Asian Cardiovasc Thorac Ann 2006;14:265-272
© 2006 Asia Publishing EXchange Ltd
Preventive Diaphragm Plasty after Pneumonectomy on Account of Lung Cancer
Dmitry Chichevatov, MD,
Alexander Gorshenev, MD,
Eugeny Sinev, MSc
Department of Thoracic Surgery, Penza Regional Oncology Health Center, Penza, Russia
For reprint information contact: Dmitry Chichevatov, MD Tel: 7 841 247 8698 Fax: 7 841 241 2501 Email: rohthor{at}sura.ru, Department of Thoracic Surgery, Penza Regional Oncology Health Center, 37a Prospect Stroitelei, 440071 Penza, Russia.
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ABSTRACT
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Experience is presented of 53 cases of diaphragm plasty of the bronchial stump, tracheobronchial anastomosis, pericardium, and esophagus wall after extended pneumonectomy on account of lung cancer. A pedicled diaphragm flap was used to prevent bronchopleural fistula in 53 patients, as well as heart dislocation after wide resection of the pericardium in 26, and esophagopleural fistula after resection of the muscle coat of the esophagus in 2. In all cases, there was a high risk of these complications. Dehiscence of the bronchial stump or tracheobronchial anastomosis occurred in 9 patients, but due to diaphragm plasty, a bronchopleural fistula formed in only 3. Restoration of the pericardium and the esophageal muscle coat was successful in all cases. Overall morbidity was 22.6%, 30-day mortality was 7.5%, hospital mortality was 11.3%. Causes of death were fulminant pneumonia of the single lung, cerebral hemorrhage, pulmonary embolism, heart failure, early tumor progression, and sepsis, in one case each. The results were compared with those in 49 patients who underwent other methods of bronchial stump or tracheobronchial anastomosis reinforcement. The analysis revealed that the diaphragm flap was highly efficacious as a multipurpose plastic material.
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INTRODUCTION
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There is a high risk of bronchopleural fistula (BPF) in some patients undergoing pneumonectomy for locally advanced or complicated lung cancer. Two current problems are how to estimate the degree of risk, and what are the most effective methods of BPF prevention. According to several reports, the risk factors for BPF include wide resections such as pneumonectomy, the stage of lung cancer, a right-sided operation, preoperative radiotherapy, lower preoperative forced expiratory volume in 1 second, and the need for postoperative ventilation.1–3 Various pedicled flaps have been used to cover the bronchial stump or tracheobronchial anastomosis. A muscle flap, pericardial fat pad or pericardiophrenic graft, a diaphragm flap, and an intercostal muscle flap have been employed for BPF prevention.4–7 We believe the diaphragm flap is technically easy and reliable. Nevertheless, it is not very popular and there are few reports of diaphragm plasty.6,8 The aim of this study was to assess the efficacy of diaphragm plasty in patients with a high risk of BPF after pneumonectomy for lung cancer.
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PATIENTS AND METHODS
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To determine the risk factors for insufficiency of the bronchial stump or tracheobronchial anastomosis, 306 pneumonectomies for lung cancer were assessed. All cases of insufficiency were confirmed by bronchoscopy. The following variables were considered: the side of the pneumonectomy; stage of lung cancer (I–IV); age; sex; chronic obstructive pulmonary disease; dose of preoperative irradiation; volume of mediastinal lymph node dissection (extended, other); resection of adjacent organs; bronchial stump closure (mechanical, hand suture); sleeve carinal resection; serum hemoglobin; leukocyte count; lymphocyte count; and serum protein.
Insufficiency of the bronchial stump or tracheobronchial anastomosis was an outcome variable with two values (yes, no). Cross-tabulation (Fisher’s exact test, Pearson and Yates corrected chi-squared test), the Mann-Whitney test, Student’s t test, and the binary logistic regression model (backward stepwise) were applied. A p-value < 0.05 was considered significant.
