BACKGROUND:Bronchial stump fistula (BSF), which is located on the bronchial stump following pulmonary resection, represents a distinct subtype of bronchopleural fistula (BPF). Although the endobronchial valve (EBV) has been used to treat BPF, few clinical studies involve BSF occluded by EBV because the abnormal bronchial stump makes EBV implantation challenging. The present research reports novel methods of using a circular loop ligation technique for securing EBV to achieve BSF occlusion and a new classification of BSF that is compatible with these novel methods. METHODS:Based on the length of the bronchial stump, small visible BSF (SVBSF, less than 8 mm) is classified into the following types: SVBSF1 (< 3 mm), SVBSF2 (≥ 3 mm but shorter than a normal bronchus), and SVBSF3 (preserves a complete bronchial structure). SVBSF2 is further classified into SVBSF2a (the stump base remains partially intact) and SVBSF2b (complete destruction of the stump base). This retrospective research involved SVBSF2 patients who underwent EBV fixation with circular loop ligation. Detailed medical records were collected and analyzed to evaluate the efficacy of the novel procedure. RESULTS:A total of 15 patients underwent EBV implantation and fixation. All patients achieved a resolution of air leakage. Postoperative assessment revealed no instances of EBV displacement among VBSF2a patients, with all cases exhibiting significant improvement. CONCLUSIONS:The circular loop ligation methods for securing the EBV enable effective BSF closure in SVBSF2, especially SVBSF2a cases. This technique enables some BSF patients with abnormal structures at bronchial stumps to successfully perform the EBV occlusion.

BACKGROUND:Chronic empyema with bronchopleural fistula (BPF) after pulmonary resection is difficult to treat. The aim of the study is to explore the efficacy of autologous muscle flap or myocutaneous flap on chronic empyema with BPF. METHODS:Retrospective analysis of 10 patients with postoperative chronic empyema with BPF treated in our hospital, including 8 males and 2 females, with ages ranging from 20 to 83 years, yielding an average age of (51.00 ± 19.22) years. The treatment of all patients with chronic empyema follows a staged surgical model. The first stage of surgery involves debridement, partial rib resection, and fistula closure, while the second stage includes autologous muscle flap transposition or free myocutaneous flap transplantation to eliminate the abscess cavity. The primary objectives of the first-stage surgery include ensuring adequate drainage, controlling infection, and achieving fistula closure. In contrast, the key focus of the second-stage surgery is the complete filling of the abscess cavity with a sufficient volume of autologous tissue flap. RESULTS:There were no perioperative deaths. The average follow-up was (19.88 ± 9.03) months. None of the 10 patients had recurrence of empyema and BPF. All autologous muscle flaps or myocutaneous flaps survived. Postoperative chest computed tomography (CT) or magnetic resonance imaging (MRI) showed that the abscess cavity disappeared. CONCLUSIONS:The application of autologous muscle flap or myocutaneous flap represents an effective approach for the treatment of chronic empyema with BPF, demonstrating satisfactory clinical outcomes in the short to medium term.

ABSTRACTThe bronchopleural fistula (BPF) is a pathological passageway between the bronchus and the pleural cavity. Diagnosing and localising BPF can be challenging, and the traditional retrograde methylene blue (MB) perfusion method may fail to identify multifocal BPFs. This article reports a novel method for locating multifocal BPFs in patients undergoing concurrent empyema debridement. Initially, selective endobronchial injection of MB solution is performed under bronchoscopic guidance. Subsequently, the thoracic surgeon determines the location of BPFs as the MB solution flows into the pleural cavity. This process of injecting MB within the bronchus is repeated to locate any additional BPFs until no new ones are found. We report a case where this new method was used to identify multifocal BPFs, ultimately diagnosing three BPFs' presence. Following treatment with bronchopleural fistula occlusion, no recurrence of BPFs was observed during the follow‐up period.

Empyema is one of the most dangerous complications in thoracic surgery. It can easily progress to severe empyema with life-threatening conditions that are extremely challenging to treat. We successfully treated a patient with critically severe empyema via extracorporeal membrane oxygenation (ECMO), and the patient eventually recovered and was discharged. A 64-year-old male developed empyema 5 years ago. The thoracic infection led to a breakdown of the left chest wall. During hospitalisation, the patient's condition gradually deteriorated. We promptly initiated ECMO support and performed multiple debridement surgeries, fistula closure, targeted anti-infection treatment, and nutritional support. Ultimately, the patient's condition improved, as he eventually recovered and was discharged.

