Intractable Bronchopleural Fistula After Lung Resection in Mycobacterial Infection; Surgical and Endoscopic Treatment With Fibrin Glue Application Followed by Latissimus Dorsi Musculocutaneous Flap Coverage: A Case Report

Postoperative bronchopleural fistula (BPF) is a challenging and complicated problem to cope with. Involving with multidisciplinary care team is essential for the best outcome. This report provides our experiences in intractable BPF after lung resection surgery which fail to completely heal after received surgical and endoscopic treatment. A 56-year-old female with no known underlying disease presented with nonmassive hemoptysis, productive cough, low-grade fever, and significant weight loss for 3 years. Her sputum consisted of Mycobacterium abscessus with multidrug resistant. Radiological examination revealed reticulonodular infiltration at middle lobe of the right lung and lingular lobe of the left lung, also a bronchiectatic change of both lungs. After 3 years of medical treatment, neither of her symptoms nor radiological findings improved. Therefore, a video-assisted thoracoscopic surgery (VATS) with middle lung lobectomy and lingulectomy was performed. After that, BPF at lingular stump occurred. Many surgical and endoscopic techniques followed by latissimus dorsi musculocutaneous flap along with vacuum dressing were introduced to encourage the complete healing of the BPF. One month later, the patient’s clinical was improved and endoscopic findings showed nearly complete healing of the BPF. In conclusion, surgical and endoscopic treatments combined with postoperative vacuum dressing encourage patient’s symptoms to be subsided.

Recurrent late seroma after immediate breast reconstruction with latissimus dorsi musculocutaneous flap

The latissimus dorsi musculocutaneous flap (LDMCF) is widely used for breast reconstruction. However, it has the disadvantage of frequent seroma formation at the donor site, and late seroma has also been reported. The authors report histological findings after the surgical treatment of a late, repeatedly recurrent seroma at 10 years after breast reconstruction with LDMCF. In 2008, a 66-year-old female patient underwent immediate breast reconstruction with LDMCF. In 2015, a late seroma was found at the donor site. After aspiration and drainage, the seroma recurred again in 2018. Total surgical excision of the seroma was performed and bloody-appearing fluid was identified in the capsule. The excised tissue was biopsied. Histological examination revealed no evidence of blood in the fluid, and multinucleated giant cells with amorphous eosinophilic proteinaceous material were identified. The cyst was suggestive of chronic granulomatous inflammation. There was no recurrence at 8 months postoperatively. The patient described herein underwent surgical treatment of late seroma that recurred after immediate breast reconstruction with LDMCF, and histological findings were identified. These results may be helpful for other future studies regarding late seroma after breast reconstruction with LDMCF.

The Utility of Disposable Negative Pressure Wound Therapy (PICO) in Wound Healing of Latissimus Dorsi Musculocutaneous Flap Donor Sites

Background: Among treatments aiming to solve surgical wound complications, negative pressure wound therapy (NPWT) is considered an innovative method. NPWT can promote wound healing, protect the wound from infection and reduce the tension on suture sites. At the same time, the large machine required in the therapy led to some inconvenience. The PICO system has recently been developed as a simple pocket-sized NPWT device. By comparing the time required for healing of the wound, incidence of wound complications, duration of hospital stays, and dressing costs, we attempted to confirm the utility of PICO for managing latissimus dorsi musculocutaneous flap donor sites.Methods: PICO was used on nine donor sites of patients who had undergone breast reconstruction using latissimus dorsi musculocutaneous flaps. PICO was applied immediately after operation and removed on the 9th day. In the control group, daily conventional dressings were administered commensurate with the condition of the wounds. We defined the wound healing time to the point when no more dressing was needed. For the costs of dressing, only costs incurred on the donor sites were included.Results: Wound healing was proven to be faster in the PICO group (P=0.035) versus the control group, and no complications were observed in the PICO group. Also, the cost of PICO was lower compared to the costs incurred by the conventional dressing method (P<0.001).Conclusion: We suggest that PICO can reduce wound complications on areas where anatomical movement could lead to tension, while also reducing dressing costs.