From December 2002 to February 2005, 53 patients (group 1) underwent diaphragm plasty of the bronchial stump or tracheobronchial anastomosis in our department. There were 51 males and 2 females, the age range was 46–75 years, and the mean age was 58.7 ± 6.6 years. All patients were considered to have a high risk of BPF formation due to: a right pneumonectomy (47 patients); preoperative radiotherapy (a single dose of 7.5 Gy in 11 patients and 4 Gy per day for 5 days in 6); extended mediastinal lymph node dissection (unilateral dissection in 45 patients and bilateral in 2; Figure 1A and 1B
); extended pneumonectomy with resection of the pericardium and the left atrium in 11 patients, of whom 2 also had resection of the muscle coat of the esophagus; locally advanced lung cancer (T3 in 12 patients, T4 in 13, N2 in 25, N3 in 2, stage IIIa in 20, IIIb in 13, IV in 4); and sleeve carinal pneumonectomy in 11 patients, including 2 superior vena cava (SVC) resections. Twenty-two patients (41.5%) had 2 risk factors, there were 3 risk factors in 17 (32.1%), 10 (18.9%) had 4 factors, and 3 (5.7%) had 5 factors; only 1 patient (1.9%) had a single risk factor.
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Figure 1. Extended unilateral lymph node dissection, (A) A right-sided pneumonectomy, (B) A left-sided pneumonectomy.
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The diaphragm flap was mobilized via an additional thoracotomy in the 8th intercostal space as it was difficult or impossible to prepare a proper flap via the standard access in the 4th or 5th intercostal space. The flap was cut out so that the lower diaphragmatic vessels served its vascular axis (Figure 2A and 2B). Any part of the diaphragm that is wide and long enough can be used. After cutting out the flap, the dome was restored with figure-of-eight sutures. If the defect in the dome could not be sutured due to significant tension, a polypropylene mesh prosthesis (Lintex, St. Petersburg, Russia) was employed for reconstruction. In the case of insufficient flap length, it can be extended by excising the tendinous part (Figure 2B). In all patients, we managed to prepare the flap so that the apical part reached a level 2–4 cm higher than the bronchial stump or tracheobronchial anastomosis. If concomitant plasty of the pericardium or muscle coat of the esophagus was necessary, a wide flap was prepared. The flap was fixed with 6 U-shaped relaxation sutures around the bronchial stump or the ipsilateral semicircle of the tracheobronchial anastomosis (Figure 3). Three rear sutures (Figure 3) were passed through the periaortic or paravertebral fascia 1.5 cm higher, level, and 1.5 cm lower than the bronchial stump or tracheobronchial anastomosis. The upper suture (Figure 3) was passed through all layers of the lateral tracheal wall 1.5 cm proximal to the bronchial stump. The lower and front (Figure 3) sutures were passed through the medial wall of the contralateral main bronchus and the anterior wall of the tracheal bifurcation, respectively.
After placing all 6 relaxation sutures, the diaphragm flap was pierced by the rear ones and they were tied. The lower, upper, and front sutures were sequentially inserted and tied; this allowed control of the flap tension and the bronchial stump could be tightly wrapped (Figure 4). The ipsilateral semicircle of the tracheobronchial anastomosis was covered similarly (Figure 5). The only difference was the front suture passed through the anterior walls of the trachea and contralateral main bronchus around the anastomosis line. In cases of pneumonectomy with wide pericardial resection (26 patients), on covering the bronchial stump or tracheobronchial anastomosis, the remaining anterior part of the flap was sewn into the pericardial defect (Figure 6).
Restoration of the resected muscle coat of the esophagus (2 patients) was undertaken with the remaining posterior part of the flap, which was sewn into the esophageal defect or wrapped around the esophageal sutures (Figure 7). In these cases, 3 more rear relaxation sutures were passed through the periaortic or paravertebral fascia from 1.5 cm above the bronchial stump to 1.5–2 cm below the esophageal defect (Figure 7).
