1566 CASE REPORT BARON ET AL Ann Thorac Surg UNUSUAL CIRCUMFLEX ARTERY APPROACH 1995;59:1566-8

direct result of FES. We have not found an association be tween ischernic t ime and graft dysfunction [3], and the p ro longed per iod of ca rd iopu lmonary bypass was the direct result rather than the cause of donor organ dys- function. A previous episode of fatal acute graft dysfunc- tion has been repor ted due to widespread ernbolization of donor cerebral tissue leading to pu lmonary vascular occlusion and respira tory failure [4]. The donor, as in our case, had good gas exchange and the lungs were macro- scopically normal.

Al though we have not found the mode of donor death to significantly influence early outcome after pu lmonary t ransplanta t ion [3], the above report highlights the po- tential pitfalls in current donor selection criteria. The classic FES is character ized by the tr iad of acute respira- tory failure (with hypoxia and diffuse pu lmonary infil- trates), cerebral dysfunction, and petechial rash develop- ing within 72 hours of injury [5]. However, these criteria are not helpful when assessing the potent ial organ donor. Radiographic changes may be caused by pu lmonary contusion; cerebral dysfunction is impossible to assess, and due to blood transfusion, the pat ient may be throm- bocytopenic with petechiae. However, bronchoalveolar lavage may be used to predict the deve lopment of FES.

In a s tudy of 18 pat ients with long bone fractures, a mean of 63% of lavage cells contained intracel lular fat deposi ts in pat ients with confirmed FES compared with less than 2% in pat ients with no FES [6]. The technique descr ibed was simple, inexpensive, p roduced no false- posit ive results, and provided a result within 3 hours of bronchoalveolar lavage. However, a larger, prospect ive s tudy of pat ients with mult iple t rauma concluded that bronchoalveolar lavage lacked specificity for FES. Fat droplets were found in alveolar macrophages in associ- ation with sepsis, mul t iorgan failure, and even l ipid infusions [7]. Bronchoalveolar lavage may be used to predict the deve lopment of post t raumat ic adul t respira- tory distress syndrome in the absence of FES. At 48 hours after injury, the total cell count on bronchoalveolar la- vage was almost twice as high in pat ients with adul t respira tory distress syndrome and lung contusion com- pared with those without [8].

Currently, a round 30% to 40% of potent ial lung donors in the United Kingdom will have suffered major t rauma (unpubl i shed data). It is therefore impract ical to decline all lungs from pat ients with long-bone fractures. In view of the deficiencies in current assessment, more detai led analysis of donor bronchoalveolar lavage fluid obta ined before donat ion would be desirable, but it is not yet appl icable to lung transplantat ion.

R e f e r e n c e s

1. Sharpies LD, Scott JP, Dennis C, et al. Risk factors for survival following combined heart-lung transplantation. Transplanta- tion 1994;57:218-23.

2. Stewart S, Ciulli F, Wells FC, Wallwork J. Pathology of unused donor lungs. Transplant Proc 1993;25:1167-8.

3. Waller DA, Thompson AM, Wrightson WN, et al. Does the mode of donor death influence early outcome of pulmonary transplantation? J Heart Lung Transplant (in press).

4. Rosendale BE, Keenan RJ, Duncan SR, et al. Donor cerebral emboli as a cause of acute graft dysfunction in lung trans- plantation. J Heart Lung Transplant 1992;11:72-6.

5. Van-Besouw J-P, Hinds CJ. Fat embolism syndrome. Br J Hosp Med 1989;42:304-11.

6. Chastre J, Fagon J-Y, Soler P, et al. Bronchoalveolar lavage for rapid diagnosis of the fat embolism syndrome in trauma patients. Ann Intern Med 1990;113:583-8.

7. Vedrinne JM, Guillaume C, Gagnieu MC, Gratadour P, Pleu- ret C, Motin J. Bronchoalveolar lavage in trauma patients for diagnosis of fat embolism syndrome. Chest 1992;102:1323-7.

8. Pison U, Brand M, Joka T, Obertacke U, Bruch J. Distribution and function of alveolar cells in multiply injured patients with trauma-induced ARDS. Intensive Care Med 1988;14:602-9.

