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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.

This article describes the surgical technique for performing an intercostal muscle flap for bronchial stump coverage using a video-assisted thoracic surgery approach., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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.

For lobectomy patients at considerable risk of developing a postoperative bronchopleural fistula, the bronchial stump reinforcement with an intercostal muscle flap is sometimes performed. This procedure usually requires a standard thoracotomy, even if video-assisted thoracoscopic surgery (VATS) is better for the patient. Our patient was a 76-year-old male with lung cancer and severe diabetes mellitus. He underwent lobectomy and systematic nodal dissection combined with bronchial stump reinforcement using an intercostal muscle flap, performed as a VATS procedure. No postoperative complications were observed. This procedure is applicable to patients who are candidates for VATS lobectomy.

Objectives: The value of the pedicled intercostal muscle flap for the closure of postpneumonectomy bronchopleural fistulas was studied retrospectively., Methods: Bronchopleural fistula was suspected in case of fever, cough, putrid or haemorrhagic expectoration, in combination with a rise of WBC and CRP. Fistula diagnosis was established bronchoscopically. Two patients underwent an initial trial of bronchoscopic sealing, the rest were reoperated immediately after fistula diagnosis. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection, WBC and CRP were controlled. Age, side, sex, histology, TNM-stage, duration of hospital stay after fistula diagnosis (days), duration of treatment (defined as the duration of chest tube drainage in days after operation), total hospital stay (including the initial hospital stay for primary resection and the hospital stay for fistula treatment in case of readmission), fistula size (mm), interval (days) between primary operation and fistula formation, and bacteriology were recorded., Results: Eight patients (seven male) were treated. Age ranged from 46 to 70 years (mean 57.86). Six fistulas were located on the right side. All patients had non small cell lung cancer. Interval ranged from 2 to 72 days (mean 26.9 days). Fistula size ranged from 1 to 7 mm (mean 3.43). Seven fistulas were successfully closed. Duration of treatment lasted from 15 to 28 days in those patients treated successfully (mean 17). Hospital stay ranged from 15 to 31 days (mean 24.4). In one patient the flap became necrotic, he was successfully treated with total thoracoplasty. One patient died on the 38th day after rethoracotomy due to aspiration pneumonia. At postmortem examination the bronchial stump was closed., Conclusion: The use of the pedicled intercostal muscular flap is an efficient method for the closure of bronchopleural fistula after pneumonectomy.

The case of a 57-year-old man who had previously undergone left lobectomy for echinococcal disease of the lung is described. Sixteen years later he presented with empyema and bronchopleural fistula, which were treated using a pedicled intercostal muscle bundle, an omental pedicle and partial thoracoplasty. The patient recovered and is well 6 years later.

Between April 1982 and March 1994, we did 384 pulmonary resections for lung cancer. Until March 1991, we did 249 pulmonary resections in which none of the bronchial stumps were reinforced; nine patients developed bronchopleural fistula (incidence, 4%). After April 1991, bronchial stumps of 135 patients were reinforced by an intercostal muscle pedicle flap for prophylaxis against bronchopleural fistula. Only one patient developed it (incidence, 1%). In these two periods, the proportion of patients in stage IIIa or more advanced stages increased from 24% to 41%, resulting in more extensive operations and more patients being given chemo-radiation therapy in the perioperative period. These are risk factors for bronchopleural fistula, but the incidence of the fistula decreased. These results suggest that reinforcement of the bronchial stump with an intercostal pedicle flap is useful for prophylaxis against developing bronchopleural fistula.

A 48-year-old woman underwent a right pneumonectomy for advanced mycobacterial disease (M. avium Complex), which followed the postoperative radiotherapy against a malignant schwannoma of the right lower chest wall treated seven years ago. On the 13th postoperative day, re-suture of the bronchial stump was performed urgently because of early bronchopleural fistula development. On the heels of that, reclosure of the bronchial fistula with coverage of the stump by parietal pleural flap was performed on the forty-first post operative day. On the 110th day, however, open drainage with thoracoplasty was performed because development of insidious aspergillous empyema was detected. Since then, local instillation of amphotellisin B, with an oral administration of antifungus drug was started. After succeeding to control the mycotic infection, reclosure of the bronchofistula, covered with pedicled intercostal muscle flap were performed on the 280th postoperative day and extraperiostal air-plombage for reducing empyema cavity. Postoperative course was uneventful and the patient was discharged one year later. With respect to pathogenetic relationship between radiation pneumonitis and feasibility of infection to atypical mycobacteria, preoperative radiotherapy and concurrence of postoperative bronchofistula, and some problems on management of empyema bronchofistula were briefly discussed.