lobectomy for early lung adenocarcinoma 3 years earlier. DIAGNOSIS: Both patients were diagnosed with BPF with empyema. INTERVENTIONS: After receiving conservative and endoscopic therapies, both patients underwent pedicled latissimus dorsi muscle flap transfers for complete filling of the empyema cavity. OUTCOMES: The patients recovered very well, with no recurrence of BPF and empyema during postoperative follow-up. LESSONS: It is crucial to not only completely control infection and occlude BPFs, but also obliterate the empyema cavity. Thus, pedicled latissimus dorsi muscle flap transfer associated with conservative and endoscopic therapies for BPF with empyema is a useful treatment option, offering feasible and efficient management with promising results.

Spontaneous Coronary Artery Rupture Causing Acute Cardiac Tamponade and Cardiogenic Shock.

Spontaneous coronary artery rupture (SCAR) is an extremely rare, life-threatening entity without any previous underlying diseases. The clinical presentation may differ according to the site of the rupture and some patients may deteriorate early into sudden death due to the abrupt evolution of the associated cardiac tamponade and cardiogenic shock.1) The correct diagnosis of SCAR deserves a high level of suspicion. It may be confirmed as a differential diagnosis in patients with cardiac tamponade using transthoracic echocardiography (TTE) and computed tomography angiography (CTA) following emergency pericardiocentesis, and a definite diagnosis can be achieved by selective angiography. Although SCAR is associated with a dismal prognosis, some patients have recovered through emergency surgical operations or catheter interventions.2) We report the case of a patient presenting cardiac tamponade and cardiogenic shock due to spontaneous rupture of the circumflex branch of the left coronary artery, which was successfully isolated by bilateral ligation.

Free vastus lateralis musculocutaneous flap transfer for radiation-induced chest wall fistula combined with osteomyelitis: Two case report.

RATIONALE: Chronic chest wall fistula is a refractory and agonizing disease that results from multiple predisposing etiologies, including radiation-induced damage. Successful management remains challenging when this condition is combined with osteomyelitis, and a limited number of reports have been published in the literature concerning this management. PATIENT CONCERNS: Two Chronic chest wall fistula patients were selected to undergo surgery in our hospital because they could not be cured by conventional therapy for several years. One is a 74-year-old female who has received a right radical mastectomy and had radiation therapy 23 years ago; the other is a 59-year-old male who underwent a excision of thyroid cancer and had chemoradiation therapy 20 years earlier. DIAGNOSIS: Both patients were diagnosed with radiation-induced chest wall fistula combined with osteomyelitis. INTERVENTIONS: After total resection of the diseased chest walls, both patients underwent free vastus lateralis musculocutaneous flap transfers, in which the vessels were microvascularly anastomosed to the transverse carotid artery and vein via a subcutaneous tunnel or a direct incision. Histologic evaluations of the specimens demonstrated inflammation and osteomyelitis. OUTCOMES: The patients recovered very well and currently have no recurrence of chest wall fistulae during the postoperative follow-up. LESSONS: It is crucial to not only completely resect chest wall fistulae and the surrounding diseased tissues but also reconstruct the chest wall. Thus, the use of the free vastus lateralis musculocutaneous flap transfer method for radiation-induced chest wall fistulae, combined with osteomyelitis, is a useful option for treatment and is also a feasible and efficient surgical procedure with promising results.

Postoperative Regulatory T-Cells and Natural Killer Cells in Stage I Nonsmall Cell Lung Cancer Underwent Video-assisted Thoracoscopic Lobectomy or Thoracotomy.

BACKGROUND: Regulatory T-cells (Treg) play key roles in suppressing cell-mediated immunity in cancer patients. Little is known about perioperative Treg fluctuations in nonsmall cell lung cancer (NSCLC). Video-assisted thoracoscopic (VATS) lobectomy, as a minimal invasive procedure for treating NSCLC, may have relatively less impact on the patient's immune system. This study aimed to observe perioperative dynamics of circulating Treg and natural killer (NK) cell levels in NSCLC patients who underwent major lobectomy by VATS or thoracotomy. METHODS: Totally, 98 consecutive patients with stage I NSCLC were recruited and assigned into VATS or thoracotomy groups. Peripheral blood samples were taken on 1-day prior to operation, postoperative days (PODs) 1, 3, 7, 30, and 90. Circulating Treg and NK cell counts were assayed by flow cytometry, defined as CD4 + CD25 + CD127 low cells in CD4 + lymphocytes and CD56 + 16 + CD3- cells within CD45 + leukocytes respectively. With SPSS software version 21.0 (SPSS Inc., USA), differences between VATS and thoracotomy groups were determined by one-way analysis of variance (ANOVA), and differences between preoperative baseline and PODs in each group were evaluated by one-way ANOVA Dunnett t-test. RESULTS: In both groups, postoperative Treg percentages were lower than preoperative status. No statistical difference was found between VATS and thoracotomy groups on PODs 1, 3, 7, and 30. On POD 90, Treg percentage in VATS group was significantly lower than in thoracotomy group (5.26 ± 2.75 vs. 6.99 ± 3.60, P = 0.012). However, a higher level of NK was found on all PODs except on POD 90 in VATS group, comparing to thoracotomy group. CONCLUSIONS: Lower Treg level on POD 90 and higher NK levels on PODs 1, 3, 7, 30 in VATS group might imply better preserved cell-mediated immune function in NSCLC patients, than those in thoracotomy group.

Long-term outcomes of maze procedure plus valve replacement in treating rheumatic valve disease resulting in atrial fibrillation.

BACKGROUND: This study aimed to analyze the long-term results of mitral valve replacement and concomitant Cox-Maze III procedure (CMP) in treating rheumatic heart valve disease and associated permanent atrial fibrillation. Outcomes of CMP using a pure "cut-and-sew" method were assessed. METHODS: Between 1995 and 2004, 60 patients received mechanical mitral (or mitral plus aortic) valve replacement and concomitant CMP. Among them, 22 underwent classic CMP that included five localized cryoablations, and 38 received a CMP without using cryoablations. All patients received periodic follow-up and oral anticoagulation therapy. RESULTS: The demographic features of both groups of patients were comparable. A total of 65 mechanic valves were implanted. Operative data and in-hospital outcomes were insignificant except that the immediate sinus conversion rate was higher in the pure cut-and-sew group. At last follow-up, sinus rhythm was 81.1% in the pure cut-and-sew group (median, 112 months) and 72.7% in the classic CMP group (median, 113 months; p = 0.4541). Actuarial freedom from atrial fibrillation was also similar (5 years, 83.8% versus 76.8%; 10 years, 79.1% versus 70.4%; p = 0.6039). In both groups, the late results of left atrium size were significantly reduced, while the proportion of long-term tricuspid regurgitation was still remarkable. CONCLUSIONS: Mitral valve replacement and concomitant CMP is effective in treating rheumatic valve disease and permanent atrial fibrillation with satisfactory results. A complete cut-and-sew method is technically practicable, and is as effective as the classic CMP in the long term.