Background: In the realm of thoracic surgery, addressing chest wall defects accompanied by infections remains a formidable task. Despite the availability of a spectrum of surgical options, attaining clinical resolution is particularly challenging in intricate cases involving extensive chest wall defects in elderly patients. Thorough debridement followed by the utilization of autologous tissue for repair and reconstruction has emerged as a prevalent approach in current clinical practice. Case presentation: Herein, we present a 72-year-old female patient with a large chest wall defect and infection. She has experienced left breast cancer surgery, multi cycle radiotherapy and chemotherapy. Nine months ago, there was yellow purulent fluid in the left chest wall. She had undergone debridement in other hospital, and the treatment effect was poor. At our hospital, Chest computed tomography (CT) imaging revealed a soft tissue anomaly on the left side of the chest wall, along with partial rib bone deterioration. Considering the patient's clinical presentation and radiological findings, a tentative diagnosis of an infected chest wall defect and chronic osteomyelitis was established. Consequently, daily dressing changes were deemed necessary for the patient's infected chest wound. Surgery for chest wall repair and reconstruction was scheduled once the wound area exhibited cleanliness with emerging granulation tissue. Preoperatively, a myocutaneous flap of an appropriate size was meticulously planned. During the surgical procedure, initial debridement of the infected chest wall area was conducted, followed by the strategic placement of a harvested pedicled latissimus dorsi myocutaneous flap to rectify the defect. Postoperative care involved stringent anti-infective measures, anti-spasmodic treatment, and preventive anticoagulation, accompanied by vigilant monitoring of the myocutaneous flap's viability and the healing progress of the defect site. Conclusions: Utilizing the pedicled latissimus dorsi myocutaneous flap for repairing extensive defects in the chest wall presents a viable and efficient strategy. This technique preserves cardiopulmonary functionality and maintains the thoracic contour. The outcomes observed in the short to medium term postoperatively have been consistently gratifying.

Chronic empyema after total pneumonectomy is a potentially fatal complication.The aim of the study is to explore the treatment strategy and clinical efficacy of chronic empyema after pneumonectomy. A retrospective analysis of 6 patients with chronic empyema after pneumonectomy in our hospital. Utilizing a staged surgical model, the treatment approach involved rib debridement drainage, open-window thoracostomy (OWT), and the application of autologous tissue flaps, including free myocutaneous flap, pedicled muscle flap, and pedicled greater omentum, to effectively eliminate the abscess cavity. All patients with empyema were successfully treated after surgery, with follow-up durations ranging from 3 to 29 months and an average of (10.50 ± 9.67) months. Re-examination using chest computed tomography (CT) or magnetic resonance imaging (MRI) revealed that the empyema residual cavity had either completely disappeared or had significantly reduced. The treatment of chronic refractory empyema after total pneumonectomy by rib debridement drainage, OWT and autologous tissue flap transplantation has a high cure rate and satisfactory clinical effect.

Background Chronic empyema with chest wall sinus is a difficult and complex disease caused by multiple causative factors. It is difficult to control local infection due to its possible combination of bronchopleural fistula (BPF) and residual bone.The relevant literature emphasizes some risk factors for empyema progression after pneumonectomy, while the correlation between empyema and BPF after pneumonectomy increases mortality by infecting the remaining lungs. After pneumonectomy, the lung function of the contralateral side is particularly important. Case presentation This paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 12 years ago and began to develop empyema with anterior chest wall sinus 3 years ago. After admission, chest computed tomography (CT) showed right pleural effusion and formation of chest wall sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the huge residual cavity of the patient,the clinical effect of using free vastus lateralis myocutaneous flap combined with pedicled pectoralis major muscle flap to fill the abscess cavity was satisfactory,but acute respiratory failure occurred due to left lung aspiration pneumonia after operation. Conclusions After a series of treatment measures such as tracheal cannula, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, the patient was ultimately rescued and cured. Postoperative follow-up showed that the muscle flaps survived and empyema was eliminated.

