Omental Flap for Bronchopleural Fistula After Pneumonectomy and Aorta Replacement

Superior vena cava graft infection in thoracic surgery: a retrospective study of the French EPITHOR database

 

OBJECTIVES

To report our experience on the management of superior vena cava graft infection.

METHODS

Between 2001 and 2018, patients with superior vena cava synthetic graft or patch reconstruction after resection of intrathoracic tumours or benign disease were selected retrospectively from the French EPITHOR database and participating thoracic centres. Our study population includes patients with superior vena cava graft infection, defined according to the MAGIC consensus. Superior vena cava synthetic grafts in an empyema or mediastinitis were considered as infected.

RESULTS

Of 111 eligible patients, superior vena cava graft infection occurred in 12 (11.9%) patients with a polytetrafluoroethylene graft secondary to contiguous contamination. Management consisted of either conservative treatment with chest tube drainage and antibiotics (n = 3) or a surgical graft-sparing strategy (n = 9). Recurrence of infection appears in 6 patients. Graft removal was performed in 2 patients among the 5 reoperated patients. The operative mortality rate was 25%.

CONCLUSIONS

Superior vena cava graft infection may develop as a surgical site infection secondary to early mediastinitis or empyema. Graft removal is not always mandatory but should be considered in late or recurrent graft infection or in infections caused by aggressive microorganisms (virulent or multidrug resistant bacteria or fungi).

Is omentectomy necessary in the treatment of benign or malignant abdominal pathologies? A systematic review

BACKGROUND

The omentum is an organ that is easily sacrificed during abdominal surgery. The scope of omentectomy and whether a routine omentectomy should be performed are still unknown.

AIM

To review the literature in order to determine the physiological functions of the omentum and the roles it plays in pathological events in order to reveal the necessity for removal and preservation of the omentum.

METHODS

A clinical review of the English language literature based on the MEDLINE (PubMed) database was conducted using the keywords: “abdomen”, “gastrointestinal”, “tumor”, “inflammation”, “omental flap”, “metastasis”, “omentum”, and “omentectomy”. In addition, reports were also identified by systematically reviewing all references in retrieved papers.

RESULTS

The omentum functions as a natural barrier in areas where pathological processes occur in the abdominal cavity. The omentum limits and controls inflammatory and infectious pathologies that occur in the abdomen. It also aids in treatment due to its cellular functions including lymphatic drainage and phagocytosis. It shows similar behavior in tumors, but it cannot cope with increasing tumor burden. The stage of the disease changes due to the tumor mass it tries to control. Therefore, it is considered an indicator of poor prognosis. Due to this feature, the omentum is one of the first organs to be sacrificed during surgical procedures. However, there are many unknowns regarding the role and efficacy of the omentum in cancer.

CONCLUSION

The omentum is a unique organ that limits and controls inflammatory processes, foreign masses, and lesions that develop in the abdominal cavity. Omental flaps can be used in all anatomical areas, including the thorax, abdomen, pelvis, and extremities. The omentum is an organ that deserves the title of the abdominal policeman. It is generally accepted that the omentum should be removed in cases where there is tumor invasion. However, the positive or negative contribution of omental resection in the treatment of abdominal pathologies should be questioned.

Negative-pressure wound therapy in combination with bronchial occlusion to treat bronchopleural fistula: a case report

Background

Bronchopleural fistula, which usually accompanies bronchial fistula and empyema, is a severe complication of lung cancer surgery. Negative-pressure wound therapy can enhance drainage and reduce the empyema cavity, potentially leading to early recovery. This therapy is not currently indicated for bronchopleural fistulas because of the risk of insufficient respiration due to air loss from the fistula.

Case presentation

A 73-year-old man, who was malnourished because of peritoneal dialysis, was referred to our hospital for the treatment of lung cancer. Right lower lobectomy with mediastinal lymph node dissection was performed via posterolateral thoracotomy, and the bronchial stump was covered with the intercostal muscle flap. His postoperative course was uneventful and he was discharged. However, he was readmitted to our hospital because of respiratory failure and diagnosed as having bronchopleural fistula on the basis of the bronchoscopic finding of a 10-mm hole at the membranous portion of the inlet of the remnant lower lobe bronchus. Thus, thoracotomy debridement and open window thoracostomy were immediately performed. After achieving infection control, bronchial occlusion was performed using fibrin glue and a polyglycolic acid sheet was inserted through a fenestrated wound. Bronchial fistula closure was observed on bronchoscopy; therefore, a negative-pressure wound therapy system was applied to close the fenestrated wound. The collapsed lung was re-expanded and the granulation tissue around the wound increased; therefore, thoracic cavity size decreased and thoracoplasty using the latissimus dorsi was performed.

Conclusions

This bronchopleural fistula was treated successfully after a right lower lobectomy using an extra-pleural bronchial occlusion and negative-pressure wound therapy.

One-stage closure of large bronchopleural fistula with pedicled latissimus dorsi muscle flap after preemptive antibiotics: A case report

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Bronchopleural fistula (BPF) often needs two-stage closure after fenestration.

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This case highlights one-stage surgical closure of a large BPF with a muscle flap.

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Pedicled latissimus dorsi muscle flap would be useful even for 3-cm sized BPF.

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Preemptive antibiotics minimized local infection in ischemic bronchitis before BPF.

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Minimum infection with a limited-size space may be a key for one-stage closure.

Introduction

Bronchopleural fistula (BPF) after lung cancer surgery is a life-threatening complication and often needs two-stage closure after fenestration. Although one-stage closure of BPF is challenging, it would provide shorter treatment time and lower patient physical burden than two-stage closure. However, there have been few reports of one-stage closure of a large BPF.

Presentation of case

A 53-year-old man underwent robotic right lower lobectomy with systematic lymph node dissection. Postoperative bronchoscopy revealed an ischemic change in the bronchial stump, which progressed to a large BPF. However, under the preemptive antibiotic treatment without chest drainage, local infection was controlled within a limited pleural space. We successfully performed one-stage closure of a 3-cm sized BPF with pedicled latissimus dorsi (PLD) muscle flap.

Discussion

Early diagnosis of ischemic bronchitis and appropriate preceding antibiotic treatment could minimize the local infection around the fistula. To our knowledge, our case represented the largest BPF that was successfully treated by one-stage procedure using preemptive antibiotics and the PLD muscle flap.

Conclusion

One-stage closure using the PLD muscle flap may be a treatment option even for a 3-cm sized BPF, wherein infection is controlled and the relevant pleural cavity is limited.