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Ann Thorac Surg 2000;69:986-988
© 2000 The Society of Thoracic Surgeons

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ORIGINAL ARTICLES: GENERAL THORACIC

Latissimus dorsi reverse flap to substitute the diaphragm after extrapleural pneumonectomy

^a Division of Thoracic Surgery, National Cancer Institute, Milan, Italy

Address reprint requests to Dr Bedini, Via P. Sottocorno 17, 20129 Milano, Italy

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. The standard procedure for diaphragm reconstruction after extrapleural pneumonectomy for a malignancy consists of the use of prosthetic patches. Our original technique utilizing the reverse flap of the latissimus dorsi is evaluated.

Methods. Once the extrapleural pneumonectomy is performed, the distal portion of the latissimus dorsi, which has been divided with a standard posterolateral thoracotomy at the level of the fifth to sixth rib, is elevated into the chest through the passage obtained by resection of the tenth rib and sutured to the lower pericardium and to the chest wall. Nine patients were evaluated.

Results. No operative death occurred. No flap-related complication nor infection was postoperatively assessed. Six patients received adjuvant radiotherapy. No late complication was observed.

Conclusions. The distal latissimus dorsi can be used for total reconstruction of one hemidiaphragm, ensuring a watertight separation between the pleural and peritoneal cavities and avoiding paradoxical respiratory motion. In our opinion, the technique was easier, faster, and more reliable than the standard procedure employing prosthetic materials. We recommend that the procedure be integrated with the standard technique of extrapleural pneumonectomy.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Total reconstruction of one hemidiaphragm is an uncommon procedure. However, thoracic surgeons involved in the treatment of malignant pleural mesotheliomas often may have to repair the extended resection required by the extrapleural pneumonectomy (EPP) technique, creating a watertight separation between the pleural and peritoneal cavities and stabilizing the mediastinum to reduce paradoxical respiratory motion to a minimum. The use of prosthetic materials is routine [1–3].

We first described the use of the distal latissimus dorsi (LD) elevated as a reverse flap to repair large defects after an extended diaphragmatic resection in the adult [4]; the technique was evaluated in a small series of 6 patients with a variety of characteristics, surgical procedures, and extent of resection. However, it was judged worthy of integration into our current procedure of EPP. We report our experience on the use of LD to repair the resection of one hemidiaphragm after EPP.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Demographic data and preoperative staging
Nine consecutive patients were submitted to an EPP at our division during the period from April 1995 to May 1998. They underwent diaphragmatic reconstruction with the reverse flap of the distal portion of the LD according to a technique previously described in detail [4]. The male to female ratio was 5:4. The mean age was 50 years (range, 30 to 65 years). Seven patients had malignant pleural mesothelioma; the pathologic stage [5] was I in 3 patients and III in 4 patients. One patient had recurrent hemangiopericytoma of the diaphragm. The patient had been submitted to a partial resection of the left hemidiaphragm 9 years before and was unsuccessfully treated with chemotherapy when an intrapleural megamass was diagnosed 8 years later at another institution. There also was 1 patient with metastatic chondrosarcoma of the mandibula (resected 5 years before) who had been treated previously with chemotherapy. Disease involved the left side in four patients.

The preoperative routine staging included physical examination, chest x-rays, bronchoscopy, and computed studies of the brain, chest, and upper abdomen. Additional procedures such as bone scan or esophageal endosonography were performed in selected cases. Cardiac, hepatic, renal, and respiratory functions were assessed. A quantitative differential lung perfusion scan was obtained in each patient. The predicted postresection forced expiratory volume in 1 second was required to be more than 1.1 L.

