Intrathoracic muscle flap transposition in the treatment of fibrocavernous tuberculosis

Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No 138, Sheng-Li Road, Tainan, Taiwan
European Journal of Cardio-Thoracic Surgery (Impact Factor: 3.3). 01/2001; 18(6):666-670. DOI: 10.1016/S1010-7940(00)00594-7


Background and objective: Conventionally, pulmonary resection with thoracoplasty is used to treat fibrocavernous complication of pulmonary tuberculosis. This operation is usually bloody, time-consuming with complicated postoperative course. To prevent massive blood loss and preserved pulmonary function, a more simplified operative procedure, cavernostomy combined intrathoracic muscle flap transposition was used and the outcome was evaluated in this study. Design: Retrospective review. Methodology: Between December 1989 and June 1996, a total of ten patients with fibrocavernous pulmonary tuberculosis were managed using cavernostomy combined with intrathoracic muscle flap transposition. Five of them had concomitant aspergilloma within the cavity while three had multiple drug resistant pulmonary tuberculosis. The muscle flap was used to plombage the cavity and reinforce the closure of bronchopleural fistula after cavernostomy. Results: Six postoperative complications occurred in five patients, including reformation of cavity (2), bronchopleurocutaneous fistulae (3), and postoperative bleeding (1). The success or failure of intrathoracic muscle flap transposition on patients with fibrocavernous tuberculosis was significantly correlated with the size of the cavity (194.0±11.2 vs. 283.0±44.6 cm3, P=0.016) and the number of bronchopleural fistulae (1.6±0.4 vs. 4.0±0.4, P=0.008). There was no operative death and in long term follow-up, there was no recurrence of hemoptysis or deterioration of pulmonary function in the successful group of patients. Conclusions: Cavernostomy combined with intrathoracic muscle flap transposition can be used to treat well-selected fibrocavernous pulmonary tuberculosis patients, except on patients with large size cavity, multiple bronchopleural fistulae or multiple drug resistance tuberculosis.

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    • "Cavernostomy, when performed in high-risk patients, carries higher morbidity and mortality. It is crucial to ensure that all bronchial openings are closed completely during the surgery [16] and prior to irrigating the cavity with Amphotericin-B solution, as scleroscent. One patient developed pneumonitis from local bronchial mucosal inflammation from intrabronchial Ampho- tericin-B. "
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    ABSTRACT: Complex pulmonary aspergilloma (CPA) following pulmonary tuberculosis may lead to massive and fatal hemoptysis. Pulmonary resection, as initial therapy, carries high morbidity and mortality. Resection is contraindicated in patients with compromised lung function (FEV1<40%) and in those with bilateral disease. We reviewed the results of patients undergoing single stage cavernostomy and myoplasty as an alternative therapy in patients with normal and compromised lung function. Patients suffering from recurrent massive hemoptysis (600ml/24h or >150ml/h) due to CPA were selected for single stage cavernostomy and myoplasty. We performed rib resection, cavernostomy, closure of the bronchial openings and total/partial obliteration of the cavity with a muscle flap as a single stage technique in patients with CPA regardless of pulmonary function or bilateral disease. Patients began oral Itracanozole two weeks prior to surgery and continued for 3 months post-operatively. Three women and four men (median age 38 years; range 24-59 years) with CPA were evaluated. Four patients had either bilateral disease or compromised lung function. Pectoralis major muscle was used for the myoplasty in five and trapezius or latissimus dorsi in the other two patients. The median number of bronchial fistulae closed during the surgery was six (range 2-12). Blood loss was minimal (median 227ml). Two patients underwent successful re-exploration for significant air leak. The median hospital stay was 9 days (6-27days). Six patients are alive and hemoptysis free (median follow-up 57.2 months). Cavernostomy and myoplasty as a single stage technique is safe and reliable in the management of patients with complex pulmonary aspergilloma. Morbidity is low even in patients with compromised lung function or bilateral disease.
    European Journal of Cardio-Thoracic Surgery 05/2005; 27(5):737-40. DOI:10.1016/j.ejcts.2005.02.008 · 3.30 Impact Factor
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    ABSTRACT: We evaluated the surgical risks associated with fibrocavernous pulmonary tuberculosis by retrospectively examining chest computed tomography (CT) scans. We reviewed the records of 40 patients who underwent pulmonary resection for fibrocavernous pulmonary tuberculosis, for whom preoperative CT scans were available. The disease was categorized as class I, defined as a cavity within one lobe without remarkable pleural thickness, in 21 patients; class II, defined as a cavity extending beyond one lobe or within one lobe with remarkable pleural thickness, in 10 patients; and class III, defined as bilateral cavities, in 9 patients. Four of the nine patients with bilateral cavities underwent bilateral pulmonary resection and five underwent unilateral pulmonary resection. The study parameters were intraoperative blood loss, operative time, hospital stay, major operative morbidity, and hospital death. Intraoperative blood loss and operative time were significantly greater and hospital stay was significantly longer in patients with advanced disease (P = 0.046, P = 0.000, and P = 0.143, respectively). Major surgical morbidity mainly occurred in association with advanced disease (P = 0.028) at the following incidences: class I, 5%; class II, 30%; class III, 44.4%. Two hospital deaths occurred, both following bilateral pulmonary resection for class III disease, accounting for an overall 5% mortality rate. The surgical risks associated with fibrocavernous pulmonary tuberculosis were well correlated with anatomic involvement, according to the extent of cavitation and the severity of pleural thickness, as depicted by CT. Staged pulmonary resection or the combination of one-sided resection with other modalities is recommended for the treatment of bilateral cavities.
    Surgery Today 02/2004; 34(3):204-8. DOI:10.1007/s00595-003-2692-2 · 1.53 Impact Factor
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    ABSTRACT: We present a modification of technique for standard muscle flap harvest, the placement of cutaneous traction sutures. This technique allows for maximal dissection of the thoracic muscles even through minimal incisions. Through improved exposure and traction, complete dissection of the muscle bed can be performed and the tissue obtained maximized. Because more muscle bulk is obtained with this technique, the need for a second muscle may be prevented.
    The Annals of Thoracic Surgery 05/2004; 77(4):1465-6. DOI:10.1016/S0003-4975(03)01420-6 · 3.85 Impact Factor
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