Article

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
ABSTRACT
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.

Full-text

Available from: Wu-Wei Lai
Intrathoracic muscle ¯ap transposition in the treatment of
®brocavernous tuberculosis
Yau-Lin Tseng
*
, Ming-Ho Wu, Mu-Yen Lin, Wu-Wei Lai
Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No 138,
Sheng-Li Road, Tainan, Taiwan
Received 17 April 2000; received in revised form 18 August 2000; accepted 25 September 2000
Abstract
Background and objective: Conventionally, pulmonary resection with thoracoplasty is used to treat ®brocavernous 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 simpli®ed operative procedure, cavernostomy combined intrathoracic muscle ¯ap transposi-
tion 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 ®brocavernous pulmonary tuberculosis were managed using cavernostomy combined with intrathoracic
muscle ¯ap transposition. Five of them had concomitant aspergilloma within the cavity while three had multiple drug resistant pulmonary
tuberculosis. The muscle ¯ap was used to plombage the cavity and reinforce the closure of bronchopleural ®stula after cavernostomy.
Results: Six postoperative complications occurred in ®ve patients, including reformation of cavity (2), bronchopleurocutaneous ®stulae (3),
and postoperative bleeding (1). The success or failure of intrathoracic muscle ¯ap transposition on patients with ®brocavernous tuberculosis
was signi®cantly correlated with the size of the cavity (194:0 ^ 11:2 vs. 283:0 ^ 44:6cm
3
, P 0:016) and the number of bronchopleural
®stulae (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 intrathor-
acic muscle ¯ap transposition can be used to treat well-selected ®brocavernous pulmonary tuberculosis patients, except on patients with large
size cavity, multiple bronchopleural ®stulae or multiple drug resistance tuberculosis. q 2000 Elsevier Science B.V. All rights reserved.
Keywords: Bronchopleural ®stula; Intrathoracic muscle ¯ap transposition; Tuberculosis
1. Introduction
The management of pulmonary tuberculosis with ®bro-
cavernous lesions is still a great challenge to most thoracic
surgeons [1,2]. These cavitary lesions, associated with lobar
parenchymal destroy, severe adhesion of pleural space and
interlobar ®ssure, and chronic peribronchial lymph nodes
in¯ammation with dense adhesion to the vessel and
bronchus of destroyed lung makes surgical resection dif®-
cult and dangerous with resultant large dead space following
resection. Traditionally, these were treated with lobar resec-
tion concomitant with thoracoplasty. This procedure is
usually bloody, time-consuming with complicated post-
operative course. To prevent massive blood loss and
preserve pulmonary function, a more simpli®ed operative
procedure was applied for these patients. As early as 1911,
muscle ¯ap was used by Abrashanoff to close a broncho-
pleural ®stula [3]. Since then, muscle ¯aps have been used
extensively to obliterate thoracic dead spaces or to close
bronchial ®stula and was used to treat patients with post-
lobectomy or post-pneumonectomy empyema as a single
stage procedure [4] during the late 1970s or early1980s.
Due to some similarity of ®brocavern and post-resectional
empyma with bronchopleural ®stula, cavernostomy
combined with intrathoracic muscle ¯ap transposition
(IMFT) was used in our institution to treat the patients
with ®brocavernous pulmonary tuberculosis from 1989±
1996 and our outcome is evaluated in this study.
2. Materials and methods
2.1. Selection of the patients
Inclusion criteria of patients with ®brocavernous tubercu-
losis in this study include the following: ®rst, presence of
chronic thickened cavity wall with dense adhesion to the
upper pleural cavity after upper lobar parenchymal destruc-
European Journal of Cardio-thoracic Surgery 18 (2000) 666±670
1010-7940/00/$ - see front matter q 2000 Elsevier Science B.V. All rights reserved.
PII: S1010-7940(00)00594-7
www.elsevier.com/locate/ejcts
* Corresponding author. Tel.: 1886-6-2353-535 ext. 5187; fax: 1886-6-
2766-676.
E-mail address: tsengyl@mail.ncku.edu.tw (Y.-L. Tseng).
Page 1
tion with the parietal pleura as its roof and lateral wall.
Second, patients with symptoms of repeated or massive
hemoptysis (.600 ml blood/day). Third, the cavity was
the only lesion that possibly caused the symptom. Fourth,
patient had understood and agreed to receive such proce-
dure. Patients with suspicion of Rasmussens aneurysm
within the cavitary lesion by CT scan were excluded from
this study.
