Omentoplasty in thoracic surgery

Pedicled Omentoplasty for Treatment of Rheumatoid Nodule Pneumothorax: A Case Report

Background  No consensus exists regarding surgical intervention for rheumatoid nodule-related pneumothorax. Clinical policy decisions rely on individual clinicians' experience and are usually intractable. Case Description  A 50-year-old man with a difficult-to-treat rheumatoid arthritis-related pneumothorax was successfully treated with pedicle omentoplasty without recurrence at approximately 2 years posttreatment. To the best of our knowledge, this is the first report of a patient where pneumothorax did not recur due to firm adhesions despite fluctuating postoperative rheumatoid nodules, as captured by regular computed tomography imaging follow-ups. Conclusion  Pedicled omentoplasty is effective for rheumatoid nodule-related pneumothorax as it reduces pneumothorax recurrence.

Spontaneous closure of a metachronous brochopleural fistula after omentoplasty for a preceding fistula: Case report

Introduction

A bronchopleural fistula (BPF) after an anatomical lung resection commonly arises singly. We report a case of a metachronous BPF, which developed after omentoplasty of a preceding fistula and subsequently closed without any intervention.

Case presentation

A 77-year-old patient underwent omentoplasty for a brochopleural fistula (BPF) following a right lower lobectomy. A sudden massive air leak developed from the novel BPF approximately 1 cm proximal to the preceding fistula 3 days later. The air leak resolved spontaneously without any intervention one week later. The corresponding fistula was found to be completely closed. Computed tomography showed the omental flap covered both fistulae.

Conclusion

The present case suggested that a metachronous BPF could develop and a harvested omental flap might migrate even after being anchored.

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A metachronous bronchopleural fistula (BPF) developed 3 days after an omentoplasty for a preceding fistula following a right lower lobectomy.

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The BPF was closed spontaneously without any subsequent intervention and a computed tomography revealed that the omental flap covered both fistulae.

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A metachronous BPF could develop and a harvested omental flap might migrate even after being anchored.

Current indications for the intrathoracic transposition of the omentum

Background

The intrathoracic transposition of the omentum (ITO) has been reported with more or less good results in various clinical circumstances but with no clear guidelines or indications.

Methodology and review

This article reviews the main clinical situations in which omento-plasty (OP) may be taken into consideration by the thoracic surgeons: mediastinitis and deep sternal infections after median sternotomy, reinforcement of the eso-gastric anastomosis after esophagectomy, prevention and treatment of the bronchial fistula after pulmonary resection, space-filling procedures for empyema, mediastinal tracheostomy, management of the infected intrathoracic vascular grafts / ventricular assist devices and heart OP. For each clinical situation we have performed a literature review with analysis of the most relevant published papers searching for an evidence-based approach for the use of the ITO/OP in thoracic surgery.

Conclusions

OP may be an elegant solution for a wide range of problems in thoracic surgery. In the published literature, there are mainly case-reports and relatively small series published resulting in a low level of evidence for both ITO as a surgical technique by itself, as well as for the use of OP in various clinical situations involving the chest structures. The indications for its use in thoracic surgery are based more on common sense and the lack of other solutions.

Omental flap for treatment of dead space after left upper lobectomy due to aspergilloma

Dead space formation in the thoracic cavity as a result of lung parenchymal resection is particularly prone to intra-thoracic infections, which are often hard to treat with systemic antibiotics; secondary interventions, such as thoracoplasty, eloesser flap, or muscle flap may be required to treat this complication. Alternatively, use of an omental flap represents an attractive option in cases of surgical cavities, due to the volumetric and immunologic advantages associated with the omentum. A 55-year-old male patient, who underwent left upper lobectomy due to an aspergilloma, was left with a surgical cavity that became infected with Pseudomonas aeruginosa. To address this complication, we performed a reconstruction of the left upper lung field through the substernal route using a section of the omental flap, and the infection was clinically eradicated.

