Eastern Cardiothoracic Surgical Society

Transverse Rectus Abdominis Flap in Pneumonectomy for Chronic Pulmonary Aspergillosis
Audrey C. Pendleton, Vadim Pisarenko, Jody Kaban, Jacobi Medical Center, Bronx, NY

OBJECTIVE: We report two cases of patients with chronic pulmonary aspergillosis (CPA) who were managed with pneumonectomy and TRAM flap.

METHODS: Case One: A 43 year old man with a history of treated tuberculosis and CPA for which he received a course of Itraconazole. He presented with hemoptysis. Chest CT revealed left lung reduced volume with parenchymal destruction. He underwent a left pneumonectomy with a latissimus dorsi and transverse rectus abdominis myocutaneous (TRAM) flap. The patient experienced no complications and was discharged. Case Two: A 49 yr old woman with a history of treated tuberculosis, aspergilloma and CPA, extensive scarring, who underwent pneumonectomy and TRAM flap, course complicated by flap edema, which ultimately resolved.

RESULTS: Surgical resection is the mainstay of treatment when there is extensive parenchymal destruction in CPA but is associated with postoperative morbidity, especially in patients who require pneumonectomy since empty thoracic space predisposes them to recurrent infections. Several approaches are described to address this issue. One is thoracoplasty with a breast implant. While this fills the cavity, it leaves a foreign body in a previously infected area, risking recurrent infection. Another method uses the pectoralis major or trapezius muscle as the flap. This also eliminates the empty space but risks chest wall deformity. Our approach with TRAM flap obliterates the empty hemithorax, decreasing the risk of chest wall deformities and recurrence.

CONCLUSIONS: TRAM flap augments the structural integrity of chest wall using native tissue while obliterating the empty space and reducing the risk of infection after pneumonectomy for aspergillosis.