Between December 1989 and June 1996, ten patients with
®brocavernous pulmonary tuberculosis were treated by
cavernostomy combined with IMFT at the National Cheng
Kung University Hospital, Tainan, Taiwan. There were
seven males and three females. The average age of the
patients was 58.7 years (29±71 years) with history of
pulmonary tuberculosis ranging from 2±25 years (average
12.3 years). Eight patients had right upper and two had left
upper lobe cavities. Five patients were associated with the
presence of aspergilloma. Three patients had proven multi-
ple drug resistant pulmonary tuberculosis (MDRTB) prior to
operation. Clinical manifestations were recurrent or massive
hemoptysis in all patients. All ten patients received caver-
notomy and IMFT and were divided into two groups based
on the outcome: successful on group A (N 5) and failed
on group B (N 5). Additional operative procedures, thor-
acoplasty (N 1) and decortication (N 1) was performed
due to complications. The muscle ¯aps used include Pector-
alis major (N 7), Serratus anterior (N 3), Latissimus
dorsi (N 1), and Omentum (N 1).
2.2. Preoperative studies and management
Standard chest radiography was studied in all patients.
Computed tomography of the chest was obtained to assess
the size and extent of ®brous cavern, the relationship
between the lesions and pulmonary vessels and the potential
function of remaining lung parenchyma. Sputum were
smeared for acid-fast bacilli and cultured for bacteria,
fungi, and tuberculous bacilli. Pulmonary function tests,
including forced vital capacity (FVC), forced expiratory
volume in ®rst second (FEV1.0), residual volume, func-
tional residual capacity, and total lung capacity were docu-
mented before operation, if conditions permit.
Preoperatively, all patients with positive sputum acid-fast
bacilli received anti-tuberculous chemotherapy (isoniazid,
ethambutol, and rifampicin) for at least 3 months, or until
the negative conversion of the sputum. Multiple drug resis-
tant tuberculosis was de®ned as tuberculous bacilli resistant
to at least two of three anti-tuberculous drugs (isoniazid,
ethambutol, and rifampicin) based on sputum culture sensi-
tivity result. Three patients with MDRTB received anti-
tuberculous treatments for 6 months to 1 year (median of
9.3 months), before surgery.
2.3. Technical considerations
The IMFT was done as an elective procedure if the
patients condition permitted. Choice of muscle ¯ap was
determined by the location of cavity. When the majority
of cavity were near the anterior chest wall, the pectoralis
major muscle was chosen and the thoracotomy wound was
performed anteriorly, along the anterior axillary fold, to
expose the muscle. Otherwise, latissimus dorsi or serratus
anterior muscle was used and was preserved before the
pleural cavity was opened.
The content of the cavity was evacuated and cultured for
bacteria, fungus and tubercles bacilli. Decortication of all
pleural adhesion was not done. Only the cavity was debrided
and B±P ®stulae were carefully identi®ed. The tissue
surrounding each ®stula was debrided meticulously and
freshened and closed with 3±0 or 4±0 mono®lament absorb-
able sutures (Maxon, Davis and Geck). The muscle ¯ap was
transposed into the cavity, usually from the 2nd or 3rd inter-
costal space with partial resection of the rib, to plombage the
cavity and re-inforce the sutures of the ®stula.
2.4. Postoperative care
Anti-TB drugs (rifampicin) were administered immedi-
ately following operation until the ®nal diagnosis of surgical
specimen was reported and continued for at least 1 year after
operation if the surgical specimens positive for tuberculosis.
Prophylactic second-generation cephalosporine and amino-
glycoside were also given for prevention of infection. Addi-
tional usage of antibiotics was based on the ®nal results of
culture and sensitivity tests. Following surgery, one or two
chest tubes were placed in the cavity with continued low-
pressure suction (210 cm H
2
O). An additional closed drai-
nage device was placed within the space of the muscle ¯ap
and removed when the daily amount of drainage was less
than 30 ml.
2.5. Statistical analysis
All data were expressed as mean ^ SEM. Differences
between the means of these groups were analyzed using
Mann±Whitney U test. The level of signi®cance was set at
P , 0:05.
