Use of the omentum in chest-wall reconstruction

Omental flaps reduces complications after pancreaticoduodenectomy

BACKGROUND

Major complications after pancreaticoduodenectomy are usually caused by a leaking pancreaticojejunal anastomosis. Omental flaps around various anastomoses were used to prevent the formation of fistula.

METHODS

We reviewed 147 patients who had undergone pancreaticoduodenectomy between March 2006 and March 2012. The patients were divided into 2 groups according to the application of omental flaps around various anastomoses: group A (101 patients) who underwent omental wrapping procedure; group B (46 patients) who did not undergo the omental wrapping procedure. Perioperative data of the two groups were reviewed to assess the effectiveness of omental flap procedure in the prevention of pancreatic fistula and other complications.

RESULTS

No differences were observed in the clinical characteristics between the 2 groups. The incidences of pancreatic fistula (4.0% vs 17.4%), post-pancreatectomy hemorrhage (0 vs 6.5%), biliary fistula (1.0% vs 13.0%), and delayed gastric emptying (4.0% vs 17.4%) were significantly less frequent in group A. The overall morbidity (18.8% vs 47.8%) and hospital stay (8.3 vs 9.6 days) were also significantly lower in group A than in group B.

CONCLUSIONS

Omental flaps around various anastomoses after pancreaticoduodenectomy can reduce the incidences of pancreatic fistula, biliary fistula, post-pancreatectomy hemorrhage and delayed gastric emptying. This procedure is simple and effective to reduce the overall morbidity after pancreaticoduodenectomy.

Morphology of the Canine Omentum Part 1: Arterial Landmarks that Define the Omentum

Although the omentum remains an enigmatic organ, research during the last decades has revealed its fascinating functions including fat storage, fluid drainage, immune activity, angiogenesis and adhesion. While clinicians both in human and veterinary medicine are continuously exploring new potential omental applications, detailed anatomical data on the canine omentum are currently lacking, and information is often retrieved from human medicine. In this study, the topographic anatomy of the canine greater and lesser omentum is explored in depth. Current nomenclature is challenged, and a more detailed terminology is proposed. Consistent arteries that are contained within folds of the superficial omental wall are documented, described and named, as they can provide the anatomical landmarks that are necessary for unambiguous scientific communication on the canine omentum. In an included dissection video, the conclusions and in situ findings described in this study are demonstrated.

Omental transposition flap for sternal wound reconstruction in diabetic patients

In 2004, we published our 12-year experience with tissue transfer for deep sternal wound infection after median sternotomy, finding increased rates of reoperation for diabetic patients. Therefore, we decided to alter our treatment approach to diabetic patients to include sternal debridement followed by omental transposition. Eleven diabetic patients underwent omental transposition by our division during the study period. Hospital records were retrospectively reviewed to determine outcomes and complications. We found that diabetic patients treated after implementation of the new treatment approach were 5.4 times less likely to require reoperation for sternal wound management than were patients in the previous series, most of whom had been treated with pectoralis muscle flaps (95% confidence interval, 0.5- 50.5). By altering our treatment approach to use omental transposition as the initial surgical therapy, we were able to demonstrate a trend toward decreased need for flap revision in diabetic patients.

Use of the greater omentum for reconstruction of infected sternotomy wounds: a prognostic indicator

INTRODUCTION

Use of the omentum for poststernotomy mediastinitis is typically viewed as a last resort. Formal debridement and muscle flap coverage is sufficient most of the time; however, there are situations when the omental flap is more appropriate. The purpose of this series is to critically evaluate the outcome in those patients who require omental flap reconstruction of poststernotomy mediastinitis.

METHODS

A retrospective review was performed on consecutive patients undergoing omentum flap transposition for poststernotomy mediastinitis from 1990-2005 at Emory University Hospitals. Data points queried included patient demographics, risk factors, type of reconstruction, and outcome. Patient survival was determined at 60 days and 1, 3, and 5 years postomentum reconstruction using the Social Security Death Index. These data points were compared with age- and risk-matched patients from our institution, treated during the same time period with muscle flaps alone.