From April 1993 to December 2003, 49 patients (group 2) underwent other methods of bronchial stump or anastomosis reinforcement. There were 46 males and 3 females, their age range was 47–73 years, and the mean age was 59.2 ± 5.9 years. These patients had the same risk factors as those in group 1: a right pneumonectomy in 34; preoperative radiotherapy (single dose of 7.5 Gy in 1 patient, 20 Gy within 5 days in 6, and 12 had 40 Gy in the standard mode); extended unilateral mediastinal lymph node dissection in 25; extended pneumonectomy with resection of adjacent organs (1 case of pericardial and atrial resection, 4 of SVC resection, and 2 of resection of the pericardium, atrium, and SVC); locally advanced lung cancer (T4 in 8, T3 in 28, N2 in 32, N3 in 1, stage IIIb in 9, stage IIIa in 32); and sleeve carinal pneumonectomy in 3. Eight patients (16.3%) had only one risk factor, 15 (30.6%) had a combination of 2 risk factors, 14 (28.6%) had 3 risk factors, 9 (18.4%) had 4 risk factors, and 3 (6.1%) had 5 risk factors. The following flaps were used for reinforcement of the bronchial stump or anastomosis: pericardial fat pad in 8 patients (16.3%); greater omentum in 15 (30.6%); pleural flap in 24 (49.0%); intercostal muscle flap in 1 (2.0%); pericardial flap in 1 (2.0%). These flaps were sutured directly to the bronchial stump or tracheobronchial anastomosis or to surrounding mediastinal structures. Three tracheobronchial anastomoses were wrapped with greater omentum, and one bronchial stump was wrapped with an intercostal muscle flap.
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RESULTS
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Cross-tabulation of potential predictors and the outcome variable revealed no association with sex ( p = 0.33), cancer stage ( p = 0.198), chronic obstructive pulmonary disease ( p = 0.833), or resection of adjacent organs ( p = 0.521). Insufficiency of the bronchial stump or tracheobronchial anastomosis was significantly associated with hand suturing of the bronchial stump ( p = 0.029), a right pneumonectomy ( p < 0.001), sleeve carinal pneumonectomy ( p = 0.038), and extended mediastinal lymph node dissection ( p = 0.036). The dose of preoperative irradiation was higher ( p = 0.001) among patients with insufficiency. The leukocyte count ( p = 0.807), serum protein ( p = 0.067), serum hemoglobin ( p = 0.183), mean age ( p = 0.512), and lymphocyte count ( p = 0.820) did not differ. In the binary logistic regression model, 2 independent predictors of insufficiency were identified: left-sided operation (b = –2.074, p < 0.001); and preoperative irradiation (b = 0.038, p = 0.012), Nagelkerke R2 = 0.249.
The efficacy of the diaphragm plasty was assessed in 51 patients in group 1; 2 died on the first postoperative day due to pulmonary embolism and cerebral hemorrhage. Nine patients (17.6%) were observed by bronchoscopy to have dehiscence of the bronchial stump or edges of the tracheobronchial anastomosis. Due to diaphragm plasty, BPF and empyema were found in only 3 (5.9%) patients. In the other 6 (11.8%), the diaphragm flap sealed the fistula tightly, and the pleural cavity was airtight and leak-proof. In one patient, a BPF formed on the 14th day. The pleural cavity was drained by tubes, empyema was treated, but the patient died on the 59th day due to progression of multiple hematogenic metastases. In the second patient, a BPF occurred on the 15th day. Resection of the diaphragm flap and omentoplasty of the bronchial stump were performed. The BPF recurred after 14 days, and the patient died of sepsis on the 45th day after omentoplasty. At the autopsy, a 3 mm BPF passing through the greater omentum was found. As expected the greater omentum was viable and adhered to the bronchial stump with fibrous tissue. It should be noted that this patient suffered from severe chronic alcoholism and was in poor condition. In the 3rd patient, a BPF had formed on the 28th day following empyema that had developed during postoperative radiotherapy (30 Gy). The BPF and empyema were complicated by aspiration pneumonia and pyocyanic sepsis. The patient underwent an open window thoracostomy. The sepsis, pneumonia, and empyema resolved completely within 43 days, subsequently, omentothoracoplasty of the BPF and residual pleural cavity was successfully performed. The patient recovered and was discharged. Of the 3 patients with BPF, only 2 suffered marginal necrosis of the diaphragm flap; both had factors that prejudiced the marginal circulation in the flap: one was irradiated (30 Gy) and then had pyocyanic empyema, the other was an alcoholic. In neither of these patients was necrosis of the entire flap observed.