3. Results
The clinical and laboratory ®ndings of patients in groups
A(N 5) and B (N 5) are summarized in Table 1. In
group A, cavity size ranged from 150±210 cm
3
with one or
two ®stula while in group B, cavity size ranged from 216±
420 cm
3
with three to six ®stula. Statistically, group B
patients had a signi®cantly larger size of cavity
(283:0 ^ 44:6 vs. 194:0 ^ 11:2cm
3
, P 0:016), more
®stula (4:0 ^ 0:4 vs. 1:6 ^ 0:4, P 0:008) and longer dura-
tion of chest tube drainage (35:4 ^ 8:8 vs. 6:8 ^ 1:3 days,
P 0:016). The length of endotracheal intubation with
ventilatory support was 0:9 ^ 0:2 days with average stay
in ICU of 1:9 ^ 0:3 days. All three patients with MDRTB
preoperatively were in group B. Five patients had concomi-
Y.-L. Tseng et al. / European Journal of Cardio-thoracic Surgery 18 (2000) 666±670 667
Page 2
tant aspergilloma within the cavity, four in group A and one
in group B.
3.1. Operative complications
A total of six postoperative complications developed in
this study (50%), including persistence of the cavitary
lesions (N 2), bronchopleurocutaneous ®stula (B±P±C
®stula) (N 3) and postoperative bleeding (N 1).
Despite repeated operative procedures, with or without a
second IMFT, B±P±C ®stula was successful closed in only
one of the three patients. One patient with ®brocavernous
tuberculous combined with invasive aspergillosis, despite
receiving 500 mg of amphotericin B preoperatively had
chest tube drainage of B±P ®stula for half a year following
surgery and a persistent cavity occurred on his left upper
pleural cavity following removal of chest tube. One patient
with bleeding underwent emergency hemostasis and rein-
forcement of bronchopleural ®stula. However, the right
upper pleural cavitary lesion persisted. In three patients
with preoperative diagnosis of open tuberculosis, positive
tuberculous bacilli in the sputum persisted postoperatively.
3.2. Long-term follow-up
There was no operative death. Seven of the ten patients
continue to be evaluated by our hospital. Five patients in
group A had no recurrence of hemoptysis or deterioration of
pulmonary function with a median 6.25 year follow-up. One
patient with invasive aspergillosis was asymptomatic with-
out recurrence of fungus ball within the reformed cavity in a
3 year follow-up. One patient, who had B±P±C ®stula
closure after repeat surgery, was also free of hemoptysis
but had exertional dyspnea due to moderate obstructive
ventilatory failure. Of the three patients who were lost to
follow up, one had recurrence of B±P±C ®stula, who refused
further operation and was still positive for sputum tubercu-
losis 2.5 years after surgery. One patient with persistent
cavity died 8 years following surgery of unknown etiology
(death on arrival) while the other one with B±P±C ®stula
died of respiratory failure 5 years after surgery.
4. Discussion
The intrathoracic muscle ¯ap has excellent blood supply,
can reach any location in the pleural cavity and is an ideal
tissue to plombage the empyema space and reinforce the
repair of bronchopleural ®stula [4,5]. How to effectively
mobilize different muscle ¯aps for those purposes have
been detailed by Mathes and Nahai, and many others
since 1982 [6,7]. The six basic principles for complete
¯ap closure of postsurgical empyema [2] as described by
Miller et al. [4] are still widely applied today.
During the period of 1989±1996, cavernostomy and
IMFT was used in our institution as a primary surgical treat-
ment modality to obliterate the cavity and reinforce the
®stula closure in patients with ®brocavernous PTB in
order to avoid massive oozing of blood from the chest
wall and injury to the pulmonary artery during dissection
of the dense and thick tuberculous ®brocaverns. Most of our
patients had poor pulmonary function, multiple broncho-
pleural ®stulae and severe pleural adhesion. According to
the literature [1,2], lung resection was feasible in only 10±
12% of patients because severe pleural and interlobar adhe-
sions and the incidence of B±P ®stula following surgery
may be as high as 30±35.2% in patients with positive
sputum tuberculosis at the time of surgery, polymicrobial
contamination, diabetes and prior chest wall irradiation
[8,9]. In our study, there was no surgical mortality but the
complication rate was higher than previously reported,
despite most of our patients having some of the factors
mentioned above. Five factors that have affected the
Y.-L. Tseng et al. / European Journal of Cardio-thoracic Surgery 18 (2000) 666±670668
Table 1
Data analysis of ten patients
a
Group Successful group (N 5) Failed group (N 5)
Age (year) 57.0 ^ 7.5 60.4 ^ 3.2 NS
Tuberculous history (year) 12.8 ^ 3.7 15.2 ^ 13.1 NS
Cavity size (cm
3
) 194.0 ^ 11.2 283.0 ^ 44.6 P , 0.05
Fistula (n) 1.6 ^ 0.4 4.0 ^ 0.4 P , 0.05
FEV1 (l/min) 1.5 ^ 0.2 1.48 ^ 0.4 NS
Intubation (day) 0.4 ^ 0.2 1.4 ^ 0.2 NS
ICU stay (day) 1.8 ^ 0.6 2.0 ^ 0.3 NS
Chest tube drainage (day) 6.8 ^ 1.3 35.4 ^ 8.8 P , 0.05
Hospital stay (day) 18.6 ^ 3.5 41.4 ^ 10.2 NS
Muscle ¯ap (n) PM (4), SA (1) PM (3), SA (2)
LD (1), OM (1)
Associated disease Aspergilloma (4) Aspergilloma (1)
DM (2)
Aspergillosis (1)
MDRTB (3)
a
NS, not signi®cant; PM, pectoralis major; SA, serratus anterior; LD, latissmus dorsi; OM, omentum; DM, diabetes mellitus; MDRTB, multiple drug
resistant tuberculosis; signi®cance, P , 0:05.
