A retrospective analysis was performed on two patients with BPF and refractory empyema, who received surgery at the Cardiothoracic Surgery and Orthopedics Repair and Reconstruction Center of Tongde Hospital of Zhejiang Province. Autologous free dermal draft combined with free myocutaneous flap was used in the treatment of disease. The patient characteristics are presented in Tables 1 and 2.
Table 2
Case
|
Type of bacteria cultured
|
Initial size of empyema cavity (mL)
|
Intraoperative bleeding (mL)
|
Operation time (h)
|
Length of stay (months)
|
Follow-up (months)
|
1
|
Mycobacterium
|
60
|
100
|
5.5
|
6.5
|
7
|
2
|
Stenotrophomonas maltophilia
|
180
|
300
|
6.2
|
1.8
|
6
|
Treatment details
Case-1
Case-1 was a young woman of age 35 years. One and a half years ago, she was admitted to a local hospital for multiple bullae in both lungs and pneumothorax, and underwent bullectomy in the right upper lung at the same time. Two weeks after the operation, she began to develop cough, sputum, and fever, and her condition gradually worsened. Over time, purulent exudates appeared in her chest tube, which continued to leak air. However, to aggravate matters further, there was also a pneumothorax in the left lung, and both lungs continued leaking. The patient had a history of old pulmonary tuberculosis, which had subsequently been cured, and exhibited poor lung function without a history of hypertension, diabetes, or other diseases. Although the patient’s condition was generally stable by adjusting antibiotics and maintaining smooth drainage, what made her uncomfortable was the drainage bottle that was always accompanied by turbidity and several bubbles, and the drainage tube fixed in the chest cavity could not be pulled out in time, giving rise to irritating cough and low fever at irregular intervals. Computed tomography (CT) of the chest indicated hydropneumothorax in the right pleural cavity, simple pneumothorax in the left pleural cavity, and localized drainage tubes in both thoracic cavities (Fig. 1A). Based on her clinical symptoms and the findings of imaging, she was diagnosed to have BPF with empyema after right upper bulla resection and left spontaneous pneumothorax (compression about 30%). Therefore, the development of a detailed treatment plan was essential. The first step was to replace the thin drainage tube on the left side of the patient with a 24F drainage tube to promote lung recruitment and then pull it out after there was no obvious air leak. In the second step, after ensuring that the left lung could function normally, we carefully examined the problem of the bronchopleural fistula with empyema on the right side. After the patient was anesthetized, bronchoscopy was performed, which confirmed that the presence of a fistula with a diameter of about 3 mm between the upper-right bronchus stump and the pleural cavity, and a covered bronchial stent (Boston Scientific Corporation, Natick, Massachusetts) was placed under the endoscope. After the condition was clarified, rib resection and thoracoplasty were performed simultaneously. After a part of the second rib was removed, the debridement, flushing, and removal of purulent pleural effusion and necrotic tissue were performed in the thoracic cavity. Two obvious alveolar pleural fistulae were seen on the surface of the right upper lung in the tympanic lung, with a diameter of about 2–3 mm. Using pus culture, the pathogen was identified to be Mycobacterium spp. After timely adjustment of antibiotics and adequate drainage after surgery, the condition of the patient improved. No obvious pathogenic bacteria were detected again after pus culture. Subsequently, she received a second surgery. The third step was to incise the pedicled latissimus dorsi muscle flap of a size of about 14.0 cm × 8.0 cm and the serratus anterior myocutaneous flap of a size of about 10.0 cm × 6.0 cm. After the fistula was sealed using medical glue, the myocutaneous flap was sutured and fixed, and the abscess was completely packed after transposition.
