Intrathoracic transposition of the serratus anterior muscle flap--personal experience with 65 consecutive patients.

OBJECTIVE: The objective of our article is to analyse the results of intrathoracic transposition of the serratus anterior (SA) muscle flap for suppurative diseases. METHOD: We performed a retrospective analysis of 65 consecutive patients operated upon in our unit between 1 January 2003 and 1 March 2009 in whom we used intrathoracic transposition of the SA muscle flap. The flap was used alone or in association with other flaps and/or thoracoplasty in patients not amenable to lung resection and/or decortication, including tuberculous (TB) lesions in 30 patients (46%), postoperative empyema in 12 patients (18%), frank intrapleural rupture of a pulmonary cavity in 13 patients (20%) and bronchial fistula(e) in 26 patients (40%). Many patients presented a combination of the afore-mentioned anatomo-clinical characteristics. The SA was used alone in 16 patients (25%) and in combination with other flaps in 49 patients (75%). In most cases (62 patients, 95%), the flap was mobilised using both the thoracodorsal branch and the lateral thoracic vessels. Associated limited rib resection was performed with an average of 4.9±1.6 resected ribs per patient. RESULTS: In general, mortality was 5% (three patients) and other two patients (3%) presented recurrence of the intrathoracic infection requiring re-operation; minor local complications were encountered in three patients (skin necrosis--two cases and external thoracic fistula--one case). Postoperative hospitalisation ranged between 4 and 172 days, with a median of 34 days. We encountered a mild impairment of shoulder mobility in five patients, but no case of true-winged scapula. Analysis of the pre- and postoperative values of the vital capacity (VC) and forced expiratory volume in 1s (FEV1) showed no statistically significant difference (paired t test -p>0.05). CONCLUSIONS: The SA muscle flap is very well suited for intrathoracic transposition. Its use is not associated with significant postoperative morbidity.

Thoracodorsal versus reversed mobilisation of the latissimus dorsi muscle for intrathoracic transposition.

OBJECTIVE: The objective of our study is to perform a comparative analysis of the mobilisation of latissimus dorsi (LD) muscle flap using the primary versus secondary blood supply. METHOD: Between 1 January 2003 and 1 March 2009 we used the LD muscle flap in 57 patients with different intrathoracic suppurations; these patients were divided according to the blood supply used for flap mobilisation. Group A consists of 26 patients in whom the LD was mobilised based on the thoracodorsal vessels (alone in eight patients, in combination with other flaps in 18 patients). Group B consists of 31 patients in whom the LD was mobilised based on the perforator branches from the last intercostals and lumbar vessels (alone in nine patients, in combination with other flaps in 22 patients). Statistical analysis was performed using the GraphPad Prism 5 and EpiInfo 3.5.1 for Windows software. RESULTS: The two groups were similar in age, sex distribution, incidence of tuberculosis, bronchial fistula, postoperative empyema and co-morbidities (p>0.05). We found no statistically significant difference between group A and group B in terms of operative time group (176 ± 33 min vs group B 170 ± 40 min), mortality (4% vs 3%), infection recurrence (8% vs 3%), incidence of minor local complications (8% vs 6%) or hospitalisation 39 ± 16 days versus 41 ± 16 days (p>0.05 for all the parameters). We encountered no significant functional sequelae in any of the 57 patients. CONCLUSIONS: Both modalities of mobilisation of the LD muscle flap are safe and allow easy transposition in any part of the chest; the choice of how to use this flap should be made based only on the location of the intrathoracic defect.

Complex space-filling procedures for intrathoracic infections - personal experience with 76 consecutive cases.

OBJECTIVE: The objective of our article is to analyse the results of complex space-filling procedures for chronic intrathoracic suppurations. METHODS: We performed a retrospective analysis of 76 consecutive patients operated in our unit between 1 January 2003 and 31 December 2008, who presented pleural and/or pulmonary suppurations not amenable to decortication or resection; 36 patients (47%) had tuberculosis (TB) lesions (28 with positive cultures at the moment of surgery, seven with multi-drug-resistant (MDR) infections), 13 patients (17%) had postoperative empyema, 18 patients (24%) presented with frank intrapleural rupture of a pulmonary cavity and 26 patients (34%) presented with bronchial fistula. In these patients, we performed a combination of thoracoplasty (5.3+/-1.3 resected ribs) and intrathoracic transposition of extrathoracic muscles - 148 flaps (60 serratus anterior, 55 latissimus dorsi, 27 pectoralis and 6 subscapularis) with an average of 1.9 flaps per patient; in all patients, we used a closed-circuit irrigation-aspiration system and primary closure of the wound. RESULTS: The overall mortality was 5% (four patients) and four other patients (5%) presented recurrence of infection requiring a modified open-window thoracostomy; other local complications included minor skin necrosis solved through excision (three cases) and external thoracic fistula closed through local lavages (two cases). Postoperative hospitalisation ranged between 4 and 180 days, with an average of 40+/-5 days; all patients were discharged with healed wounds. Statistical analysis performed with the Fischer's exact test suggested that the flap or combination of flaps used to obliterate the space did not influence the rate of recurrence or the incidence of other major postoperative complications (p>0.05). Mild impairment of shoulder function was encountered in five patients. A comparative evaluation of the pre- and postoperative VC and forced expiratory volume of 1s (FEV1) showed no statistically significant difference (Wilcoxon signed-rank test -p>0.05). CONCLUSIONS: Patients with complex intrathoracic suppurations not amenable to decortication or lung resection require complex space-filling procedures to achieve complete obliteration of the infected space. The association between thoracoplasty and intrathoracic muscle transposition is a safe and simple solution allowing a quick recovery with good functional and aesthetic postoperative outcome.