Acute postoperative empyema without BPF developed in one patient on the 17th day. It was successfully treated, and he was discharged on the 49th day. There was one case of esophagopleural fistula and empyema on the 9th day due to focal necrosis of the esophageal wall. At the same time, dehiscence of the bronchial stump edges was detected but no BPF formed as the esophagopleural fistula was closed by omentoplasty. The patient recovered and was discharged on the 52nd day. There was no esophagopleural fistula in patients who underwent resection of the muscle coat of the esophagus. The other postoperative complications were: single-lung pneumonia (2 cases), heart failure, and 1 case each of chylothorax and hemothorax. Overall morbidity was 22.6% (12 patients), 30-day mortality was 7.5% (4 patients), and hospital mortality was 11.3% (6 patients). Causes of death were fulminant pneumonia of the single lung, cerebral hemorrhage, pulmonary embolism, heart failure, early tumor progression, and sepsis (one of each). After discharge, the remaining 47 patients were followed up at 0.2 to 25.7 months (median, 3.9 months; lower quartile, 1.6 months; upper quartile, 8.75 months). Within this period, empyema developed in 5 (10.6%) patients on the 30th, 35th, 104th, 105th, and 180th day after the operation. No BPF occurred in any of them. All were hospitalized and the pleural cavities were drained by tubes. In 4 cases, empyema was completely cured without further surgery, and one patient underwent thoracoplasty with tamponade of the residual pleural cavity using greater omentum. He died in the early postoperative period from pulmonary embolism.
In group 2, insufficiency of the bronchial stump or tracheobronchial anastomosis was observed in 15 of 48 patients (31.3%). Only one (2.0%) had preventive omentoplasty; he died of severe respiratory failure on the 3rd postoperative day. Bronchopleural fistula developed in 2 of 8 patients (25.0%) who had pericardial fat pad reinforcement, in 7 of 14 (50.0%) who had an omental flap, and in 6 of 24 (25.0%) who had a pleural flap. Use of intercostal muscle and pericardial flaps was successful. In this group, all cases of bronchial stump or anastomosis dehiscence were followed by BPF formation. All fistulas developed within 2 to 18 days (median, 8; lower quartile, 6; upper quartile, 12.5 days). Immediate closure of the BPF and reinforcement of the stump with latissimus dorsi flap were performed in one patient; the BPF did not recur. After the operation, empyema was successfully treated, and he was discharged on the 57th day. Five BPF were closed by immediate omentoplasty, all but one of the 5 fistulas recurred. The 4 patients with recurrent BPF died of aspiration pneumonia (in 3) and early progression of blood metastases (in 1). The other patient was successfully treated for postoperative empyema and discharged on the 80th day.
There was no re-operation in 9 of 15 patients with BPF. Their pleural cavities were drained by tubes. Spontaneous closure of the BPF was observed in only one who was discharged on the 52nd day with a sterile pleural cavity. Two patients with persistent chronic BPF and empyema were discharged after 98 and 108 days. The other 6 patients died within 8 to 40 days due to aspiration pneumonia (in 5) or myocardial infarction. Empyema developed in all 15 of the patients with BPF; 5 were cured and discharged and 10 died. Fistula-related complications caused the death of 8 of these 15 patients (53.3%). Acute pleural empyema without BPF was observed in 5 of the 49 patients in group 2; all were cured without re-operation, 4 were discharged, and one died due to progression of blood metastases. The other postoperative complications were: bleeding (2), disseminated intravascular coagulation (1), arrhythmia (1), heart failure (1), and respiratory distress syndrome (1). Overall morbidity was 55.1% (27/49). The 30-day mortality was 18.4% (9 patients), hospital mortality was 28.6% (14 patients). Causes of death were aspiration pneumonia (8), respiratory failure (1), respiratory distress syndrome (1), disseminated intravascular coagulation (1), myocardial infarction (1), and progression of blood metastases (2).