Although the surgery went smoothly, the patient struggled with postoperative recovery. We discussed and agreed that the root cause was air leakage and infection. After the operation, the pedicled muscle flap also appeared to show partial atrophy, and the placed bronchial stent was coughed out of the body. The patient stayed for a long period in the hospital, during which she had undergone several debridement operations and bronchial stent closures with unsatisfactory effect. After multidisciplinary consultation, the free dermal draft combined with free myocutaneous flap was ultimately selected for the surgery. After anesthesia, the patient was placed in a semi-recumbent position. After sufficient debridement, healthy skin around the incision was selected, and the subcutaneous and epidermal tissues were removed to make a dermal graft (Fig. 1B). The graft was inserted into the two fistulas, and the exposed part was sutured and fixed with surrounding tissues. There was no obvious air leakage after the lung bulged (Fig. 1C). Later, the line connecting the right anterior superior iliac spine with the outer side of the patella was selected. Starting from the inside of the flap, the skin, subcutaneous tissue, and deep fascia were incised layer-by-layer to expose the muscle tissue. The rectus femoris and lateral femoral muscles were bluntly separated, and the descending branches of the lateral femoral muscle arteries and accompanying veins and nerves were separated. Ligation of the branches was distributed at the distal end of the muscle to completely free the muscle, its vascular pedicle, and nerve. The vascular pedicle was about 3 cm long. Finally, the pedicle was cut according to the length required by the recipient area, and a myocutaneous flap of a size of about 20 cm × 12 cm, composed of skin, subcutaneous tissue, fascia, and lateral femoral muscle was obtained, with the descending branch of the lateral femoral artery as the pedicle. The size of the island was about 5 cm × 3 cm. After the myocutaneous flap was transplanted to the recipient area and the residual cavity was filled, the descending branch of the lateral femoral artery, vein, and nerve, and the thoracic dorsal artery, vein, and nerve were intermittently sutured under the microscope using a 9–0 prolene thread to ensure the blood supply of the tissue flap and muscle activity (Fig. 1D, E). Suture between dermal graft and myocutaneous flap was also performed to enhance the vascularization to dermal graft. After the operation, the flap was sutured to normal skin around the chest without tension (Fig. 1F), and the drainage tube and drainage skin were placed. The postoperative treatment consisted of postoperative anti-infection, anti-spasm, anti-coagulation, and other treatments. The color and temperature of the myocutaneous flap were closely monitored, and the transplanted myocutaneous flap was applied to keep it warm; thus, avoiding the compression of the anastomotic wound to ensure smooth blood flow [6]. The postoperative process went smoothly, and she was discharged from the hospital after complete recovery. The chest magnetic resonance imaging (MRI) indicated that the empyema cavity and BPF were successfully sutured after surgery (Fig. 1G). During the 6-month follow-up, there was no obvious recurrence of pleural fistula and empyema.
Case-2
Case-2 was a young man of age 21 years with a history of multiple bullae in the right lung with pneumothorax. Two and a half years ago, he was admitted to a local hospital and received surgical treatment. On the third day after the operation, purulent exudates appeared in the closed drainage tube of the chest cavity, accompanied by an unpleasant smell. His main symptoms were intermittent cough and low fever. Although his fever was relieved by antibiotics and active drainage, his cough continued, and several air bubbles overflowed from the drainage bottle. The chest CT showed an abscess in the upper right chest, a gas-liquid plane in the chest cavity, a reduction in the thoracic volume, and a thickening of the pleura (Fig. 2A). Based on these observations, the patient was diagnosed to have the right BPF with empyema. After active pre-operative preparations, using the position of the original drainage tube as the appropriate incision plane, 2 mm BPF could be seen on the pleural surface near the top of the abscess cavity after removing the 3rd, 4th, and 5th ribs along with part of the thickened pleura, and the volume of the abscess cavity was about 180 mL. Intraoperative debridement, flushing, and the removal of pus and necrotic tissue in the thoracic cavity were also performed. This patient had a lot of blood loss during the operation and was given a blood transfusion after the operation. During the next few weeks, anti-infection and nutritional support were the main treatment options to maintain a smooth flow. When the patient coughed actively, air leakage in the drainage bottle could be seen. The identified bacterium in the postoperative pus culture was Maltophilia stenotrophomonas, and antibiotics were adjusted in time for symptomatic treatment. When the patient’s general condition was stable, we combined the first patient’s successful experience in repairing the fistula with a dermal skin flap to evaluate whether the same approach was similarly effective. After careful pre-operative discussion and summary, considering the patient’s larger abscess cavity, it was decided to directly treat the empyema with free dermal graft combined with free myocutaneous flap. The procedure was the same as that followed for the first patient, and the postoperative recovery was unremarkable. After 1.8 months of hospitalization, he was discharged from the hospital, and the incision recovered well (Fig. 2B). Re-examination of chest MRI empyema showed no recurrence and disappearance of BPF (Fig. 2C). After six months of follow-up, he lived as a healthy person.