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Eur J Cardiothorac Surg 1999;15:465-468
© 1999 Elsevier Science NL

The possibilities of greater omentum usage in thoracic surgery¹

Department of Lung Surgery and Transplantation, State Research Centre of Pulmonology, 12 Rentgen Street, 197089, St. Petersburg, Russia

Received 23 March 1998; received in revised form 9 December 1998; accepted 18 January 1999.

Corresponding author. Tel.: +007-812-233-1461; fax: 007-812-234-9046.

	Abstract

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Objective: To illustrate the wider role of an omental pedicle flap in surgical treatment for diverse thoracic organ disorders we have, retrospectively, reviewed our experience over the last 8 years. Methods: We used the greater omental pedicle flap in 68 patients. Bronchial stump omentopexy was performed in 35 patients with a high risk of impaired bronchial healing after right pneumonectomy as a preventive method and in two patients with an acute bronchial fistula. In 13 patients after circular tracheal or carinal resections and in four after esophago-respiratory disjoints of fistulas we applied anastomoses or circular omentopexy of the fistula zone. The omental coverage was performed in four patients with chronic empyema, in seven patients after extensive chest wall resection and in two patients with poststernotomy mediastinites. In one patient with idiopathic fibrosing mediastinitis, one-stage allotransplantation of tracheal thoracic segment was conducted and greater omentum (GO) was used to wrap the allograft. Results: Three patients developed major complications. The first, bronchial fistula after bronchial stump omentoplasty. In two patients circular wide tracheal resection (11–12 rings) was complicated by a tracheal divergence of anastomoses. These complications were cured in a conservative way since a displaced omental flap substituted the tracheal wall and, therefore, the trachea remained hermetically sealed. In other cases, perfect adhesive properties of the omental tissue promoted prevention of incompetence and inflammatory complications. Immunological and bacteriological examinations showed that pediculated omental flap is a lymphocyte source and promotes a decrease in bacterial quantity and activity. Conclusion: We think the series demonstrates the value of the omental method, which offers excellent therapeutic results following an easy surgical procedure. This method extends indications for surgical treatment and decreases the postoperative complications.

Key Words: Thoracic surgery • Greater omentum • Pedicle flap • Omentoplasty

	Introduction

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The greater omentum (GO) has attracted significant attention from thoracic surgeons over the last years. The following features of GO are especially valuable for clinical practice: plasticity, immunocompetence, angiogeneity and good blood supply [1].

In thoracic surgery the GO is used most widely for the filling of so-called dead spaces at chronic empyema, frontal mediastinitis, chest-wall defects after resection and to strengthen a main bronchus stump in case of a failure after pneumonectomy [2] [3]. At that, the majority of authors reported good results after such surgery. Many surgeons prefer to use muscle plastics that do not require the opening of the abdomen and, according to their opinion, are more easily borne by patients [4] [5] [6].

Besides, in some cases, there might appear complications at raising the GO graft due to individual blood supply particularities. Previously performed topographic-anatomic GO study on cadavers, evaluating its thickness, fatty tissue development, blood supply form and type, allowed us to apply the GO graft transposition on a vascular pedicle in clinical work.

In this report we retrospectively reviewed our cases on thoracic surgery, where pedicle omental flaps were used.

	Materials and methods

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Over a period of 8 years, December 1989 to December 1997, pedicle omental flaps were applied to 68 patients. There were 59 men and nine women with a mean age of 54.4 years (range, 21 to 69 years). None of the patients have undergone abdominal surgery before.

Most of the patients had lung (44) or tracheal (3) cancer (69.1%). Squamous cell cancer was diagnosed in 33 cases. Lung cancer involving carina was found in 5 patients. Two patients had lung cancer solitary metastases into chest wall, primary tumours were removed earlier. Benign tracheal stenoses (5) were caused by prolonged tracheal intubation and auxiliary ventilation before. Oesophageal-respiratory fistula (4) in one case was inherent, in three cases there were complications due to previous medical manipulations. Poststernotomy mediastinitis (2) developed after coronary vessels surgery. Costal osteomyelites and chronic empyema (9) were diagnosed as complications after previous thoracic operations. One patient had idiopathic fibrosing mediastinitis.