After discharge, the 35 survivors were followed up for 1.8 to 120 months (median, 20; lower quartile, 8; upper quartile, 47.5 months). Two patients with persistent chronic BPF and empyema died in the 5th month due to progression of blood metastases. Late BPF and empyema developed in one patient (with a preventive intercostal muscle flap) on the 30th day after discharge. He was hospitalized and the pleural cavity was drained by tube. He refused a second operation. There were 32 patients who had neither BPF nor empyema.
The number of patients who received preoperative irradiation ( p = 0.537) or had locally advanced lung cancer ( p = 0.109), or resection of adjacent organs ( p = 0.444) did not differ between groups 1 and 2. Right-sided pneumonectomy ( p = 0.026), extended mediastinal lymph node dissection ( p < 0.001), and sleeve carinal pneumonectomy ( p = 0.043) were more frequent in group 1. The frequency of bronchial stump or tracheobronchial anastomosis dehiscence in group 1 (9/51) and group 2 (15/48) did not differ ( p = 0.159). This was expected because the groups were determined on the basis of identical risk factors. Nevertheless, the frequency of BPF was significantly lower ( p = 0.001) in group 1 (3/51) than in group 2 (15/48). Overall morbidity was higher in group 2 ( p = 0.001). The 30-day mortality was not significantly different between groups 1 and 2, but hospital mortality in group 1 was lower ( p = 0.044). Mortality from fistula-related complications in group 1 (1/53) was significantly lower ( p = 0.013) than in group 2 (8/49).
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DISCUSSION
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Six risk factors (indications for covering of the bronchial stump or tracheobronchial anastomosis) for BPF formation were defined on the basis of the experience of other surgeons and results of our own research on 306 pneumonectomies for lung cancer. A right-sided operation was a significant predictor of bronchial stump or tracheobronchial anastomosis insufficiency in this study. Others have also reported a significant association of right pneumonectomy with a high risk of BPF.2,3,9 Preoperative radiotherapy is considered a fundamental predictor of this complication and the results of our investigation support this.1,10 We used traditional regimes of irradiation as well as intensive fractionated radiotherapy or large single-dose irradiation.11,12 Extended mediastinal lymph node dissection was more often associated with a right pneumonectomy. This is probably why it was significantly related to bronchial stump or anastomosis insufficiency in the simple cross-tabulation analysis. It was not an independent predictor in the regression model, but we believe that its influence on BPF development cannot be excluded entirely. Denudation of the trachea, contralateral bronchus, and bronchial stump is more or less caused by extended mediastinal lymph node dissection. This must decrease circulation to the bronchial stump and increase the risk of the BPF. Minimal as well as extended lymph node dissection in our series caused approximately equal decreases in bronchial stump circulation. As we have never employed pneumonectomy for lung cancer without lymph node dissection, we cannot estimate how preserving the peribronchial and peritracheal tissue affects BPF frequency. Khan and colleagues13 believe that devitalization and devascularization by excessive peribronchial dissection are technical factors associated with BPF development. Analyzing the efficacy of the pedicled pericardial flap, Taghavi and colleagues10 included patients with concomitant mediastinal lymph node dissection, resection of adjacent organs, neoadjuvant or planned adjuvant chemotherapy, and/or radiotherapy. Taking into account the opinions of colleagues, we treated our statistical results critically and considered extended mediastinal lymph node dissection to be a risk factor.
