Schreiner W, Fuchs P, Autschbach R, Pallua N, Sirbu H
Department of Thoracic Surgery, Friedrich-Alexander-University, Erlangen, Germany.
Thorac Cardiovasc Surg. 2010 Mar;58(2):98-101. doi: 10.1055/s-0029-1186268. Epub 2010 Mar 23.
Thoracomyoplasty after prior posterolateral thoracotomy (PLT) remains a challenge for the thoracic surgeon. Thoracodorsal artery division after PLT impairs the vascularization supply of the latissimus dorsi muscle (LDM) resulting in muscle mass reduction due to distal atrophy. This makes adequate filling of residual empyema space and/or surgical closure of bronchial stump insufficiency more difficult, and they require alternative surgical procedures. We present an alternative approach using a four-muscle flap technique to include the infraspinatus, the subscapularis and the teres major muscle group, all pedicled from the subscapular artery as a part of a modified thoracomyoplasty technique for closing residual empyema space and bronchial stump insufficiency.
Between 2002 and 2008 we performed the technique in 7 patients with residual empyema space. Three patients had post-tuberculosis syndrome, 2 had postpneumectomy empyema, and 2 had chronic parapneumonic empyema. Three cases were combined with a bronchopleural fistula. All patients underwent a two-stage procedure. First, open window thoracostomy was performed followed by definitive surgical treatment after 3-6 months. In all cases with bronchial insufficiency the stump was covered with a subscapularis muscle flap. The infraspinatus and the teres muscle group were used in combination with a local thoracoplasty.
Mean age was 68 +/- 7.9 years. Time from open window thoracostomy to thoracomyoplasty averaged 4 +/- 1.3 months. The number of resected ribs ranged between 4 and 8. Mean postoperative stay in the ICU was 3 +/- 2.9 days. The thoracic drains were removed after 5 +/- 2.3 days. Total hospital stay was 15 +/- 7.6 days. No hospital mortality was noted. Minor postoperative complications occurred in 2 cases. Shoulder function without pain allowed abduction up to 90 degrees. Function was decreased by 16 +/- 9 degrees compared to preoperative evaluation. No severe progressive scoliosis was noted.
Division of the LDM and its vascular supply after posterolateral thoracotomy results in a reduction of muscle mass. The shoulder girdle muscles offer an adequate alternative to fill residual empyema space with acceptable long-term results and restriction in shoulder motion. In all cases with bronchial fistula, bronchial stump closure with a pedicled subscapular muscle was an effective alternative operative technique.
在先前进行后外侧开胸术（PLT）后进行胸廓成形术对胸外科医生来说仍然是一项挑战。PLT后胸背动脉离断会损害背阔肌（LDM）的血管供应，导致由于远端萎缩而使肌肉量减少。这使得充分填充残留脓腔和/或手术闭合支气管残端不足变得更加困难，并且需要采用替代手术方法。我们提出一种替代方法，即使用四肌瓣技术，包括冈下肌、肩胛下肌和大圆肌群，所有这些肌肉均由肩胛下动脉供血，作为改良胸廓成形术技术的一部分，用于闭合残留脓腔和支气管残端不足。
2002年至2008年期间，我们对7例有残留脓腔的患者实施了该技术。3例患有结核后综合征，2例患有肺切除术后脓胸，2例患有慢性肺炎旁脓胸。3例合并支气管胸膜瘘。所有患者均接受两阶段手术。首先进行开窗胸廓造口术，3至6个月后进行确定性手术治疗。在所有支气管残端不足的病例中，残端均用肩胛下肌瓣覆盖。冈下肌和大圆肌群与局部胸廓成形术联合使用。
平均年龄为68±7.9岁。从开窗胸廓造口术到胸廓成形术的时间平均为4±1.3个月。切除肋骨的数量在4至8根之间。术后在重症监护病房的平均停留时间为3±2.9天。胸腔引流管在5±2.3天后拔除。总住院时间为15±7.6天。未观察到医院死亡病例。2例发生轻微术后并发症。肩部功能无疼痛，外展可达90度。与术前评估相比，功能下降了16±9度。未观察到严重的进行性脊柱侧弯。
后外侧开胸术后LDM及其血管供应的离断导致肌肉量减少。肩胛带肌提供了一种合适的替代方法来填充残留脓腔，具有可接受的长期效果且肩部活动受限。在所有支气管瘘病例中，用带蒂肩胛下肌闭合支气管残端是一种有效的替代手术技术。