Patients were routinely evaluated with chest rentgenography, bronchoscopy, spirometry and computed tomography. A complete work-up was undertaken to find extrathoracic metastatic sites. The surgical procedures characteristics are shown in Table 1.

The indications for preventive right main bronchial stump coverage were the following: bacterial infection in pleural cavity; tumour in the main right bronchus less than 2 cm distal to carina; uncertain of the radical character of the surgery, in spite of intraoperative negative histology.

The main indication in tracheal resections was great tension between the anastomosis parts.

After tracheal resection or dissection of oesophageal fistula circular tracheal coverage by the GO flap was necessary. In case of oesophageal fistula we always performed gastrostomy.

We used GO in chronic intrathoracic cavities if one of the space dimensions was 10 cm or more. The same indications were applied after the chest wall resections and in these cases we did not use prosthetic materials. One allotransplantation of thoracic tracheal section was made in 1990, the GO pedicle flap was used to wrap the allograft including each anastomosis.

Contraindication for GO usage was a previously performed major abdominal operation only.

The surgery duration increased by 80 min on average during the first operations (compared with surgery without the GO flap usage). Subsequently the time lessened to 50 min against the non-GO operations when we mastered the method. The results of operations were complexly assessed: clinically, radiologically, by tracheo-bronchoscopy.

	Results

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One patient who underwent right pneumonectomy developed a broncho-pleural fistula and right empyema and died 24 days later of intoxication.

There were two other major local complications. In both cases the divergence of the tracheal anastomoses appeared after the circular wide tracheal resection (11–12 rings) at 8 and 11 days after the surgery. In one case there was a fistula 2 mm in size, in the other there was a complete divergence with a distance of 20 mm. The GO tissue in these situations substituted the tracheal wall and the trachea was kept leak-proof. At bronchoscopy, the flap omental tissue was visible bulging into the tracheal lumen but no tracheal fistula, no mediastinitis and empyema developed. Both patients fully recovered. In the second case granulating stenosis of the tracheal anastomosis formed. The laser photodestruction of the granulating tissue and stenting by a silicone prosthesis were applied to treat the complication in 4 months. There were no other long-term complications (observation term was 4 month–8 years).

No signs of the late stump failure after pneumonectomy were registered.

In spite of the chest wall reconstruction without prosthetic materials, satisfactory cosmetic and functional results were achieved. In all seven cases breathing and coughing produced paradoxical movements at the resected part of the chest wall. It required some external pressure on the flap to help expectoration, but in the early postoperative phase only.

There were no recurrences of mediastinites after the surgery and the coronary prostheses functioned adequately. All chronic pleural cavities and osteomyelites were treated completely after the GO usage despite the large size of the cavities. The empty cavity anaplerosis had no complications.

The oesophageal fistulas did not recur and no oesophageal stenoses developed. The observation terms in these patients were 2–6 years.

The patient after tracheal allotransplantation is alive and he is working 8 years after operation [7].

No flap-related complications were observed. The complications in abdominal cavity were not registered.

In the microbiological examination of 30 patients after right pneumonectomy the bacterial quantity, 2–3 days after operations in pleural discharge, was 82 times less than after the surgery without omentopexy. Cytological examinations showed the rapid lymphocyte count increased as compared with similar patients without the omental usage.

	Discussion

Top Abstract Introduction Materials and methods Results Discussion References

 
The GO tissue transfer into body cavities in order to treat fistulas or infected cavities is a procedure that has already been described numerous times during the last few decades. In addition to described data on the GO flap application, the anatomical conditions and technical requirements for the transposition and use of GO in the pleural cavity were investigated.

The GO flap exsection technique is very important. Angiography showed many types of vascular supply for GO. Only taking into account these peculiarities, the thickness of the GO fat, the adequate GO flap pedicling without the threat of necrosis or complications in abdominal cavity is possible. The flap transposition through the diaphragm is not difficult. The opening should not be very wide for good GO tissue adhesion to the openings of the walls and too narrow to prevent compression of the vessels.

The pedicled omental flap has the advantage of its own blood supply, and is autologous compared with synthetic materials. It can serve to isolate and reduce abrasion between tracheobronchial, vascular and oesophageal suture lines, thus preventing fistula formation and can aid in sealing leaks from suture lines.

