Omentoplasty in Treatment of Early Bronchopleural Fistulas after Pneumonectomy

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.

[Omentum Transplantation in Thorax to Cover Bronchial Stump as Treatment of Bronchopleural Fistula After Pulmonary Resection: Report of 6 Cases' Experience]

背景与目的

支气管胸膜瘘（bronchopleural fistula, BPF）是胸外科肺切除术后常见并发症，临床治疗复杂且效果不佳。对于肺切除术后支气管胸膜瘘的处理一直困扰着胸外科医生。总结我院胸外科中心予大网膜胸腔移植覆盖支气管残端治疗肺切除术后出现BPF的临床资料，分析出现BPF的原因，总结外科治疗的方法，探讨其可行性、安全性及小样本的成功率。

方法

2016年8月-2018年2月，我中心对接受肺切除术后发生BPF的患者6例，进行再次开胸补救性手术、大网膜胸腔内移植覆盖支气管残端治疗。2例首次手术行肺叶切除（分别为右肺上叶及中下叶切除，再次手术均行患侧残肺切除，直线切割器缝合主支气管），4例首次手术行全肺切除（左右各2例）。术中予4-0微荞线修补主支气管残端后于心膈角处打开膈肌将大网膜移植入胸腔内后覆盖支气管残端。S术后予生理盐水浸泡胸腔。回顾分析上述6例患者的临床资料，总结该术式治疗肺切除术后BPF的临床效果。

结果

6例均为男性，中位年龄66岁（61岁-73岁）；术后发生BPF中位时间为术后25天（10天-45天）。再次手术中位时间为110 min（80 min-150 min），术中中位出血量450 mL（200 mL-1, 000 mL），再次手术后住院时间中位天数14天（12天-17天）。6例患者术后均恢复良好痊愈出院，支气管残端闭合良好，成功率为100%。随访1个月-18个月各病例均未再出现BPF相关并发症。

结论

肺切除术后发生BPF，如患者全身情况尚可耐受手术，应尽早行补救性手术，带蒂大网膜瓣容易获取，胸腔内移植覆盖支气管残端疗效确切可靠，值得临床推广应用。

Surgical management of recalcitrant peripheral bronchopleural fistula with empyema: A preliminary experience

Background:

Peripheral bronchopleural fistula (BPF) and empyema from necrotising infections of the lung and pleural is difficult to treat resulting in increased morbidity and mortality rates. The aim of this study was to show the effectiveness of the Latissimus Dorsi muscle (LDM) flap and patch closure techniques in the management of recalcitrant peripheral BPFs with the aid of thoracotomy.

Materials and Methods:

Five patients with BPF and empyema out of 26 patients who were initially treated for empyema thoracis by single or multiple chest tube insertions and/or ultrasound-guided drainage were prospectively identified and followed up for 2 years, postoperatively. The postoperative hospital stay, dyspnoea score, function of the ipsilateral upper limb and any deformity of chest wall were assessed at follow-up visits by asking relevant questions.

Results:

The mean age was 46.8 years (23-69 years) (4 males and 1 female). The cause of the BPF in 18 patients was Mycobacterium tuberculosis and 8 was pneumonia. The mean total months of the chest tube insertions was 1.5 months (range 2.5-6 months) prior to the thoracotomy and closure of fistula procedures performed on the 5 patients (with LDM flap in 4 patients and pleural patch in 1 patient). The complications recorded were: subcutaneous emphysema, residual pus and haemothorax in three patients. The mean postoperative hospital stay was 20.8 days (13-28 days);There was improved dyspnoea score to 1 or 2 in the 5 (19.2%) patients. There was no recurrence of BPF or residual pus in all the patients; no loss of function or deformity of the chest wall.

Conclusion:

The use of LDM Flap was effective in treating peripheral BFP without any adverse long-term outcome.

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.

Transthoracic Closure of a Postpneumonectomy Bronchopleural Fistula With Coils and Cyanoacrylate

Standard treatment for persistent bronchopleural fistulas involves thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. This major operation may be ineffective or medically contraindicated. We successfully treated 2 patients by insertion of coils and cyanoacrylate glue into and adjacent to the fistula of a postpneumonectomy bronchial stump with computed tomographic-guided transthoracic needle. The coils served as scaffolding for cyanoacrylate glue to control the bronchopleural fistula.