Pedicled intercostal muscle flap: a simple technique of closing pancreatico-pleural fistula from a thoracic approach

European Journal of Cardio-thoracic Surgery 22 (2002) 831–832 www.elsevier.com/locate/ejcts

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Pedicled intercostal muscle flap: a simple technique of closing pancreatico-pleural fistula from a thoracic approach Khalid Amer*, Balakrishnan Mahesh, Raimondo Ascione Department of Cardiothoracic Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK Received 27 May 2002; received in revised form 15 July 2002; accepted 30 July 2002

Abstract A simple technique to close a pancreatico-pleural fistula in the course of thoracotomy and decortication for multiloculated empyema complicating acute haemorrhagic pancreatitis is described. Friable diaphragmatic tissue around the fistula made direct closure not a suitable option. The intercostal muscle flap of the thoracotomy space was mobilized on the anterior intercostal artery, tagged around the fistula into healthy diaphragmatic tissue. This simple technique was successful in closing the fistula and helping control the sepsis. q 2002 Elsevier Science B.V. All rights reserved. Keywords: Pancreatico-pleural fistula; Empyema; Decortication; Pedicled intercostal muscle flap; Pancreatitis

1. Case description

2. Surgical repair

A 22-year-old man was diagnosed by computed tomography (CT) of the chest to have multiloculated left-sided empyema, complicating acute haemorrhagic pancreatitis. The pleural space was drained by placement of an intercostal chest drain. Three litres were drained in the first 24 h of sero-purulent fluid. Pseudomonas organisms were isolated from the pleural fluid and appropriate antibiotics were commenced. CT scan of his abdomen revealed the presence of a large 8-cm diameter peripancreatic fluid collection, and very little enhancing normal pancreatic tissue remaining. Soon after this investigation a left flank boil came to a point and burst with pus. This proved to be a persistent sinus, shown by contrast sinugraphy to communicate with a large abscess cavity in the region of the pancreatic head and tail. A Pigtail catheter was inserted through the track to drain an average of 250–300 ml of purulent fluid per day. However, despite drainage of the collections, he remained ill and toxic and therefore underwent combined left thoracotomy, lung decortication, and retroperitoneal pancreatic necrosectomy. A pancreatico-pleural fistula was seen during the thoracic procedure and treated as described below. The patient made a complete recovery, and repeat CT scan of the chest and abdomen 6 weeks later showed absence of fluid recollection.

The chest was opened through the fifth intercostal space. The findings were those of typical chronic empyema, with 1.5-cm thick parietal pleura, and an empyema cavity occupying most of the hemithorax. The lung was trapped by a thick rind of visceral pleura and formal lung decortication allowed the lung to fully expand. A 1-cm diameter fistulous track was noted, communicating the retroperitoneal pancreatic abscess and the empyema cavity, situated in the central tendon of the diaphragm, close to the pericardio-diaphragmatic angle. The margin of the fistula was lined with friable granulation tissue. Direct suture of the fistula would have resulted in undue tension and eventually break down of tissue. Therefore, the thoracotomy space intercostal muscles were mobilized as a flap based on the anterior intercostal vascular bundle. This was achieved by diathermy flush with the subcostal groove of the rib. The anterior limit of mobilization fell short of the left internal mammary artery, and posteriorly the flap was disconnected near the vertebral end. The free end of the flap was allowed to bleed to confirm viability. We thought this step was necessary as this arrangement is the reverse of the usual intercostal blood supply. The flap was tagged down to seal off the fistula, using interrupted 3/0 Prolene stitches taken into healthylooking tissue 1.5 cm away from the fistula (Figs. 1 and 2). The pedicle was of sufficient length not to interfere with full expansion of the lung, neither was its blood supply hampered by the lung full expansion. The thoracotomy was

* Corresponding author. Tel.: 144-117-928-3835; fax: 144-117-9283871.

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K. Amer et al. / European Journal of Cardio-thoracic Surgery 22 (2002) 831–832

Fig. 2. Drawing of the same photograph showing the anatomical landmarks and the site of the pancreatico-pleural fistula covered by the muscle flap. Fig. 1. Thoracotomy space view after full decortication of the lung. The intercostal pedicled muscle flap could be seen stitched around the pancreatico pleural fistula.

then closed over two standard, apical and basal drainage tubes, and retroperitoneal necrosectomy and debridement was performed through a separate left flank incision below the 12th rib. The abscess cavity was adequately drained by the placement of two large-bore tubes, and the wound was closed in layers with delayed absorbable sutures.

abdominal approach had been previously described [4]. To the best of our knowledge the intercostal muscle flap technique has not been described before. We feel that this simple technique should be used more often in such cases, especially where the management of the patient depends solely on successful clearance of sepsis.

References 3. Discussion Empyema rarely complicates acute pancreatitis [1], and the presence of pancreatico-pleural fistula is estimated to be 1% [2–4]. Pancreatico-pleural fistula is an epithelialized track directly communicating the source of pancreatic enzymes and the pleural space. The fistula could originate directly from the pancreatic ductal system or most commonly, from an enlarging pseudocyst [3]. Pancreaticopleural fistulae are often demonstrable radiologically, or endoscopically by retrograde cholangio-pancreatography (ERCP) [5,6]. Such imaging techniques including CT scan may fail to demonstrate the fistula [3]. In our case the presence of a pancreatico-pleural fistula was not suspected and the diagnosis was made on gross observation at the time of surgery. This is in complete agreement with the experience of Cameron et al. [8]. Treatment of these fistulas remains controversial, and surgical closure is considered unnecessary [3], as stenting the pancreatic duct and debridement of the abscess stops further drainage into the chest [7]. Debridement of the fistula and direct closure from an

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[1] Iacono C, Procacci C, Frigo F, Andreis IA, Cesaro G, Caia S, Bassi C, Pederzoli P, Serio G, Dagradi A. Thoracic complications of pancreatitis. Pancreas 1989;4(2):228–236. [2] Grossman A, Jackson BT, Thompson RP, Braimbridge MV. Pancreatico-broncho-pleural fistula as a complication of acute pancreatitis. Br J Clin Pract 1978;32(10):298–301. [3] Burgess NA, Moore HE, Williams JO, Lewis MH. A review of pancreatico-pleural fistula in pancreatitis and its management. HPB Surg 1992;5(2):79–86. [4] Chen HY. Pancreatico-pleural fistula an unusual complication of pancreatitis. J Surg Assoc ROC 1998;31(1):37–40. [5] Fulcher AS, Capps GW, Turner MA. Thoracopancreatic fistula: clinical and imaging findings. J Comput Assist Tomogr 1999;23(2):181– 187. [6] Ihse I, Lindstrom E, Evander A, Lundstedt C. The value of preoperative imaging techniques in patients with chronic pancreatic pleural effusions. Int J Pancreatol 1987;2:269–276. [7] Saeed ZA, Ramirez FC, Hepps KS. Endoscopic stent placement for internal and external pancreatic fistulas. Gastroenterology 1993;105(4):1213–1217. [8] Cameron JL, Kieffer RS, Anderson WJ, Zuidema GD. Internal pancreatic fistulas: pancreatic ascites and pleural effusion. Ann Surg 1976;184(5):587–593.