Complete Myocardial Revascularization Through a Right Thoracotomy Olivier Baron, MD, Phi l ippe Despins, MD, Daniel Duveau, MD, and Jean-Luc Michaud, MD

Department of Cardiovascular Surgery, H6pital La~nnec, Nantes, France

We report the case of a 57-year-old woman who benefited from a complete revascularization of the heart, including a circumflex marginal coronary bypass grafting, through a right thoracotomy. This approach avoids sternal wound complications that can occur after high-dose mediastinal radiotherapy and omental flap reconstruction on the sternum.

(Ann Thorac Surg 1995;59:1566-8)

A l though a m e d i a n s t e rno tomy is the s t a n d a r d incision for coronary ar tery bypass grafting, in

certain rare circumstances it mus t be avoided; for in- stance, in some cases of redo coronary ar tery bypass grafting for which redo s ternotomy has been associated with increased mortal i ty and morbidi ty, especial ly in patients with pa tent grafts to the anterior surface of the heart [1]. Before per forming a s ternotomy, it also is essential to consider the risk factors of sternal wound complications. For this reason, we prefer red a right thoracotomy for complete heart revascular izat ion in a woman who presented a high risk of sternal wound complications.

A 57-year-old woman had been t reated in 1983 for a left breas t adenocarc inoma by left radical m a m m e c t o m y (Patey), chemotherapy, and high-dose rad io therapy com- pl icated by skin necrosis. This necrosis requi red skin t ransplanta t ion and omenta l flap reconstruct ion on the left side of the thorax and the sternum. For several

Accepted for publication Oct 22, 1994.

Address reprint requests to Dr Baron, Cardiovascular Research, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada MSG 1X8.

© 1995 by The Society of Thoracic Surgeons 0003-4975/95/$9.50 0003-4975(94)00911-P

Ann Thorac Surg CASE REPORT BARON ET AL 1567 1995;59:1566-8 UNUSUAL CIRCUMFLEX ARTERY A P P R O A C H

months, angina developed, which eventual ly became unstable. The stress test revealed a very low level, at 25 W. Cardiac catheterization showed an ostial stenosis of the left main coronary ar tery and an ostial stenosis of the right coronary artery.

As s te rnotomy through t ransplan ted skin and omenta l flap reconstruct ion p resen ted a very high risk of sternal wound complications, we dec ided to per form the coro- nary artery bypass grafting through a right thoracotomy. After intubat ion with a s tandard endotracheal tube, the saphenous vein grafts were harves ted and the pat ient was pos i t ioned properly. We entered the chest through a right thoracotomy with resection of a port ion of the sixth rib in the usual subper ios tea l manner .

Card iopu lmonary bypass was es tabl ished between the right femoral artery, the right femoral vein, and the super ior vena cava. After the venti lat ion was s topped, the hear t ' s contents were discharged through the right supe- rior pu lmonary vein. After c lamping of the aorta, the right a t r ium was opened and 650 mL of crystal loid cardioplegia was infused through the coronary sinus. The rectal t empera tu re was main ta ined at 28°C.

After f l ipping the heart along the axis of both venae cavae, we had a very wide access to the left side of the hear t and to the circumflex-marginal artery. Two sutures of 2-0 silk were p laced deep in the myocard ium to expose the coronary artery; meanwhile , compresses p laced in the per ica rd ium main ta ined the hear t at a high level, avoiding traction of the coronary artery by the silk suture. The saphenous vein was p repared and the distal anasto- mosis done very easily. Then the graft was su tured to the ascending aorta through the t ransverse sinus of pericar- dium. In the same manner , the two other grafts were placed on the left anter ior descending ar tery and on the right coronary ar tery at the beginning of the third section. For these two last bypass grafts, exposure was easier because in the case of the left anterior descending ar tery it was not necessary to complete ly flip the heart along the axis of both venae cavae; and even simpler, in the case of the right coronary artery, the heart was left in the per icardium.

The aortic c lamping t ime was 47 minutes and the ca rd iopulmonary bypass t ime was 117 minutes. The pa t ien t had an uncompl ica ted pos topera t ive course and was d ischarged home on the fifteenth postoperat ive day.

Comment

Sternal wound complicat ion is a catastrophic complica- tion of open hear t operation, occurring in 0.4% to 5% of cases [2]. An abundance of risk factors for deve lopment of s ternal wound complicat ions have been cited in retro- spective studies [2, 3].

