Patients with chronic empyema with chest wall sinus need long-term flap drainage or closed drainage of empyema, especially those who have undergone postpneumonectomy or have lung tissue infection necrosis, BPF, which is a major challenge for current clinical treatment. It is very important to choose the operation method and deal with the postoperative complications in time, especially in the elderly patients, once there is such as muscle flap necrosis, respiratory failure and other critical cases, timely treatment has a positive impact on the prognosis (5, 6). Respiratory failure caused by acute empyema is very common in clinic, and even some special bacteria have been reported (7). However, acute respiratory failure caused by chronic empyema combined with chest wall sinus tract tissue flap transplantation is rarely reported.
Aspiration pneumonia complicated with respiratory failure is a common acute and severe disease, which often occurs in patients with long-term bedridden, severe trauma, shock after major surgery. Due to the experience of transplantation of free lateral thigh myocutaneous flap and pedicled pectoralis major myocutaneous flap, this patient has great trauma and needs special posture after operation. At the same time, because of analgesia or anesthesia, the ability of airway protection such as swallowing reflex and cough reflex weakened or disappeared, gastrointestinal function weakened, and the risk of reflux and aspiration increased. Of course, bronchoscopy found suspicious air bubbles in the tracheal stump, and it cannot be completely ruled out that there is a tracheal stump fistula on the surgical side. In any case, rescue treatment measures for acute respiratory failure are inevitable. Despite the increased risk of mechanical ventilation caused by rescue treatment, prolonged hospital stay in EICU, the use of antibacterial drugs is inevitable, and even de-escalation treatment and combination medication are required (8), for patients with only one lung and suffering from extensive inhalation infection, such successful rescue and cure cases are commendable.
For patients with refractory chronic empyema complicated with chest wall sinus, most of them underwent thoracic surgery such as closed thoracic drainage, open window thoracostomy(OWT) or thoracoplasty, especially the posterolateral thoracic incision cut off the local muscles and blood vessels of the chest wall.It is impossible to obtain a large enough muscle flap nearby to eliminate the huge empyema cavity(9, 10). Since it was reported that extrathoracic skeletal muscle was implanted into the thoracic cavity in 1989, living tissues such as omental flaps, rectus abdominis myocutaneous flaps and latissimus dorsi myocutaneous flaps have also been clinically used. Although the surgical trauma is great, the tissue utilization rate is higher and the empyema cavity can be completely eliminated. In this case, we selected the free vastus lateralis musculocutaneous flap and pedicled pectoralis major myocutaneous flap for treatment. Compared with other free myocutaneous flaps, this combined myocutaneous flaps have the advantage of convenient anatomy, easy access, large volume and rich muscle tissue, which can meet the requirements of filling huge cavities, it can enrich the vascular anastomosis between donor and recipient (11, 12).
To analyze and summarize this operation, we can't just focus on whether there is tissue flap necrosis caused by vasospasm and blockage after reconstruction. Due to the occurrence of acute respiratory failure, we should reflect on the causes, because no tracheal stump fistula was found during the operation, and the postoperative fiberoptic bronchoscopy was verified for many times, only suspicious signs were found in one examination, Is it the aspiration of the patient or the existence of a small fistula? Combined with this experience, it is worth discussing the feasibility of prophylactic use of sclerosing agent in the next operation for patients with the same condition.
In conclusion,the chest CT of the patient showed that there was no recurrence of empyema and chest wall sinus in the later follow-up, and the transplanted combined tissue flap survived. Although there was acute respiratory failure after the operation, it correctly grasped the rescue opportunity and accumulated some valuable experience for the full evaluation of the next operation.