Operative technique
The approach consists of a posterolateral incision with division of the LD from its medial margin at the level of the sixth rib, straight to the lateral margin at the level of the fifth rib. The serratus anterior muscle is mobilized to avoid its division in performing the primary thoracotomy. After subperiosteal resection of the sixth rib, the extrapleural blunt dissection of the lung is begun. The subsequent procedures, except for diaphragmatic resection and reconstruction, follow the technique proposed by Sugarbaker and colleagues [3], with minor modifications. Once dissection of the parietal pleura is obtained (before the pericardial resection is approached), the denervated distal portion of the LD is mobilized through extrafascial planes just down to the tenth rib. The posterolateral subperiosteal tract of the tenth (or ninth) rib is then resected over a distance of approximately 10 cm, starting from the margin of the spinalis muscle. Complete excision of the hemidiaphragm is then performed. The second thoracotomy can be extended by division of the intercostal muscles, if required. Pericardial resection and suture of the pulmonary vessels and the mainstem bronchus are finally performed, and the surgical specimen is removed. The distal portion of the LD is brought into the chest through the passage obtained by resection of the tenth (or ninth) rib. The apex of the flap is fixed to the most distant point of the diaphragmatic defect, then the medial margin to the lower pericardium, and finally the lateral margin to the chest wall by means of to-and-fro continuous Maxon 1 mattress sutures, which are extended to the point of entry of the flap into the chest (Fig 1). At this site, the superior fascial and superficial portion of the flap is sewn to the overlying tissue (consisting of the periostium of the resected tenth [or ninth] rib and the ninth [or eighth] intercostal muscle) with a tight continuous Maxon 00 mattress suture to construct a new costophrenic sinus. The chest is then closed. The distal margin of the proximal portion of the LD is sutured to the posterior margin of the serratus anterior, and both muscles to the rib plane with a continuous Maxon 1 mattress suture, in accord with their original anatomic position. A very limited detachment of the tendon of the serratus anterior muscle from the scapula tip occasionally may be necessary. A chest tube is left at the bottom of the pleural cavity to allow drainage of fluids and another at the apex of the chest to properly position the mediastinum. One drain is placed in the subcutaneous plane. A peritoneal drain is provided only if the peritoneal membrane was damaged by the maneuvers in performing the diaphragmatic resection. Postoperative cephalosporin and calciparine are administered routinely.

View larger version (29K): [in this window] [in a new window]   Fig 1. A computed tomographic-like axial image of the reconstruction of the left hemidiaphragm. (A) Reverse flap of the latissimus dorsi. (B) Lower pericardium. (C) Tenth rib (resected). (D) Spinalis muscle. (E) Right hemidiaphragm.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The surgical procedure was macroscopically nonradical (R2) in 1 patient with mesothelioma and radical at macroscopic and microscopic evaluation (R0) in the remaining 8 patients. In 1 patient in whom the resection involved half of the lower pericardium, the suture between the flap and the remnant pericardium was reinforced by a prosthetic mesh because of tension of the sutured tissues. The patient with recurrent hemangiopericytoma underwent an additional chest wall resection, which was reconstructed by means of a prosthetic mesh and methacrylate; repair of the spleen (accidentally damaged) was also required. The patient with metastatic chondrosarcoma had a subtotal resection of the diaphragm, the remnant medial portion of which was sutured to the flap.

The mean duration of operation was 4.5 hours (range, 2.5 to 6 hours). No paradoxical respiratory motion or signs of a nonwatertight separation between the pleural and peritoneal cavities were observed. Postoperative complications included one case of "slow recovery" without any objective impairment. There was one case of atrial fibrillation. Malfunctioning of the abdominal drain required two transcutaneous blood aspirations from the upper peritoneal cavity in the patient who had had intraoperative spleen damage. Repeated needle aspirations were required in 2 patients with subcutaneous seromas, which resolved within 40 days of operation. One patient had a bronchopleural fistula without empyema after a right-sided EPP. Treatment consisted of tube thoracostomy and various endoscopic procedures, but recovery was not obtained. However, the patient remained free of infection until death (which occurred 8 months after the operation). Neither flap-related complications nor infections were assessed. No operative death occurred. The mean postoperative hospitalization was 20 days (range, 13 to 34 days).

Six patients (the 1 with metastatic chondrosarcoma and 5 of those with mesothelioma) received adjuvant radiotherapy at the lower chest wall, and the 5 with mesothelioma also at the surgical incision. The mean dose was 49.7 Gy (range, 42 to 55.8 Gy).