The omental tissue has the advantage of producing angiogenic factors, anti-inflammatory effect [8]. The immunological effect of GO is also well known. Owing to the increase of the lymphocyte count and other immunocompetent elements the bacterial count decreased significantly. Therefore, the empyema, mediastinitis, and osteomyelitis were prevented after using the GO.

Many techniques have been proposed for encircling the bronchial stump or tracheal anastomosis after broncho- and tracheoplastic procedures. The risk of erosion may be minimized by encircling the anastomosis with the well-vascularized GO tissue and the bronchopleural fistula, due to dehiscence, may be avoided. Morgan (1982) demonstrated early revascularization of the bronchial mucosa in canine models by the omentum usage [9]. In our experience, after the right pneumonectomy the frequency of the bronchial stump dehiscence was about 20%, but after the GO usage it was 3.3%. The GO flap can be easily exsected, transferred and sutured to the bronchial stump or tracheal anastomosis to ensure positive isolation and the anastomosis protection. The case with the tracheal anastomosis diverges after the resection of 12 rings indicated that the GO usage might salvage patients in hopeless situations.

The treatment of esophago-tracheal fistulas is a very serious problem accompanied by the high risk of morbidity and mortality. In the tracheoesophageal fistula repair the pleural flaps were initially used as an interposition flap between oesophageal and tracheal closures. Later they were abandoned in favour of pericardial flaps due to high recurrences rates [10]. We have four excellent results after the fistula dissection and tracheal coverage by GO tissue. In the event of an oesophageal leak Botham and Coran (1986) state that the GO pedicle may act as a template for the oesophageal neomucosa ingrowth [11].

At the moment the most wide-spread method for chronic empyema treatment is myoplastics. Lately thoracoplastics are used more seldomly. The usage of mescular grafts, according to different authors' reports, issues well at the treatment of chronic empyema with bronchial-pleural fistula, post-sternotomic mediastinitis, at the chest wall reconstruction [6] [12]. Simultaneously, in case of large cavities it is recommended to apply a combination of larger omentum or plastic methods but, however, with obligatory larger omentum inclusion.

From our point of view, the disadvantages of myoplastics are the used muscle function elimination, as well as developed defects in the donor area. The GO application allows the avoidance of these complications.

On the other hand, the GO square is large and allows the covering of various tissue defects. The GO abundant tissue grants to the surgeon freedom for radical and extensive debridement of the necrotic or tumour tissues, extensive resection with safety margins, gives satisfactory cosmetic and functional results and prevents recurrences [2] [13]. It is very important that the soft and bulky, well-vascularized GO completely fills the cavity and obliterates the dead space, comes into close contact with the debrided structures, brings vascularity to the tissues and prevents bacterial growth [14]. In all cases of the chest wall resection, the operative aim was achieved and the defect was satisfactorily covered with good functional integrity. Except for some paradoxical movement of the reconstruction during coughing and breathing, the flap provided sufficient, pain-free stability of the chest to allow normal daily activities [15] [16]. It needs supplementary investigations but the GO flap sometimes alone provides sufficient material for reconstruction after chest wall resection.

All infected spaces in pleura and mediastinum were filled with healthy tissue of sufficient size. GO supports skin and vascular grafts, it performs well covering rigid prostheses [12].

We do not think that the GO usage in oncological patients is risky regarding cancer dissemination. This matter requires separate research as well.

In numerous experimental reports it is proved that the tracheal graft can be revascularized by the omentum [17] [18]. Nakanishi (1994) showed that all of the tracheal autografts implanted into GO survived [19]. We applied this observation in practice [7]. Due only to the GO pedicle flap the tracheal graft was revascularized well and it could carry out its function.

The GO pedicle flap transposition is not novel in thoracic surgery. However, we demonstrated that due to the anatomical, functional and vascular peculiarities of GO this method is safe for patients. Omentoplasty in thoracic surgery allows the improvement of the treatment results, decrease of the complication frequency and it extends indications for surgical procedures owing to such an easy technique.

	Footnotes

 
Presented at the 11th Annual Meeting of the European Association for Cardio-thoracic Surgery, Copenhagen, Denmark, September 28 – October 1, 1997.

	References

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