Management of recalcitrant bronchopleural fistulas with muscle flap obliteration

Use of muscle flap obliteration for bronchopleural fistulas appears to be indicated with (1) failure of a previous thoracoplasty, (2) anticipated failure of a thoracoplasty alone, and (3) the need to obviate a formal debilitating thoracoplasty. With the use of well-vascularized muscle flaps to fully obliterate the densely scarred cavities associated with persistent bronchopleural fistulas, we may hope to see improved healing in the bronchial stump and, in cases of residual infection, better resistance of the flap to necrosis, as well as improved delivery of chemotherapeutic agents to the local tissues. These factors may confer improved cure rates for bronchopleural fistulas similar to those seen in lower extremity salvage surgery for osteomyelitis following the introduction of vascularized pedicle and free muscle flaps. In this article we have described the versatility of the island pedicle latissimus dorsi muscle flap for closure of recalcitrant bronchopleural fistulas and associated empyema cavities. Utilizing either the dominant thoracodorsal or the minor paraspinal pedicle(s), it can reach any intrathoracic cavity by means of the appropriate thoracotomy incision.