Because of its rarity, the presence of an omenta l flap reconstruct ion with t ransp lan ted skin on the s te rnum does not appear as a significant preopera t ive risk factor in those studies. However, it was obvious that perform- ing a s te rnotomy through such avascular tissue would incur a high risk of complicat ions and, as do others, we

think that prevent ion of sternal wound complicat ions should be a major goal in assuring the highest quali ty of cardiovascular surgical care [3]. For this reason we pre- ferred to perform the coronary ar tery bypass grafting through a lateral thoracotomy.

Lateral thoracotomy has long been wel l -known for the repai r of atrial septal defects [4] and often has been used for coronary ar tery bypass procedures [5, 6]. All of these reports concern left thoracotomy as an approach to isolated circumflex coronary bypass reopera t ions or after previous medias t ianal i r radiat ion [6]. Right thoracotomy has been repor ted for reoperat ive right coronary bypass procedures [7]; here we repor t its use for a complete revascularizat ion of the myocard ium with circumflex bypass. After r ight pneumonec tomy with per icardec- tomy, it is manda to ry to close the per ica rd ium with a patch to avoid possible herniat ion of the hear t [8]. Aware of that complication, it was obvious to us that after establ ishing the ca rd iopu lmonary bypass and a wide opening of the per icardium, it would become easy to remove the heart from the per icardium, f l ipping it along the axis of both venae cavae, al lowing very good access to the left side of the heart.

An endotracheal tube that allows selective venti lat ion may facilitate exposure for the cannulat ion of the supe- rior vena cava, but it is not mandatory , as shown in our observation. However, we think it is impor tant to have a wide access to the hear t through a large posterolateral thoracotomy that can suppor t the herniat ion of the hear t out of the per ica rd ium very easily.

Finally, we think that the cannulat ion of the right femoral ar tery is safer than that of the aorta through a lateral thoracotomy. Moreover, the fewer cannulas in the operat ing field, the easier it is to gain access to the heart. This is why we prefer red to cannulate the right femoral vein rather than the inferior vena cava. The cannula in the super ior vena cava was necessary to open the right atr ium to infuse the cardioplegia into the coronary sinus because of the presence of the two ostial stenoses.

Al though this technique is not in tended for common use, we present it to r emind surgeons of al ternat ives for select patients. If the median s ternotomy has become almost the exclusive incision used by cardiac surgeons, pe rhaps there are t imes when our t ra ining in thoracic surgery is of unique and distinct advantage in the care of pat ients with coronary ar tery disease.

References

1. Loop FD. Catastrophic hemorrhage during sternal reentry. Ann Thorac Surg 1984;37:271-2.

2. Newman LS, Szczukowski LC, Bain PR, Perlino CA. Suppu- rative mediastinitis after open heart surgery. Chest 1988;94: 546 -53.

3. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-87.

4. Rosengart TK, Stark ]F. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-40.

5. Faro RS, Javid H, Najafi H, Serry C. Left thoracotomy for

1568 CASE REPORT MORIURA ET AL Ann Thorac Surg JEJUNUM FOR BRONCHIAL FISTULA 1995;59:1568-70

reoperation for coronary revascularization. J Thorac Cardio- vasc Surg 1982;84:453-5.

6. Ungerleider RM, Mills NI, Wechsler AS. Left thoracotomy for reoperative coronary bypass procedures. Ann Thorac Surg 1985;40:11-15.

7. Uppal R, Wolfe WG, Lowe JE, Smith PK. Right thoracotomy for reoperative right coronary artery bypass procedures. Ann Thorac Surg 1994;57:123-5.

8. Groh J, Sunder-Plassman L. Heart dislocation following ex- tensive lung resection with pericardial resection. Anesthesist 1987;36:182-4.

Pedicled Jejunal Seromuscular Flap for Bronchocutaneous Fistula Shigeaki Moriura, MD, Atsushi Kimura, MD, Shuhei Ikeda, MD, Yasushi Iwatsuka, MD, Teruo Ikezawa, MD, and Kenichi Naiki, MD

Department of Surgery, Aichi Prefectural Owari Hospital, Ichinomiya, Japan

We report the successful closure of a complicated bron- chocutaneous fistula using a pedic led je junal flap. The fistula, secondary to tuberculosis and irradiation, previ- ously had been closed with a latissimus dorsi musculo- cutaneous flap. This initial repair failed. The recurrent fistulas were closed again using a jejunal seromuscular flap, and the chest wall defect was reconstructed with a rectus abdominis musculocutaneous flap.