Benefits of using omental pedicle flap over muscle flap for closure of open window thoracotomy

BACKGROUND

Open window thoracotomy (OWT) as well as its closure are challenging. Transposition of omental pedicle and muscle flaps is often performed for OWT closure; however, the better technique among the two is unknown. The purpose of this series was to evaluate the outcomes of using both omental pedicle and muscle flaps for the aforementioned closure.

METHODS

This was an observational retrospective cohort study on 27 consecutive patients who underwent OWT closure at a single institution between January 2005 and December 2014. The operation was performed using either omental pedicle or muscle flap with thoracoplasty. We compared both techniques in terms of the patient background [sex, age, body mass index (BMI) and C-reactive protein (CRP) before OWT and serum albumin levels before OWT closure], presence of methicillin-resistant Staphylococcus aureus (MRSA) infection, rate of bronchopleural fistula (BPF), duration of OWT, recurrence of local infection, morbidity, duration of indwelling drainage after operation, success, mortality and postoperative hospital stay.

RESULTS

There were 9 (33.3%) omental pedicle flap procedures and 18 (66.7%) muscle flap procedures. The rate of local recurrence after closure of OWT was significantly higher with muscle flap than with omental pedicle flap (0% vs. 50.0%, P=0.012). The median duration of postoperative hospital stay was significantly shorter with omental pedicle flap than that with muscle flap (16.0 vs. 41.5 days, P=0.037). Mortality was observed in 2 patients (11.2%) in the muscle flap group and no patient in the omental pedicle flap group. Success rate was similar between the two groups (100% for omental pedicle flap vs. 83.3% for muscle flap).

CONCLUSIONS

Omental pedicle flap was superior to muscle flap in terms of reducing local recurrence and shortening postoperative hospital stay. However, mortality, morbidity and success rates were not affected by the choice of flap.

Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure

Extravasation is a rare but serious complication of vasopressor administration. A 60-year-old female who underwent ascending and hemiarch repair of the aorta along with aortic valve replacement developed extensive right breast and chest wall necrosis after vasopressor extravasation from an internal jugular vein central line. The patient underwent a total mastectomy due to deep tissue necrosis detected by laser-assisted indocyanine green dye angiography, and eventually required omental flap reconstruction to obtain adequate sternal coverage. This case represents a previously unreported complication of internal jugular central line extravasation of vasopressors with resultant breast and chest wall necrosis, and highlights the utility of the omentum in chest wall reconstruction.

The treatment of chronic pleural empyema with laparoscopic omentoplasty. Initial report

Introduction

Pleural empyema is the most serious, life-threatening postoperative complication of pneumonectomy, observed after 1–12% of all pneumonectomies, with bronchopleural fistula being its main cause.

Aim

The aim of this publication is to present early outcomes of minimally invasive surgical management of pleural empyema. Patients were subjected to a single, complex procedure, consisting of the laparoscopic mobilization of the greater omentum and its transposition via the diaphragm into the pleural cavity to fill in the empyema cavity with the consecutive pleuro-cutaneous fistuloplasty (thoracoplasty).

Material and methods

Between May 2011 and April 2013, 8 patients were qualified to undergo the procedure. The mean age was 61 years (range: 46–77 years). Presence of bronchopleural fistula was confirmed in 3 cases. The median time of treatment with thoracostomy was 14.5 months.

Results

The mean operative time was 125 min. The mean duration of post-operative hospital stay was 13.5 days (range: 7–31 days). In 6 patients (75%) the objective of permanent resolution of pleural empyema was achieved. In total, 4 patients had complications: pleural empyema recurrence (2 patients), splenic injury, hiatal hernia, gastrointestinal bleed. Two patients with empyema recurrence had Staphylococcus aureus infections prior to surgery. They were successfully managed both with prolonged thoracic drainage and antibiotics.

