A case of Aspergillus empyema successfully treated by a single-stage cavernostomy and a covering procedure using both fat pad and muscle flap.

backgroundAspergillus empyema due to rupture of a pulmonary cavity including an aspergilloma is a serious condition especially in immunocompromised patients with various co-morbidities. Open window thoracotomy is usually performed to control infection, followed by secondary myoplasty. However, such a two-stage strategy requires long treatment period and accompanies the invasiveness of multiple operations. On the other hand, single-stage surgery is minimally invasive, and patients' activities of daily living are less impaired. We present a single-stage surgery consisting of cavernostomy and a covering procedure using both fat pad and muscle flap. CASE PRESENTATION: A 28-year-old man taking 20 mg of prednisone for rheumatoid arthritis presented with right-sided chest pain. A chest computed tomography and thoracoscopy showed a perforated pulmonary cavity including an aspergilloma in the right apex of the lung. Antifungal medication was started, but the thoracic and pulmonary cavities persisted. Therefore, surgical intervention was indicated, and considering the patient's general condition and anticipated length of treatment period, we decided to conduct a single-stage operation. A cavernostomy was performed on the ruptured cavity. To reliably close the air leak and to occlude the air space to prevent recurrence of infection, a subcutaneous free fat pad was harvested and filled into the cavity. A pedicled latissimus dorsi muscle flap was further introduced into the thoracic space to cover the fat pad. There was no postoperative air leak and the patient was discharged on postoperative day 20 with no adverse events and no limitation of movement in the arm. A series of post-operative CT showed that the pedicled latissimus dorsi muscle flap and free fat pad gradually shrank with lung re-expansion, but they were still present and filled the thoracic and pulmonary cavities 10 months after surgery.

conclusionA single-stage surgery consisting of cavernostomy and a covering procedure using both a fat pad and muscle flap was effective in sealing air leaks, filling the air space, and preventing recurrence of infection. The fat pad and muscle flap appear to have worked in a complementary way.