Treatment of a bronchial fistula and empyema with a free rectus abdominis muscle and pedicled omental flap after panpleuropneumonectomy; a case report

症例は42歳,男性.悪性胸膜中皮腫に対して右胸膜肺全摘術施行後4ヵ月経って気管支断端瘻と膿胸を発症した.開窓して,82日後に根治術を施行した.胸腔内を掻爬した後,右下腹壁動静脈を茎とする遊離腹直筋弁と右胃十二指腸動静脈を茎とする有茎大網弁を作成した.大網を胸腔内に誘導して瘻孔を閉鎖した上で,大網の左胃十二指腸動静脈と腹直筋弁の右下腹壁動静脈を顕微鏡下に吻合し,血流の良好な部分をドップラーで確認して,気管支断端を被覆した大網の上に重ねて充填した.術後経過は良好で,根治術後4年以上経過して,膿胸の再発は認めていない.遊離腹直筋弁と大網の併用は,断端部の補強と,死腔を減少させる上で有効な方法である. Empyema with bronchial fistula developed in a 42-year-old man about 4 months after right panpleuropneumonectomy for diffuse malignant mesothelioma. A fenestration was performed and 82 days later, closure of the fistula and the fenestra was carried out. After curetting the thoracic cavity, a right rectus abdominis muscle (RAM) flap based on the right inferior epigastric vessels and a pedicled omental flap supplied by the right gastroepiploic vessels were prepared. The omental flap was transposed to the thoracic cavity and the fistula was sealed with this flap. Then the RAM flap with pedicle of inferior epigastric vessels was made free, and microscopic anastomosis was established between these vessels and left gastroepiploic vessels of the omental flap. The revasculized RAM flap was fixed over the omenal flap to reinforce the bronchial stump and these flaps decreased the residual cavity. Clinical course after the reoperation was satisfactory and there was no evidence of recurrence of empyema during 4 years of follow-up observation. Simultaneous use of free RAM flap and pedicled omental flap could be of great help in treatment of broncial fistulas and empyema.rights: 特定非営利活動法人日本呼吸器外科学会rights: 本文データは学協会の許諾に基づきCiNiiから複製したものであるrelation：isVersionOf: http://ci.nii.ac.jp/naid/110001270085