BACKGROUND:Chronic empyema is usually considered to be very challenging in clinical management and has a high mortality rate. On this basis, if combined with bronchopleural fistula (BPF) and huge irregular abscess cavity, there are not many treatment options available, and some patients may even develop cachexia due to long-term chronic consumption. The application of pedicled combined muscle flaps to repair and reconstruct according to the region of abscess cavity may improve the quality of life for such complex cases. CASE PRESENTATION:A 59-year-old male patient underwent surgical treatment for lung squamous cell carcinoma 2 years ago. Due to the low differentiation of malignant tumor, empyema complicated with BPF occurred after the fourth cycle of chemotherapy. His past medical history was free of other illnesses. The patient was admitted to our hospital for further treatment because of long-term chest tube drainage and obvious respiratory irritation symptoms such as cough during body position change. Chest computed tomography (CT) scan revealed a left-sided hydropneumothorax. Bronchoscopy revealed BPF. Considering that the volume of the abscess cavity did not shrink significantly after long-term drainage, we chose first-stage surgery to complete the debridement of empyema and the closure of the fistula. In the second-stage surgery, the combined pedicled muscle flaps were used to complete the filling in different areas of the huge irregular residual cavity. This surgical mode of staging and sub-regional treatment of abscess cavity has achieved satisfactory clinical results. CONCLUSIONS:Utilizing the pedicled combined muscle flaps to address chronic empyema accompanied by a huge irregular abscess cavity shows promise as a treatment method for eliminating residual cavity in various regions.

Chest wall sinus with infection is a refractory disease caused by a variety of susceptible factors, and the treatment is still challenging. For clinically complex cases, although there are various surgical methods to choose from, it is still very difficult to achieve clinical cure, especially for patients with older age and many underlying diseases. Complete resection of chest wall sinus and application of repair and reconstruction technology may bring hope to refractory cases. Herein, we report a case of a 67 year-old woman who had undergone breast cancer surgery and a history of multiple cycles of radiotherapy and chemotherapy. One year ago, she had a fistula in the left chest wall with yellow purulent fluid. After admission to our hospital, chest computed tomography (CT) showed the formation of the left chest wall sinus, accompanied by high-density images of the left clavicle, part of the ribs and part of the sternu. According to the patient's symptoms, signs and imaging examination, we preliminarily diagnosed the patient as chest wall sinus with infection and chronic osteomyelitis. Therefore, in the first-stage operation, the patient underwent left chest wall sinus resection, left partial rib resection, left partial clavicular resection and left partial sternal resection, After surgery, the wound surface was changed with gauze dressing with sensitive antibiotic solution every day until the wound surface was clean and new granulation was formed. In the second-stage operation, the wound surface was appropriately expanded, and the pedicled latissimus dorsi myocutaneous flap was transferred to the chest wall defect. Finally, the skin paddle was sutured without tension to the normal skin around the chest, and two drainage tubes were placed. Anti-infection, anti-spasm, anti-coagulation and other treatments were given after operation, and the survival of myocutaneous flap, wound healing and sinus disappearance were observed. The application of pedicled latissimus dorsi myocutaneous flap in the treatment of intractable chronic chest wall sinus is an effective method. It does not change the shape of the thorax. The clinical effect is satisfactory in the near and medium term, which is worthy of clinical promotion.

RATIONALE:Fungal empyema is a chronic refractory disease. It is difficult to control thoracic infection, and it is faced with the problem of recurrence. How to control the infection and reduce the probability of recurrence is a difficult problem. Surgical operation combined with endobronchial therapy was used to control infection, seal the fistula and eliminate residual cavity and achieved good results.PATIENT CONCERNS:A total of 5 patients with fungal empyema were treated from 2019 to 2021, aged 27 to 72 years, with an average age of 54.8 ± 7.6 years. Two cases were on the left side and 3 cases on the right side.DIAGNOSIS:While meeting the diagnostic criteria of empyema, the diagnosis of fungus in pus culture or the discovery of fungus in deep tissue pathology confirmed the diagnosis of fungal empyema in the 5 cases.INTERVENTIONS:Through surgical operations combined with bronchoscopy and individualized treatment, the infection was controlled, the fistulas were blocked, and the pus cavity was filled.OUTCOMES:After 11 to 30 months of follow-up, the muscle flap in the abscess cavity was mildly atrophied, and there was no recurrence of empyema. Three patients who completed the second-stage operation had their chest tubes removed and returned to normal life. The 2 patients who did not complete the second-stage operation had no recurrence of thoracic infection and no recurrence of cough or fever, and their quality of life was greatly improved.LESSONS:Surgical operation combined with bronchoscopy is a reliable method for the treatment of fungal empyema, which can find and plug the fistula more efficiently and eliminate the residual cavity by surgery to avoid recurrence. Therefore, it is a recommended treatment method.