(Ann Thorac Surg 1995;59:1568-70)

G rafting of the omen tum and transfer of muscle or a musculocutaneous flap commonly are employed to

close bronchial fistulae with chronic thoracic empyerna. When these methods are not available or have failed, a new approach is required. We repor t use of a pedic led jejunal seromuscular flap in the case of a complicated bronchocutaneous fistula.

A 77-year-old woman was referred to the hospital be- cause of a bronchocutaneous fistula. She had undergone gastrectomy with an omental resection for gastric cancer 35 years previously, followed by a s tandard radical mas- tectomy with rad io therapy for left breas t cancer 13 years later.

A 1.5-cm cutaneous fistula was located at the left second intercostal space. A sur rounding 20 cm × 6 cm area of skin demons t ra ted post i r radiat ion changes. Fis- tu lography demons t ra ted an abscess cavity toward the apex of the left lung, which was continuous with the left upper lobe bronchus. Culture of the pat ient ' s spu tum and fistula discharge indica ted the presence of tubercu- losis. Isoniazid, rifampicin, and s t reptomycin were ad- minis te red to the patient. Subsequent ly , the abscess

Accepted for publication Oct 26, 1994.

Address reprint requests to Dr Moriura, Department of Surgery, Nagoya Posts and Telecommunications Hospital, 2-2-5 lzumi Higashi-Ku, Nagoya, Japan 461.

cavity was dra ined and the chest wall, including the uppe r half of the i r radia ted site, was resected. After a repeat culture was negative for tuberculosis, closure of the fistula was a t t empted with a left la t iss imus dorsi musculocutaneous flap, which resis ted 25 m m Hg of bronchial pressure . The flap was also used to reconstruct the defect in the chest wall. Postoperatively, air leakage cont inued for 3 weeks and a cavity suggestive of a recurrent pleural fistula was ident if ied with computed tomography 1 month later. Recurrence of the cutaneous fistula occurred be tween the graft and the remain ing i r radia ted site 1 month later.

A definitive operat ion was pe r fo rmed on March 1, 1994. The lower two-thi rds of the lat issimus dorsi flap was de tached and the res idual i r radia ted chest wall was resected. Two pleural fistulas which measured 7 and 2 m m in diameter , respectively, were recognized. The larger fistula appea red consistent with the original fistula and was identif ied by previous sutures. A right rectus abdominis musculocutaneous flap was created using the entire length of the muscle. The abdomen was entered through the same incision. The arcade be tween the first and second jejunal vessels was t ransected and a 20-cm segment of je junum was isolated for the flap. The second to fourth jejunal vessels were t ransected so that the jejunal flap could reach the left apex; the je junum, measur ing about 80 cm, was sacrificed. The je junum for the flap was opened longi tudinal ly along the an t imesen- teric border (Fig 1). We held the seromuscular layer with Babcock's forceps and separa ted it from the mucosal layer using an electrocautery device. Thus, a jejunal seromuscular flap with a mesenter ic vascular pedicle was created. The flap was t ransposed through the re t rosternal space and the two fistulas were closed by approximat ing the muscular surface with suture. The flap covered most of the exposed visceral p leura and filled the apical cavity (Fig 2). A drainage tube was inser ted at the apex. The lower half of the chest wall defect was reconstructed with the rectus abdominis musculocutaneous flap (Fig 3). The postopera t ive course was excellent except for a small area of skin necrosis that occurred at the tip of the rectus abdominis flap, which resolved with conservative treat- ment. Air leakage from the drainage tube was not ob- served and the tube was removed on postopera t ive day 7, when the c-reactive protein level had normalized. The pat ient since has recovered to her original body weight and was doing well 7 months postoperat ively.

C o m m e n t

The pedic led jejunal flap offers many advantages when it is used to close a bronchial fistula. The flap features greater tensile s trength and is more easily hand led than is muscle flap. It has a rich vascular and lymphat ic supply to promote cure. Jejunum resists abdominal infections, as does the omentum. It has been repor ted that a jejunal flap can protect an infected aortic s tump [1]. Successful closure of vesicovaginal and rectovaginal fistulas by seromuscular flaps of small intest ine has demons t ra ted that the flap is suitable for repai r of an i r radia ted site [2].

© 1995 by The Society of Thoracic Surgeons 0003-4975/95/$9.50 0003-4975(94)00970-t