A Case Of Chronic Empyema With Pulmonary Fistula After Right Upper Lobectomy Effectively Treated Via Plombage Of A Pedicled Latissimus Dorsi Musculocutaneous Flap

A thin 78-year-old man (height 169 cm, weight 51 kg) was found to have an abnormal shadow in the chest in November 2016. Lung cancer was suspected, and he underwent right upper lobectomy at Hospital A in February 2017. The pathological diagnosis was lung abscess. In May 2017, he produced a large amount of purulent sputum and examination showed decreased niveau in the dead space after the right upper lobectomy. Bronchoscopy showed no bronchial stump fistula. Thoracoscopy revealed a pulmonary fistula in the right lower lobe. Pleural effusion was positive for grain-negative bacillus. and empyema with pulmonary fistula was diagnosed. Three-dimensional computed tomography angiography showed that the right thoracodorsal artery (side of previous surgery) was intact. Plombage of a pedicled latissimus dorsi musculocutaneous flap was planned. In July 2017, surgery was performed. While preserving the thoracodorsal artery (feeding vessel), a large musculocutaneous flap (including a 28x10 cm spindle-shaped skin island) was harvested. The second, third, and fourth ribs were resected, and the empyema cavity was opened. The created musculocutaneous flap was introduced into the empyema cavity, and the volume of the musculocutaneous flap was found insufficient to till the entire cavity. The flap was fixed by suturing so that it covered the pulmonary fistula, and part of the empyema cavity remained open. There was no postoperative impairment of upper-limb motor dysfunction due to loss of the latissimus dorsi muscle. The musculocutaneous flap survived well. Two months after surgery, the patient was allowed to take a bath while lesion remained open, and was discharged from the hospital. Twelve months after the musculocutaneous flap plombage, favorable epithelialization of the empyema cavity was observed. For successful plombage of musculocutaneous flaps, it is important to cooperate with plastic surgeons with highly specific skills. However, when the volume of the musculocutaneous flap is insufficient to fill the entire empyema cavity, additional thoracoplasty or combination with open window thoracostomy may be needed.