Surgical management of bronchopleural fistula in pediatric empyema and necrotizing pneumonia: efficacy of the serratus anterior muscle digitation flap.
OBJECTIVE
Surgical management of bronchopleural (B-P) fistula associated with thoracic empyema and necrotizing pneumonia is challenging. We evaluated the treatment and outcome of early surgical intervention with limited decortication and insertion of a serratus anterior muscle digitation flap.


METHODS
A retrospective review during a 10-year period of children with empyema and B-P fistula secondary to necrotizing pneumonia was performed. During this period, 335 children with empyema were admitted, of which 20 developed a B-P fistula. All underwent a thoracotomy with insertion of a serratus anterior muscle digitation flap.


RESULTS
Prethoracotomy chest computed tomographic scan was performed to define the pathologic characteristic. Streptococcus pneumoniae was identified by pus culture (n = 6) and by polymerase chain reaction (n = 4). The median postoperative time with pyrexia after surgical intervention was 2 days (range, 1-3 days). The median period of thoracostomy drain was 7 days (range, 5-15 days). Length of hospital stay was 21 days (range, 7-43 days). This parenchyma-preserving technique was able to control the B-P fistula successfully in all cases. No reintervention was necessary in any case. Respiratory symptoms and radiology improved in all children on follow-up, except for 3 who required oral antibiotics for subsequent chest infections.


CONCLUSIONS
Early surgical intervention with insertion of a serratus anterior muscle digitation flap is effective and safe and avoids morbidity associated with conservative management and necrotic lung resection surgery.
Department of Paediatric Surgery, Birmingham Children's Hospital, Steelhouse Lane, B4 6NH Birmingham, United Kingdom. Ingo.Jester@bch.nhs.uk
Ingo
I
Jester
Amit
A
Nijran
Michael
M
Singh
Dakshesh H
DH
Parikh
D001983:Bronchial Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D016724:Empyema, Pleural / Q000150:complications* / Q000175:diagnosis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008297:Male; D010995:Pleural Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D011018:Pneumonia, Pneumococcal / Q000150:complications* / Q000175:diagnosis; D013510:Pulmonary Surgical Procedures / Q000379:methods*; D016156:Respiratory Tract Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D012189:Retrospective Studies; D013524:Surgical Flaps; D013908:Thoracotomy; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome