Two-stage Omental Flap Approach for Ascending Aortic Graft Infection

Soft tissue reconstruction of the trunk with pedicled perforator and musculocutaneous flaps: A single-center comparative retrospective study

BACKGROUND

Soft tissue trunk reconstruction is often challenging. Although free microvascular flaps are a feasible option in case of extensive defects involving deep structures, pedicled flaps represent a good alternative, especially if harvested and dissected with a "microsurgical" approach. The aim of this study is to evaluate the feasibility of trunk reconstruction with the use of pedicled flaps, according to the application of our reconstructive algorithm, and to compare it to other reconstructive methods.

PATIENTS AND METHODS

From January 2017 to December 2021, we retrospectively analyzed patients who underwent soft tissue reconstruction of the trunk with pedicled flaps at the authors' institution. Patient's demographic, clinical and surgical characteristics and postoperative complications were recorded and analyzed by descriptive statistics. A comparative analysis was made between the study group and two other groups who underwent reconstruction of trunk defects with free flaps and skin grafts, respectively, at the authors' institution.

RESULTS

Forty-seven patients were included in the study. Patients' age ranged between 36 and 82 years (mean: 57.8 years). Twenty-eight patients were male, while 19 patients were female. In 76.6% of patients (36 out of 47), reconstructive procedures were performed to repair defects resulting from cancer resection. Reconstruction of superficial defects was always achieved with perforator flaps (n = 25). In case of full-thickness defects, reconstruction was carried out with musculocutaneous flaps (n = 22); latissimus dorsi and vastus lateralis were the most used flaps for chest and abdominal wall reconstruction, respectively. In our series, we observed only one case of total flap loss requiring re-operation under general anesthesia. Minor complications occurred in 8.5% of cases (4 out of 47 patients). We observed two cases of partial flap necrosis and two cases of wound dehiscence. In the skin grafts group (n = 53), the mean age was 54.5 years (range 39-85) and 56% of patients were male (n = 30). In 66% of cases (n = 30) the defect resulted from oncological resection. The overall complication rate was 18.8% (n = 10). In the free flaps group (n = 10), the mean age was 49.0 years (range 29-77) and 60% of patients (n = 6) were male. In 70% of cases (n = 7) the defect was caused by oncological resection. Complications occurred in two patients (20%). No statistically significant differences were found in terms of overall complication rate between the study group and the two comparative groups (p = .48). A significant correlation was found between the reconstructive method and the type and size of the defect, with reconstruction through free flaps being associated with larger (344.0 vs. 220.4 cm2 ) (p = .04) and full-thickness defects (80.0% vs. 46.8%) (p < .01) if compared to pedicled flaps.

CONCLUSIONS

In the new era of microsurgery, pedicled flaps represent a valid alternative to free flaps for the majority of soft tissue defects of the trunk. In our series, no statistically significant differences in terms of complications were found between reconstructions of similar defects achieved with pedicled and free flaps, and free flap use was limited to extensive full-thickness defects. In addition, the rate of postoperative complications with pedicled flaps found in our cohort was lower than the rate reported in the literature.

Omental Flap for Complex Sternal Wounds and Mediastinal Infection Following Cardiac Surgery

INTRODUCTION

Omental flap (OF) is a traditional surgical option to counteract severe postcardiotomy mediastinal infection and to cover extensive sternal defects. We reviewed our experience with omental flap transfer (OFT) in various clinical circumstances, in which omentoplasty may be considered by cardiac surgeons.

METHODS

Twenty-one patients, who underwent OFT from January 2012 to December 2021, were studied. The main indication was treatment of infected foreign material implants including vascular grafts and ventricular assist devices or prevention of its infection (16 patients). In five patients, an OFT was used to cure mediastinitis following deep sternal wound infection after median sternotomy.

RESULTS

All patients had a high surgical risk with 3 ± 1.9 previous sternotomies and a mean Euro Score II of 55.0 ± 20.1. OF was successful in its prophylactic or therapeutic purpose in all patients, no complications related to the operative procedure were noted, that is, no early or late flap failure and no herniation of abdominal organs occurred. In-hospital mortality was six patients as three patients each died from multiple organ dysfunction syndrome and cerebral hemorrhage. All fifteen patients discharged demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. The mean follow-up of 18 months was uneventful.

CONCLUSION

OFT seems to be an excellent solution for extensive mediastinal and deep sternal wound infections.

Complex Hybrid Repair of a Secondary Aortoenteric Fistula

Background

Secondary aortoenteric fistula is a rare, highly morbid and often difficult to diagnose, cause of gastrointestinal bleeding. It is associated with prior aortic surgery or placement of a synthetic aortic graft. Our case features staged hybrid endovascular stent-grafting, graft excision, aortoplasty using a bovine pericardial patch, extra-anatomical bypass and complex bowel repair.

Case Report

An 82-year-old man presented with gastrointestinal bleeding and Streptococcus Anginosus bacteraemia, with previous aorto-bi-iliac bypass surgery for left common iliac occlusive disease 15 years ago. Computed tomography angiography (CTA), gastroscopy, colonoscopy, capsule endoscopy and enteroscopy identified no bleeding source. Repeat CTA showed gas locules and stranding around the graft and the third part of the duodenum, concerning for fistulous communication. On the next day, a Zenith TX2 thoracic 28x80mm stent-graft was deployed into the infrarenal aorta. On laparotomy, a fistula was present between the Dacron graft and fourth part of the duodenum. The Dacron graft was excised, followed by aortic patching with bovine pericardium. A right-to-left femoral-femoral crossover graft was constructed. CT at one-month post-laparotomy showed no signs of perigraft endoleak and interval resolution of gas locules. He was transferred to a rehabilitation facility on the 34th post-operative day with a multidisciplinary follow-up arranged.

Discussion

Aortoduodenal fistula is a challenging entity to diagnose and should be suspected in patients with GI bleeding and prior aortic surgery. Endovascular repair alone is a less invasive option but with higher re-infection and late failure rates. Liberal use of appropriate imaging modalities, a judicious repair strategy, long-term follow-up and multidisciplinary approach are critical for its management.