Conclusions

Use of the greater omentum that was laparoscopically mobilized and transpositioned into the pleural cavity allows simultaneous management of the pleural empyema cavity and thoracostomy. The procedure is safe, with few direct complications. It is well tolerated and has at least a satisfactory cosmetic effect. The minimally invasive approach allows faster recovery and return to daily activities in comparison to the fully open technique.

Successful treatment of refractory chylothorax by pedicled omentoplasty

A 52-year-old female with a history of past surgery for arteriovenous malformation of the thoracic spinal cord presented with left chylothorax. Lymphangiography identified diffuse lymphatic vessel (LV) growth with ectasia at the left supradiaphragmatic level. On the right side, the LVs were absent due to previous surgery. Given the ineffectiveness of conservative management, the patient required surgery. Thoracotomy showed extensive pleural fibrosis, lung atelectasis, and diffuse chyle defluxion on the parietal pleura. The diffuse chyle defluxion was not resolved by ligation. Therefore, we performed pedicled omentoplasty to fill the pleural space and to utilize its drainage and angiogenic capacity. Two years after the procedure, there was no sign of relapse. There are very few reports of refractory chylothorax successfully treated by pedicled omentoplasty. The procedure would be useful for the treatment of chylothorax when non-surgical or typical surgical management fails.

Thoracomyoplasty in the treatment of empyema: current indications, basic principles, and results

Empyema remains a challenge for modern medicine. Cases not amenable to lung decortication are particularly difficult to treat, requiring prolonged hospitalizations and mutilating procedures. This paper presents the current role of thoracomyoplasty procedures, which allow complete and definitive obliteration of the infected pleural space by a combination of thoracoplasty and the use of neighbourhood muscle flaps (latissimus dorsi, serratus anterior, pectoralis, rectus abdominis, omentum, etc). Recent publications show an overall rate of success of 90%, with a quick and definitive healing. Although rarely indicated in our days, this kind of procedures remain in the armamentarium of modern thoracic surgery. The importance of thoracomyoplasty derives from the fact that it may be a simple and definitive solution for complicated cases of chronic empyema not amenable to standard decortication.

Contrast-enhanced endoscopic ultrasonography (CE-EUS) findings in adrenal metastasis from renal cell carcinoma

Solitary adrenal metastasis is often difficult to distinguish from benign adrenal tumor using only plain computed tomography (CT) scanning. We describe a solitary left adrenal gland mass in a patient who had undergone simultaneous gastrectomy and right nephrectomy for advanced gastric cancer and renal cell carcinoma (RCC), respectively. Contrast-enhanced endoscopic ultrasonography (CE-EUS) findings indicated a hypervascular adrenal mass, and EUS-guided fine needle aspiration (EUS-FNA) revealed clear cell carcinoma. Adrenalectomy confirmed metastatic clear cell carcinoma of the kidney.

Intractable lung abscess successfully treated with cavernostomy and free omental plombage using microvascular surgery

A 68-year-old man, complaining of fever and puriform sputum, was referred to our hospital. A giant abscess was detected in the upper lobe of the right lung. Percutaneous drainage of a lung abscess was carried out. When the pus collected was cultured, Candida was 1+ and Escherichia coli was 2+. Later, it became difficult to control the abscess by drainage, and cavernostomy was selected. The contents of the abscess cavity were removed, and the cavity was opened, followed by exchange of gauze every day. For 14 months after cavernostomy, once-weekly gauze exchange was continued at the outpatient clinic to clean the abscess cavity. Finally, the abscess was filled with a free greater omentum flap, accompanied by microvascular anastomosis. In this way, the intractable lung abscess was successfully cured. Conventionally, surgical treatment, particularly cavernostomy, has been applied only to limited cases when dealing with a lung abscess. Our experience with the present case suggests that surgical treatment, including cavernostomy as one option, should also be considered when dealing with lung abscesses resisting medical treatment and causing compromised respiratory function. To enable maximum utilization of the greater omental flap, which is available in only a limited amount, it seems useful to prepare and graft a free omental flap making use of microvascular surgery.