Page 3
outcome of group A and B in our study include:
1. The number of bronchopleural ®stulae in the ®brocaver-
nous lesions: The edges of these ®stulae were often
fragile, necrotic, and bled easily with a tendency to reoc-
cur during the early postoperative period. In our series,
three patients hand reoccurrence of air leakage from
chest tube on the 7th, 10th, and 12th postoperative day.
If the number of ®stulae was one or two, the IMFT
appeared effective.
2. The size of the cavern: IMFT appeared more likely to fail
if the cavitary lesions were larger than 210 cm
3
, regard-
less of which muscle ¯ap was used. All types of muscle
¯ap including Pectoralis major, Serratus anterior, Latis-
simus dorsi and Omentum, initially appeared to appro-
priately ®ll the cavity. However, disuse atrophy of the
muscle occurred following transposition. This, combined
with the failure of the remaining lung to expand from
severe destruction, ®brosis, and adhesion was probably
responsible for the late failure. In our series, two patients
developed B±P±C ®stula on 40th and 44th postoperative
day, in which chest tubes were removed successfully
without sign of air leakage initially on 10th and 14th
postoperative day.
3. Patients with MDRTB were probably not suitable for this
procedure, (Group B only- three of ®ve patients). Multi-
ple secondary procedures improve the outcome only in
one of these patients. Since removal of heavy bacterial
burden is essential in the treatment of MDRTB [8], intra-
operative cavitary instillation of anti-tuberculous drugs
followed by postoperative continuous instillation via
chest tube might help in decreasing the bacterial load
within the cavity. These drugs could also induce in¯am-
matory reaction between muscle ¯ap and cavity wall and
hasten the adhesion which might improve the result of
IMFT. The risk of drug irritation or bacterial spread to
another portion of the lung is probably nil since the
bronchopleural ®stula is closed during operation.
However, lobectomy or pneumonectomy, if possible,
continues to be the treatment of choice for patients
with MDRTB [10,11].
4. Aspergilloma within ®brocavernous tuberculosis often
causes severe hemoptysis and needs to be resected [12±
14]. In high risk patients, some authors use palliative
procedures to evacuate it [15]. In our study, the presence
of aspergilloma in the cavity didn't appear to in¯uence
the outcome of IMFT. Grossly, all fungal material could
be readily evacuated intra-operatively without major
blood loss or technical dif®culty. In cases of tuberculous
cavity with aspergilloma treated by resection, it is safe
not to administer anti-fungal regimen during the pre- and
post- operative period and should be used only in case
with invasive aspergillosis to minimize postoperative
complication. One patient in this study had invasive
aspergillosis involving both lungs and the empty old
tuberculous cavity on left upper lobe. He was operated
on after toxic sign and fungal in®ltration on CXR
subsided. Despite the reformation of cavity, there was
no recurrence of fungal ball within the cavity for more
than 3 years of a follow-up period.
5. In our patients, cavernostomy with IMFT appeared to be
a less invasive procedure. The length of endotracheal
intubation with ventilatory support was 0:9 ^ 0:2 days
with an average stay in ICU of 1:9 ^ 0:3 days.
Based on the result of this study, cavernostomy with
IMFT should be carried out on carefully selected ®broca-
vernous tuberculosis patients based on the following consid-
erations. Firstly surgical intervention of patients with
MDRTB probably should be deferred until the disease is
medically controlled [16]. Secondly all bronchopleural
®stulas should be carefully identi®ed and closed intra-
operatively with enforcement using muscle ¯ap transposi-
tion and thirdly, the size of the cavity should be estimated
preoperatively by computed tomography with cavities
larger than 210 cm
3
probably needing alternative operative
procedure. Chronicity of the cavity, poor pulmonary func-
tion tests, and recurrent hemoptysis are probably not contra-
indication for IMFT.
