Vertical rectus abdominis myocutaneous free flap repair of post-pneumonectomy bronchopleural fistula: a case report

Our plain-English summary of Vertical rectus abdominis myocutaneous free flap repair of post-pneumonectomy bronchopleural fistula: a case report, by P.G. Brennan, D.S. Hsu, K.C. Banks, et al (AME Case Reports, 2022).

The study

• Authors: P.G. Brennan, D.S. Hsu, K.C. Banks, C.L. Maxim, B. Hornik, J.B. Velotta
• Journal: AME Case Reports
• Published: 2022;6:33
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Bronchopleural fistula (BPF) is a seldom encountered yet serious complication after thoracic surgery, and is often difficult to treat. Large BPFs usually require surgical intervention, and a variety of different surgical reconstruction options have been previously described. This case report presents the first description of a successful vertical rectus abdominis myocutaneous (VRAM) free flap repair of a BPF after pneumonectomy.

Case Description: A 46-year-old male with a cough was found to have a right upper lobe lung mass with hilar involvement initially remarkable for epithelioid malignant mesothelioma on biopsy. After neoadjuvant chemotherapy, he underwent right extrapleural pneumonectomy and developed a late right mainstem BPF with associated empyema from adjuvant chemotherapy and COVID-19 pneumonia. He was treated with open Clagett window (OCW) to address the infection and then staged VRAM free flap coverage of the BPF. The patient recovered successfully and has since been able to pursue more demanding activities at home.

Conclusions: This case presents the only successful VRAM free flap for a BPF involving the entire right mainstem bronchus at the carina. VRAM free flap repair offers a useful treatment option for BPFs, especially in patients with large pleural cavity defects.

2022 AME Case Reports. All rights reserved.

In plain English

This article is a case report about one patient. It does not mention asbestos exposure. A 46-year-old man with a 12 pack-year smoking history had a right upper lobe lung mass. A biopsy first showed epithelioid malignant mesothelioma. After chemotherapy and immunotherapy his disease progressed, and he had urgent palliative right extrapleural pneumonectomy (removal of the right lung and its lining). Final pathology showed marginal zone B-cell lymphoma without evidence of malignant mesothelioma. On post-operative day 82, after further chemotherapy and a COVID-19 pneumonia hospitalization, bronchoscopy found his stapled right main airway stump had completely come apart, with infection (empyema). During surgery opening the chest wall to clear infection (open Clagett window), surgeons saw a 2 cm bronchopleural fistula, an abnormal opening between airway and chest cavity. 106 days later, they covered it with abdominal muscle and skin moved to the chest (a VRAM free flap). The only notable complication, persistent air under the skin, needed a chest tube for 39 days before resolving. The authors concluded this repair offers a useful option, especially for large chest cavity defects.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 46-year-old previously healthy man with a prior 12 pack-year smoking history who had a right upper lobe lung mass; treated at Kaiser Permanente Northern California, Oakland, CA, USA
• Exposure: The article does not report any asbestos or fiber exposure. The only exposure history given is smoking (12 pack-years). The article is about a surgical repair technique.
• Main results:
  • A biopsy initially showed epithelioid malignant mesothelioma, but the final pathology after pneumonectomy showed marginal zone B-cell lymphoma without evidence of malignant mesothelioma
  • On post-operative day 40 the patient started adjuvant chemotherapy and was admitted for COVID-19 pneumonia, staying in hospital for 30 days
  • On post-operative day 82, bronchoscopy found the right main bronchus stump completely dehisced (split open) with an associated empyema
  • At the open Clagett window operation on post-operative day 88, a 2 cm bronchopleural fistula was seen at the right main bronchus opening
  • On day 106 after the open Clagett window, the patient had VRAM free flap repair to cover the fistula and pleural cavity
  • The only notable complication was persistent subcutaneous emphysema (air under the skin). It was treated with a chest tube placed on post-operative day 13, which stayed in for 39 days until the emphysema resolved.
  • Breathing and activity improved after the repair. The patient still needed low-dose oxygen at home but could go without it for several hours at a time.
• The authors' conclusion: The authors concluded that VRAM free flap repair offers a useful treatment option for bronchopleural fistulas, especially in patients with large pleural cavity defects
• Limitations the authors state:
  • The authors state that the long-term effectiveness of the VRAM free flap compared with other coverage options for bronchopleural fistula is unclear
  • The authors state there is no evidence establishing the complication burden of VRAM flap reconstruction for bronchopleural fistula defects

Topics

Medical terms in this study, explained in our Lexicon: Pneumonectomy, Thoracic Surgery, Epithelioid, Mesothelioma, Biopsy, Neoadjuvant Therapy, Extrapleural Pneumonectomy (EPP), Empyema.

Related studies

• Transsternal transpericardial operations in the treatment of bronchopleural fistulas after pneumonectomy — G. Stamatis, G. Martini, et al. (1996)
• Single site venovenous extracorporeal membrane oxygenation as an alternative to invasive ventilation in post-pneumonectomy fistula with acute respiratory failure — M. Fica, F. Suárez, et al. (2012)
• Rectus abdominis muscle resection for abdominal wall recurrence of mucinous adenocarcinoma or peritoneal mesothelioma — T. Yan, P. Sugarbaker (2008)
• Healing of bronchopleural fistula using a modified Dumon stent: a case report — G.M. Ferraroli, A. Testori, et al. (2006)
• The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients — M. Beshay, G. Carboni, et al. (2008)
• Radical extrapleural pneumonectomy with bronchial fistula by pulmonary function test evaluation technique — S. Marzban-Rad, R. Bozorgmehr, et al. (2021)

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