Patients with resection of adjacent structures were selected for bronchial stump reinforcement because empyema or BPF were expected to be fatal due to purulent pericarditis and erosion of the atrium, SVC, or esophagus. Results relating to the effect of tumor stage on BPF development are controversial. Hollaus and colleagues14 found no significant difference in TNM stage between patients with or without BPF. In contrast, Asamura and colleagues1 identified postoperative cancer stage as a risk factor for BPF by univariate analysis. In our analysis, neither cross-tabulation nor the regression model determined stage (I–IV) to be a risk factor for bronchial stump or tracheobronchial anastomosis insufficiency. As we expected pneumonectomy for locally advanced cancer to have a higher frequency of BPF, we compared bronchial stump or anastomosis insufficiency between patients in early (I–II) and advanced (III–IV) stages. Insufficiency was significantly higher in those with advanced tumors ( p = 0.029), but we have not found consensus among other reports. All sleeve carinal pneumonectomies analyzed in this study were right-sided. The dose of preoperative irradiation did not affect the need for carinal resection (Mann-Whitney test, p = 0.612). Thus, neither side nor irradiation could be related to insufficiency and sleeve carinal resection. As we identified carinal resection in cross-tabulation ( p = 0.038), it could be considered a valid risk factor. In a large series, Porhanov and colleagues15 reported a high frequency of anastomotic problems and related mortality.
The numerous preventive methods include the use of greater omentum.16 It is sufficiently large, well supplied with blood, can be fitted precisely, and has remarkable adhesive properties and capacity for revascularization of attached organs. However, we found that omentoplasty was not without drawbacks. To prepare the omentum, it is necessary to change the patient’s position on the operating table. The abdominal phase of the operation takes an extra 50 to 70 minutes. The duration of an extended pneumonectomy and its level of trauma can be substantial; turning the patient and adding an operation in the abdominal cavity would increase both. Patients with locally advanced lung cancer are often in poor condition so their omentum can be thin with reduced plastic potential. It may be extremely difficult to obtain in patients with previous abdominal operations. In our series, omentoplasty was unsuccessful in 50% of patients (7 of 14), all of these had severe empyema, and 5 of them died. At autopsy, we found 5 viable omental flaps that did not seal the fistulas. We concluded that while greater omentum is a reliable plastic material, inadequate fixation to the bronchial stump or tracheobronchial anastomosis caused these poor results. This stimulated investigation of a new technique of fixation which was executed with the diaphragm flap. However, most surgeons consider omentoplasty to be effective, and its most serious drawback is the necessity for abdominal exploration.7,17
The intercostal muscle flap has been successfully used to cover bronchial sutures.7,8 In our opinion, the only advantage of this flap is simplicity of preparation, and our experience of it has been unsatisfactory. Despite mobilizing the flap en block with the periosteum of adjacent ribs for controlling axis vessels, its apical circulation was doubtful. Contraction of intercostal muscles after separation from the ribs narrowed the flap so that it became cord-shaped. Intercostal muscles are thin and have no tight connective tissue cover, so they split easily and become perforated during fixation. As the flap is narrow, it is not suitable for fixing around the bronchial stump or tracheobronchial anastomosis. We used an intercostal flap in one patient who subsequently developed BPF and empyema on the 30th day after discharge. Klepetko and colleagues17 believe that the intercostal muscle flap may have poor circulation at the end of the operation. Prommegger and Salzer18 described another drawback: heterotopic ossification. Covering the anastomosis with a chest wall muscle flap is a common method of BPF prevention, regarded as highly effective.4,19 Its proximity to the bronchial stump or anastomosis and simplicity of mobilization add to its popularity. We covered the bronchial stump with latissimus dorsi and serratus anterior flaps in 2 patients during redo surgery for BPF, but we did not use them at the primary pneumonectomy. The plasty failed in one of these patients, and we consider chest wall muscle flaps to have some disadvantages.
Full-layer muscle flaps are thick and cannot be modeled and fitted into narrow areas of the mediastinum. After mobilizing them, they retain the ability to contract, so they can shorten and increase the tension after fixation. The most significant drawback is the capacity to stratify easily along bundles of fibers, losing integrity and splitting. Furthermore, mobilizing chest wall muscle may result in extremity dysfunction, and one or more ribs must be resected for flap transposition into the pleural cavity. We think the muscle flap is more suited to tamponade of residual pleural cavities and chronic BPF, especially as such operations are usually combined with thoracoplasty. Deschamps and colleagues3 reported wide experience of preventive plasty using muscle flaps, but they failed to demonstrate a reduced incidence of BPF with tissue reinforcement, although this might be explained by patient selection.