5. Conclusion
Based on this study, cavernostomy combined with
intrathoracic muscle ¯ap transposition, a less invasive
procedure, can be used to treat well-selected ®brocavernous
pulmonary tuberculosis patients, except in patients with
large size cavity, multiple bronchopleural ®stulae or multi-
ple drug resistant tuberculosis.
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  • Source
    • "Due to the difficulty in obtaining a really clean cavity, we do not suggest surgeons perform cavernostomy plus myoplasty at the single stage. The success of this technique depends on the closure of bronchial fistula [12] , adequate drainage , intracavitary antifungal instillation and an obliterated sterile space from a muscle flap with an efficient blood supply. We believe, like many others [2, 6], that cavernostomy combined with myoplasty may be an alternative technique to prevent the recurrence of the disease and to reduce operative complications in patients in a poor general condition. "
    [Show abstract] [Hide abstract] ABSTRACT: The surgical treatment of pulmonary aspergilloma is challenging and controversial. This study was designed to evaluate the clinical profile, indications and surgical outcomes of pulmonary aspergilloma operated on in our institute. A total of 256 patients with pulmonary aspergilloma underwent surgical treatment from 1975 to 2010. The patients were divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160). The principal underlying lung disease was tuberculosis (71.1%). The surgical procedures consisted of 212 lobectomies in both groups; eight cavernoplasties, 10 bilobectomies, 16 pneumonectomies and six thoracoplasties in Group B; four segmentectomies and six wedge resections in Group A. Postoperative complications occurred in 40 patients (15.6%). The major complications were residual pleural space (3.9%), prolonged air leak (3.1%), bronchopleural fistula (1.6%), excessive bleeding (1.6%), respiratory insufficiency (1.9%) and empyema (1.2%). No intraoperative deaths occurred. The overall mortality within 30 days post-operation was 1.2%, occurring only in Group B. There was no statistically significant difference in the postoperative morbidity between Groups A and B (P = 0.27). With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.
    Preview · Article · Apr 2012 · Interactive Cardiovascular and Thoracic Surgery
  • Source
    • "However, empyema has been reported to recur in 25% of cases when muscle flaps alone are used to obliterate post- OWT cavity [13]. Tseng and colleagues [15] hypothesise that disuse atrophy of the muscle occurs during the first 5—6 weeks following transposition and may account for failure to achieve long-term obliteration of thick and rigid fibrocavernous cavities. We suggest that this phenomenon, combined with the failure of the chest wall to retract, may also explain recurring small pleural spaces and thus be responsible for the late failure of muscle flap transposition alone. "
    [Show abstract] [Hide abstract] ABSTRACT: Thoracoplasty has lost much of its popularity and is being supplanted by space-reduction operations using muscle flaps. Our purpose is to retrospectively study the remaining indications and the evolving modifications of this ancient technique in our current surgical practice. From 1994 to 2008, 35 patients underwent a thoracoplasty procedure in a single thoracic surgery centre for treatment of infectious complications of previous thoracic surgery. The number and length of ribs excised were dictated by the size and location of the thoracic cavity to obliterate. Muscle flaps were used to buttress bronchial fistulas and to fill out residual spaces. We reviewed the immediate and long-term results concerning infection control and procedure tolerance. The infectious complications of previous thoracic surgery were related to cancer in 25, tuberculosis in six, oesophageo-pleural fistula in two, ruptured lung abscess and pleural thickening in one each. The thoracoplasty procedure was performed for: (1) post-pneumonectomy empyema, n=20 (bronchial fistula, n=11; open window thoracostomy, n=14; mean number of resected ribs, n=7.5; associated intrathoracic muscle transposition, n=12; postoperative death, n=3); (2) post-lobectomy empyema, n=8 (bronchial fistula n=8; open window thoracostomy n=1; mean number of resected ribs n=3.6; associated intrathoracic muscle transposition n=7; no death); (3) other indications, n=7 (mean number of resected ribs n=4.8; associated intrathoracic muscle transposition n=3; no death). All patients discharged from the hospital except one were cured and did not complain of symptoms of secondary lung function and shoulder impairment. Although thoracoplasty is rarely indicated nowadays, this does not imply that the procedure should be avoided. Thoracoplasty may be associated with myoplasty, which permits achieving complete space obliteration by combining resection of a few rib segments and limited intrathoracic muscle transposition.
    Preview · Article · May 2010 · European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery
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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. "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · May 2005 · European Journal of Cardio-Thoracic Surgery
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