The mean postoperative observation period was 16.8 months (range, 6 to 45 months). The first 6 operated patients underwent physiatric and neurologic examinations at 3 to 4 months from resection: no impairment was observed as regards arm motion. None of the remaining 3 patients complained of reduced arm function, nor was it assessed at a standard physical examination.

Four patients suffered from recurrent mesothelioma at 5 to 7 months after operation, in all but 1 patient at distant sites. The patient with metastatic chondrosarcoma had a distant relapse 14 months after EPP and died 10 months later. The patient with hemangiopericytoma had a chest wall recurrence 43 months after EPP. She is free from disease at the 45th month of follow-up after R0 surgery, which required the partial resection of two ribs. The remaining 3 patients were alive and free from disease at 12 to 21 months.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Bianchi and coworkers [6] first used the reverse flap of the whole LD to treat diaphragmatic hernia in 3 neonates. The congenital absence of a diaphragm was repaired in 5 children by means of a resorbable patch and the innervated reverse flap of the whole LD by Wallace and Roden [7]. Our technique of repairing large diaphragmatic defects used only the distal portion of the LD [4] and was originally performed after an extended resection in the adult. It was developed in a small series of 6 patients submitted to a variety of surgical procedures but was judged worthy of integration in our current EPP technique.

The distal LD elevated as a reverse flap was utilizable for total reconstruction of one hemidiaphragm; the paraspinous dorsal perforating branches of the lower intercostal arteries and the lumbar vessels ensured a reliable vascular supply. The goals of achieving a watertight separation between the pleural and peritoneal cavities and avoiding paradoxical respiratory motion were obtained.

A reliable comparison between patients submitted to the procedure and those who had been treated by means of prosthetic materials during the previous 3 years was precluded: the limited number of patients in the former series and the small number of those included in the latter series, together with an imbalance in some relevant features in the patient sets did not allow any valid statistical analysis. However, in our opinion, our original technique was easier and faster not only due to the very satisfactory adaptability and plastic properties of the muscular tissue in repairing the diaphragmatic defects, but also because two demolitive procedures of EPP were transformed into means of reconstruction. In fact, the division of the LD required to perform the primary thoracotomy provided a nonfunctional portion of muscle that could be used to tailor a reliable neodiaphragm; the second thoracotomy, required for the diaphragmatic resection, was used as a passage for elevation of the flap into the chest.

The procedure was complication-free in the postoperative period and at mid- and long-term evaluations. Adjuvant high-dose radiation therapy had no adverse effects on the surgical result. No infection occurred, even in the patient with a bronchial stump fistula. In conclusion, the distal LD elevated as a reverse flap was utilizable for a very reliable reconstruction of one whole hemidiaphragm, thus confirming our previous evaluation [4]. We recommend that the procedure be integrated with the standard technique of EPP.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. DaValle M.J., Faber L.P., Kittle C.F., Jensik R.J. Extrapleural pneumonectomy for diffuse malignant mesothelioma. Ann Thorac Surg 1986;42:612-618.[Abstract]
2. Harlow C.L., Newell J.D., Cink T.M., Johnston M.R. Imaging of the expanded polytetrafluoroethylene prosthetic diaphragm following extrapleural pneumonectomy for mesothelioma. J Thorac Imag 1991;6:81-84.[Medline]
3. Sugarbaker D.J., Mentzer S.J., Strauss G. Extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma. Ann Thorac Surg 1992;54:941-946.[Abstract]
4. Bedini A.V., Valente M., Andreani S., Ravasi G. Reverse flap of distal latissimus dorsi for diaphragm reconstruction in the adult. J Thorac Cardiovasc Surg 1997;114:846-848.[Free Full Text]
5. International Mesothelioma Interest Group. A proposed new international TNM staging system for malignant pleural mesothelioma. Chest 1995;108:1122-1128.[Abstract/Free Full Text]
6. Bianchi A., Doig C.M., Cohen S.J. The reverse latissimus dorsi flap for congenital diaphragmatic hernia repair. J Pediatr Surg 1983;18:560-563.[Medline]
7. Wallace C.A., Roden J.S. Reverse, innervated latissimus dorsi flap reconstruction of congenital diaphragmatic absence. Plast Reconstr Surg 1995;96:761-769.[Medline]

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