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J Thorac Cardiovasc Surg 1998;116:182
© 1998 Mosby, Inc.

Letters To The Editor

Heterotopic ossification in pedicled intercostal muscle flaps causing clinical problems

To the Editor:

I read with great interest the article of Prommegger and Salzer titled "Heterotopic Ossification in Pedicled Intercostal Muscle Flaps Causing Clinical Problems" (J Thorac Cardiovasc Surg 1998;115:466-7). I sincerely appreciate their kind reference to my laboratory research in this area. ¹ As the authors indicated, the pedicled intercostal muscle flap is a useful adjunctive measure in a variety of thoracic surgical procedures, having been used as early as 1936 by Shenstone. ³ Besides its application in sleeve resections of the tracheobronchial tree, the pedicled intercostal flap is invaluable in the management of esophageal perforations to buttress the suture line or as an onlay patch to close the esophageal defect when the tissues are too friable to hold sutures. In these instances, I have cautioned that the pedicled flap should not be wrapped circumferentially about the esophagus to avoid napkin ring restriction. ³

To avoid the complication that the authors noted in three of their 22 patients, I would suggest that the pedicled flap be applied loosely and that a 20% silver nitrate solution be applied to the periosteum with a cotton applicator swab, as reported by Bryant. ⁴ Loose circumferential application of the flap would tend to avoid the constriction that occurs when the muscle atrophies. As the authors indicate, the periosteum affords a tough fibrous matrix to the pedicle, and removing the periosteum would endanger the vascularity of the flap. The intraoperative use of silver nitrate is certainly simpler than the other methods that the authors propose to inhibit osteogenesis. Laboratory study of the periosteal bed of resected ribs in experimental animals with and without the application of silver nitrate might clarify the usefulness of this agent.

Department of Cardiothoracic SurgeryMontefiore Medical Center, 111 East 210 St., Bronx, NY 10467

References

1. Fell SC, Mollenkopt FP, Montefusco CM, Mitsudo S, Kamholz S, Goldsmith J, et al. Revascularization of ischemic bronchial anastomoses by an intercostal pedicle flap. J Thorac Cardiovasc Surg 1985;90:172-8.[Abstract]
   
2. Shenstone NS. The use of intercostal muscle in the closure of bronchial fistulae. Ann Surg 1936;104:560.[Medline]
   
3. Fell SC. Esophageal perforation. In: Pearson FG, editor. Esophageal surgery. New York: Churchill Livingstone; 1995. p. 509.
   
4. Bryant L. Experimental evaluation of intercostal pedicle grafts in esophageal repair. J Thorac Cardiovasc Surg 1965;50:626-33.[Medline]