Background: Bronchopleural fistula (BPF) after pulmonary resection is difficult to treat. To explore the efficacy of autologous muscle flap or myocutaneous flap on refractory empyema with bronchopleural fistula. Methods: Retrospective analysis of 10 patients with postoperative refractory empyema with bronchopleural fistula treated in our hospital. All patients were treated with empyema debridement and drainage to control infection and / or interventional occlusion therapy. After the patients' condition were stable, the abscess cavity was filled with pedicled muscle flap or free vastus lateralis muscle flap. Results: There was no perioperative death. During the follow-up, no empyema and bronchopleural fistula recurred in all patients, and the muscle flaps and myocutaneous flaps survived. Postoperative chest computed tomography (CT) or magnetic resonance imaging (MRI) showed that the abscess cavity disappeared. Conclusions: The application of muscle flap or musculocutaneous flap is an ideal method for the treatment of refractory empyema with bronchopleural fistula, and the clinical effect is satisfactory.Funding Statement: NoneDeclaration of Interests: The authors declare that they have no competing interests.Ethics Approval Statement: This study was approved by the Ethics Committee of Tongde Hospital of Zhejiang Province. Informed consent was obtained from all individual patients included in the study.

RATIONALE:Pulmonary sequestration, which can be divided into 2 main types: intralobar pulmonary sequestration (IPS) and extralobar pulmonary sequestration, is an uncommon congenital condition for which surgical resection is usually indicated. Video-assisted thoracoscopic surgery, as compared with open thoracotomy, has increasingly become the preferred operative procedure in the treatment of PS, owing to less postoperative pain and faster recovery. This report describes a rare and challenging case with a giant IPS undergoing video-assisted thoracic lobectomy.PATIENT CONCERNS:A 39-year old woman suffered from recurrent pneumonia for nearly 3 years. An enhanced computed tomography scan performed in our hospital revealed a 12.0 cm × 10.0 cm-sized IPS in the left lower lobe, supplied by an 8-mm aberrant artery originating from the descending thoracic aorta.DIAGNOSIS:Histology of the resected lobe confirmed the diagnosis of giant intralobar pulmonary sequestration associated with infection.INTERVENTIONS:Thoracoscopic left lower lobectomy was performed.OUTCOMES:The patient has been discharged from the hospital on the ninth day after surgery with an uneventful recovery, she was in good health after a 1-year follow-up.LESSONS:Although full of challenges, thoracoscopic lobectomy for giant IPS is a safe and feasible surgical procedure associated with reduced surgical trauma and postoperative pain as well as improved cosmetic results compared with traditional thoracotomy.

Objectives:To explore the effects of autologous free dermal graft combined with free myocutaneous flap on bronchopleural fistula (BPF) with empyema, we summarized and analyzed two cases. Methods:Two patients with refractory empyema and BPF were treated with autologous free dermal graft combined with free myocutaneous flap. The treatment included debridement of empyema, rib resection drainage, repair of bronchopleural fistula, and free vastus lateralis myocutaneous flap transplantation to eliminate the empyema. After the free dermal graft was harvested from the healthy skin around the incision, it was inserted into the fistula and sutured with the surrounding pleural tissue. The keys to the operation lies in the anastomosis of the lateral circumflex femoral artery (LCFA), vein and nerve that supply the vastus lateralis muscle flap to the thoracodorsal vessels and nerves. After surgery, the empyema, air leakage, and the survival of the myocutaneous flap were observed. Results:There was no disease recurrence after follow-up for seven and six months, respectively. Re-examination of the chest computed tomography (CT) or magnetic resonance imaging (MRI) indicated that the abscess cavity had disappeared. No necrosis of the myocutaneous flap was observed after surgery. Conclusion:The application of autologous free dermal graft combined with free vastus lateralis myocutaneous flap transplantation is effective in the treatment of patients with bronchopleural fistula with refractory chronic empyema, and the clinical effect is satisfactory.

Bronchopleural fistula (BPF) with empyema is a severe complication in patients undergoing lobectomy or pneumonectomy and is associated with high morbidity and mortality rates. Although a wide variety of treatment options exist, refractory cases with larger fistulas are still difficult to cure, especially in elderly patients. Here, we report a case of an 83-year-old man with stage I squamous cell lung carcinoma who underwent minimally invasive right lower lobectomy. After an initially uneventful postoperative course, he was readmitted to our hospital due to the progression of severe cough with fever after lung resection. Chest computed tomography (CT) showed an empyema cavity containing pleural effusion and a drainage tube in the right lower thorax. Bronchoscopy confirmed the presence of a fistula between the right lower bronchial stump and the pleural cavity. On the basis of his clinical symptoms and these imaging findings, the patient was diagnosed with BPF with empyema after lobectomy. He was successfully treated with multidisciplinary management including adequate pleural drainage by open-window thoracostomy, closure of the BPF by endoscopic therapy using an Amplatzer device, and complete obliteration of the empyema cavity with pedicled muscle flap. Multidisciplinary management combining thoracostomy, endoscopic therapy, and pedicled muscle flap transfer is a safe and effective treatment for elderly patients with larger fistulas and empyema.

Objective:To evaluate the safety and clinical efficacy of transplanting a muscle flap to treat the postoperative refractory empyema with a bronchopleural fistula.Methods:From July 2015 to December 2019, the clinical data of 15 patients who suffered from postoperative refractory empyema with bronchopleural fistula was retrospectively summarized. There were 13 males and two females with a mean age of 61.7 years. Ten cases had previous posterolateral thoracotomy and four cases underwent minimally invasive surgery. After conservative and endoscopic therapy, a pedicled latissimus dorsi muscle flap, a pectoralis major muscle flap, or a free vastus lateralis myocutaneous flap was harvested from the ipsilateral local thorax or thigh and was transferred to cover the intrathoracic cavity.Results:There was no perioperative death. During a mean follow-up of 14.8 months, one patient was dead, one suffered from a recurrence of refractory empyema, and l3 patients had an uneventful course with no recurrence of refractory empyema and bronchopleural fistula. Postoperative chest computed tomography or magnetic resonance imaging showed the empyema cavity was satisfactorily covered with a pedicle or free muscle flap.Conclusions:Muscle flap transplantation is an effective alternative for treating the postoperative refractory empyema with bronchopleural fistula, which can achieve promising short-medium-term results.

BACKGROUND:Empyema is a severe complication following pneumonectomy that is associated with high morbidity and mortality rates. Although there are a wide variety of treatment options, successful management remains challenging when this condition is combined with a large cavity in very thin patients who had previously undergone a posterolateral thoracotomy.CASE SUMMARY:We reported the case of a thin, 63-year-old man with a progressive pulmonary cyst who underwent left pneumonectomy via posterolateral thoracotomy 23 years ago. After an initially uneventful postoperative course, he was readmitted with empyema and a large cavity 21 years after surgery. He was successfully treated with limited thoracoplasty, followed by free vastus lateralis musculocutaneous flap transposition.CONCLUSION:This case highlights that the treatment mode of limited thoracoplasty and free vastus lateralis musculocutaneous flap transposition is safe and effective for the management of postpneumonectomy empyema with a large cavity in thin patients who had previously undergone a posterolateral thoracotomy.

BackgroundChronic empyema with chest wall sinus is a complex and refractory disease caused by multiple factors.It may be combined with bronchopleural fistula, residual bone and other necrotic tissue,causing local infection difficult to control, and the disease is a vicious circle.Case presentationThis paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 11 years ago and began to develop empyema with purulent sinus in the anterior chest wall 3 years ago. Therefore, he was admitted to our medical center for further treatment. Chest computed tomography (CT) showed the right pleural effusion with the chest wall rupture sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the large empyema cavity,the patient should be treated with free vastus lateralis musculocutaneous flap combined with pedicled pectoralis major muscle flap transplantation.After the operation, acute respiratory failure occurred due to left lung aspiration pneumonia.ConclusionsAfter a series of treatment measures such as tracheal intubation, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, he was finally rescued and cured.Follow-up after discharge showed that the tissue flap survived and empyema was eliminated.

目的 比较术前运用Hook-wire和医用胶两种定位方式行胸腔镜手术(VATS)切除孤立性肺小结节(SPN)的临床疗效.方法 选取2016年3月至2019年9月在浙江省立同德医院心胸外科同一医疗组行VATS的SPN患者共70例.所有患者均为单个结节定位,其中采用CT引导下Hook-wire定位者42例,医用胶定位者28例,观察和比较两组患者定位时间、定位成功率,气胸、出血、刺激性咳嗽等定位相关并发症发生率,同时记录比较两组患者VATS时间,统计两组术中冷冻切片病理检查结果.结果 所有患者均顺利完成术前CT引导下肺结节穿刺定位.两组患者定位时间比较差异无统计学意义(P>0.05);Hook-wire组定位成功率明显低于医用胶组,差异有统计学意义(P<0.05).Hook-wire组气胸和渗血的发生率均明显高于医用胶组,差异均有统计学意义(均P<0.05);医用胶定位组咳嗽的发生率明显高于Hook-wire组,差异有统计学意义(P<0.05).所有患者均顺利完成VATS,Hook-wire组VATS时间明显长于医用胶组,差异有统计学意义(P<0.05);而两组患者术中冷冻切片病理检查结果比较差异无统计学意义(P>0.05).结论 CT引导下Hook-wire或医用胶定位均可用于VATS切除SPN,安全性高,可简化VATS操作难度,缩短时间,医用胶相比Hook-wire定位成功率高、手术用时更短,相关并发症少,予以优先推荐.