A 67-year-old female patient presented with left chest wall sinus one year ago. Local redness, pain and persistent purulent discharge occurred around the sinus orifice.Reviewing the medical history, the patient had undergone left mastectomy 20 years ago due to the diagnosis of left breast cancer, followed by regular radiotherapy and chemotherapy for several times. At the same time, she suffered from coronary heart disease, hypertension and other cardiovascular diseases.She underwent coronary stent implantation in 2017, 2019 and 2020 respectively.Currently, she regularly takes anticoagulant drugs and antihypertensive drugs.Due to repeated non-healing of chest wall wound and formation of chest wall defect, ulcer and fistula caused by debridement, the patient was admitted to our hospital for further treatment.Chest CT scan showed partial defect of left chest wall with sinus formation, high-density shadow of left clavicle and some ribs. According to the patient's symptoms and imaging examination, we diagnosed chest wall sinus with infection and chronic osteomyelitis.
After admission, the patient continued to be given local cleaning and dressing changes on the wound surface. The purulent secretions at the sinus orifice were subjected to microbial culture and drug susceptibility tests. The results of the three secretion cultures were all suggestive of Pseudomonas aeruginosa. We chose sensitive antibiotics for systemic anti-infective treatment. At the same time, nutritional support, correction of hypoalbuminemia, and strict control of blood sugar were given.Enhanced chest CT and three-dimensional reconstruction were performed. Before chest CT examination, 50% meglumine solution was injected into sinus orifice through a thin drainage tube to fully understand the shape, scope and adjacent conditions of sinus.Due to the long course of disease and lack of confidence in treatment, the patients were given necessary psychological counseling and appropriate anti anxiety drug treatment.
The operation was divided into two stages, both under general anesthesia.Before first- stage operation, we injected methylene blue solution from sinus orifice to make sinus wall fully stained to guide the scope of surgical curettage, which could not only ensure the complete removal of the diseased sinus wall tissue, but also avoided too much damage to the normal tissue and even the important organs behind the sternum.Taking the sinus orifice of chest wall as a center, a fusiform incision with a length of about 8 cm was made along the 1 cm around sinus orifice. The direction and length of the incision were determined according to the sinus shape shown on preoperative chest CT and the position of the myocutaneous flap to be filled.After incision of the skin, the sternum and infected area were fully exposed, sinus wall tissue was fully scraped with a curette, and then necrotic bone was completely removed with a rongeur, including part of first rib on the left, part of clavicle on the left, and part of sternum. When the chest wall wound tissue was fresh and there was no dye attached, the wound was washed alternately with iodophor water, hydrogen peroxide and normal saline.Due to the huge wound defect after debridement, in order to ensure the cleanliness of the wound, improve local blood supply and prepare for the second-stage operation, vacuum sealing drainage(VSD) were performed after the operation(Fig. 1).
When the patient's general condition was good after first-stage operation, after the vacuum sealing drainage device was removed, the daily incision dressing change, anti-infection, nutritional support and other treatments were continued.When the granulation of sinus wound was fresh, the secretion was significantly reduced, and the infection was preliminarily controlled,we were ready for the second-stage operation.Continue to appropriately expanded the wound along the original incision, thoroughly debrideed the necrotic tissue until the wound was fresh, and measured the size of the chest wall defect was about 15 cm x 8 cm. After hemostasis, rinsed the wound with a large amount of iodophor, hydrogen peroxide, and normal saline alternately.The patient's body position was changed to 90°lateral lying position. According to the preoperative planned flap incision, the pedicled latissimus dorsi myocutaneous flap was selected as the living tissue to fill the defect wound. The computed tomography angiography(CTA) examination of the subclavian artery showed that there were internal thoracic artery and thoracodorsal artery on the affected side without malformation.During the operation,first of all,an incision was made along the outer edge of latissimus dorsi muscle, starting from the proximal axillary apex, and the proximal and distal ends of latissimus dorsi muscle were dissociated and fully exposed in turn to protect the thoracodorsal artery and vein. Finally, a latissimus dorsi muscle flap with thoracodorsal neurovascular bundle of sufficient length was formed. The size of the latissimus dorsi muscle flap was about 30cmx8cm, while the skin island of about 16cmx8cm was reserved.During harvesting of the myocutaneous flap, the blood supply should be preserved as much as possible, while avoiding excessive distortion of the pedicle of the myocutaneous flap.We first made a subcutaneous tunnel between the acquisition site of the myocutaneous flap and the sternal wound, transferred the myocutaneous flap to the chest wall defect wound, then sutured and fixed it with the soft tissue around the wound, closely combined the myocutaneous flap with the bottom of the chest wall wound to eliminate the dead space, and finally placed a drainage tube(Fig. 2).The patient was treated with anti infection, anti spasm and anticoagulation after operation. The color and temperature of the myocutaneous flap was closely observed and tested. The transplanted myocutaneous flap was kept warm, and the incision was avoided from compression to protect the smooth blood flow.The patient pulled out all drainage tubes on the 4th postoperative day and was discharged from the hospital on the 7th day. At present, the patient was followed up for 4 months after the operation, and no malignant tumor tissue was found in the routine pathology after the two operations. Repeat chest CT showed that the chest wall sinus disappeared completely, and the pedicled myocutaneous flap grew well.