Upper thoracic empyema and concomitant superior vena cava syndrome treated with reconstructive surgery using a pedicled omental flap

Abstract

Superior vena cava (SVC) syndrome refers to a constellation of symptoms secondary to obstruction of blood flow through the SVC. In this condition, venous blood that usually drains into the SVC is diverted into the inferior vena cava (IVC) via collateral veins. Reconstructive surgery is challenging in such cases owing to the anomalous venous system. In this case report, we describe reconstructive surgery using a pedicled omental flap in a patient with upper thoracic empyema and concomitant SVC syndrome. A 68-year-old man underwent resection of malignant thymoma, the bilateral brachiocephalic veins, and a part of the right upper lobe, followed by polytetrafluoroethylene (PTFE) graft placement for venous system reconstruction, 2 years prior to presentation. He developed postoperative upper thoracic cavity empyema, which necessitated PTFE graft removal. Although the infection was controlled after 2 months, multiple right upper lobe pulmonary fistulas persisted, and the patient was referred to our department for further evaluation. Contrast-enhanced computed tomography revealed SVC syndrome characterized by SVC obstruction and consequent drainage of venous blood from the upper trunk into the IVC via collateral vessels. We debrided necrotic and infected tissues, and a pedicled omental flap was placed for upper lobe fistula coverage. The patient showed an uncomplicated postoperative course, and no recurrent empyema or pulmonary fistulas were observed 3 years postoperatively. Flaps associated with the SVC system show high venous pressures. The use of a pedicled omental flap was deemed feasible because this graft reaches the upper thorax even though it is associated with the IVC system.

Keywords: empyema; omental flap; reconstructive surgery; superior vena cava syndrome.

Fig. 1

Preoperative images Fig. 1A: Preoperative appearance of the chest. Pulmonary fistulas (PF) and exposure of the ascending aorta (AA) with varicose veins (V) were observed. Fig. 1B: Preoperative appearance of the back. Varicose veins (V) over the back were observed. Fig. 1C: Preoperative CT image. Pulmonary fistulas (PF) and exposed ascending aorta (AA) were observed. PF: pulmonary fistulas AA: ascending aorta V: varicose veins

Fig. 2

Preoperative contrast-enhanced CT angiography Fig. 2A: Front view Fig. 2B: Back view The collateral vascular network (white arrowheads) drained the venous flow from the upper body into the IVC system via the azygos vein (yellow arrowheads).

Fig. 3

Intraoperative photographs Fig. 3A: The pedicled omental flap was harvested. Fig. 3B: The flap was passed through the lesser curvature route (white arrowheads). Fig. 3C: The flap was transferred to the pulmonary fistulas and to obliterate all dead space.

Fig. 4

Postoperative images Fig. 4A: Postoperative appearance of the chest. No recurrent empyema was seen. Fig. 4B: Postoperative CT image. The space was sell obliterate by the flap.