Other flaps such as pleural, pericardial fat pad, pericardiophrenic graft, azygos vein, and surrounding tissues of the mediastinum have been effectively employed.5,10,17 These flaps are easily accessible but we think some of them do not meet the requirements of a plastic material. The pleural flap and pericardial fat pad have poor circulation compared to muscle or omentum. They lack adhesion, and we found bronchial stump or anastomosis insufficiency in 25% of patients. During repeat thoracotomy for BPF or at autopsy, we often observed total necrosis of pleural or pericardial fat flaps. This could be evidence of poor blood supply and low tolerance to pleural purulent inflammation. Wright and colleagues2 rarely used a pleural flap because of its perceived low strength; they chose a pericardial fat pad in standard cases and intercostal muscle or omentum flaps in high-risk patients. Kruger and colleagues20 showed that a pleural flap was ineffective in patients undergoing bronchoplastic procedures. Rendina and colleagues7 noted that pleural and pericardial flaps were often insufficient in length, width, consistency, or vascularization. Pericardial flaps are considered very effective.5,17 We used a vascularized pericardial flap successfully in one patient, but we think it has some important drawbacks: repair of the pericardial defect is necessary to avoid heart dislocation; in the case of empyema, there can be purulent pericarditis; and many patients (49% in group 1) underwent extended pneumonectomy with wide pericardial resection so this method was impossible. We cannot estimate the efficacy of bronchial stump wrapping with surrounding tissues because adequate mediastinal lymph node dissection requires denudation of the mediastinal organs with total excision of the fascia (Figure 1A and 1B
).
The diaphragm flap avoids many of the disadvantages inherent in other flaps. Its axis vessels are well-marked and provide good circulation. It can be prepared rapidly and easily. It has a strong bilateral serous cover that guarantees mechanical fastness and integrity, and it cannot be split, stratified, or broken off. Its dimensions and form can be varied, and the flap reaches most areas of surgical interest. It is thin, elastic, and flat, so it can be modeled to give a dense airtight and leak-proof covering. Due to its structure, it is suitable for concomitant plasty of adjacent organs (pericardium, esophagus), which is frequently required after extended combined operations. The patient’s position on the operating table need not be changed for diaphragm flap preparation, avoiding dysfunction of other organs or cosmetic defects. Some authors have remarked on the efficacy and universality of the diaphragm flap.6,8 We believe the crucial attributes of a flap for successful BPF prevention are fastness, a good blood supply, and adequate fixation to the bronchial stump or tracheobronchial anastomosis. It must be fixed so that security of the pleural cavity is provided by the flap only, and it must withstand cough pressure to avoid BPF after bronchial stump or anastomosis dehiscence. The flap must be fixed to stable tissues beyond the bronchial stump or anastomosis area so that destructive inflammation cannot spread to the site of the sutures and loosen them. In patients who have undergone mediastinal lymph node dissection, fixation of the flap directly to the stump or to adjacent mediastinal structures could fail. Marginal necrosis of the bronchial stump results in rapid relaxation of fixing sutures and separation of the flap. If fixed to adjacent mediastinal structures, proper tightness of the seal might not be obtained. In both cases, a viable and fast flap would be useless, which occurred in our early experience of omentoplasty. Only with the fixation technique described above have results improved significantly. At present, we prefer a diaphragm flap for primary reinforcement of the bronchial stump or tracheobronchial anastomosis, and greater omentum for immediate closure of a BPF, because these flaps have the best blood supply and can be fixed securely.
The results of our study demonstrate the great efficacy of the diaphragm flap as a multipurpose plastic material. Use of this flap helps to prevent bronchopleural and esophagopleural fistulas, as well as heart dislocation in patients at high risk of these complications after pneumonectomy.
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ABSTRACT
INTRODUCTION