RESULTS

Fifty-two patients had omental flap reconstruction, with an average age of 61 years (range: 35 to 78). The average follow-up was 5.1 years (range: 1 day to 15 years). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism identified at time of omental transfer (56%). The omentum was used either for primary reconstruction, n = 35/52 (67%), or as a salvage procedure following failed muscle flap coverage, n = 17/52 (33%). Complications included donor site 27%, flap related 23%, and general 71% of patients. Those patients undergoing salvage reconstruction had a proportionally greater 60-day mortality (24%) and complication rate. The overall mortality was higher in those patients who required an omental flap transfer when compared with 52 muscle-flap controls (42% versus 18% at 3 years).

DISCUSSION

The greater omentum is still an invaluable tool in the management of mediastinal wound infections when other options have failed or are insufficient. Although reliable and well indicated, the omental flap appears to be a marker for increased mortality, especially when used as a salvage procedure. This association is not directly related to the omental flap but rather to the complexity of the clinical situation leading up to its use. Patients who require omental flap coverage should be counseled and treated appropriately.

Comparison of mersilene mesh-methyl metacrylate sandwich and polytetrafluoroethylene grafts for chest wall reconstruction

We report the outcomes of patients who underwent reconstruction with Mersilene mesh-methyl methacrylate (MM-MM) sandwich and polytetrafluoroethylene (PTFE) grafts after a large chest wall resection. Between June 1990 and September 2001, 59 consecutive patients (37 men, 22 women; mean age, 48.1 +/- 11.8 years; range 22-74 years) underwent large chest wall resection (greater than 5 cm diameter) and reconstruction with prosthetic material in our department. Twenty-one patients (33%) underwent reconstruction with a PTFE graft (group 2) between 1990 and 1994, and 38 patients (67%) underwent reconstruction with an MM-MM sandwich graft (group 1) between 1994 and 2001. Operative morbidity ratios were 5.2% (2/38) in group 1 and 24% (5/21) in group 2 (p = .036). The paradoxical respiration ratio was significantly higher (p = .018) in group 2 (5/21: 24%) than it was in group 1 (1/38: 2.6%). The operative mortality ratio was 4.5% (1/21) in group 2 and 0% in group 1. Mean hospital stay was 10.6 days (range 5-21 days) in group 1 and 13.3 days (range 7-36 days) in group 2 (p = .015). The MM-MM graft is inexpensive and easy to apply, provides better cosmetic options, and offers minimal morbidity. We therefore recommend that the MM-MM sandwich graft be used rather than the PTFE graft for large defects of the anterolateral chest wall and sternum where successful prevention of paradoxical respiration is required.

Current concepts in the management and reconstruction of the dehisced median sternotomy

This review will delineate the underlying conditions that predispose patients to deep mediastinal infection and sternal dehiscence, discuss the principles of thorough debridement and preparation of the wound, and assess the appropriate options available for successful reconstruction.

Omental free-tissue transfer: indications and results from personal experience

Between 1987-2002, omental free-tissue transfer was used in 11 patients, aged 6-65 years (mean age, 37.6). The omentum was used for the treatment of brachial plexus injury pain (3 cases), Romberg's disease (1 case), defects of the extremities occurring with chronic obstructive arterial disease (2 cases), posttraumatic lesions (3 cases), and following oncological resections (2 cases). In 2 cases, omental tissue represented the secondary option, after the failure of muscular tissue transfer. In 2 patients, the omental tissue transfer helped to preserve the knee. There was 1 failure, followed by amputation of the thigh. Two patients died from their underlying disease 10 and 36 months, respectively, after the operation.

Abdominoplasty repair for abdominal wall hernias

The objectives of abdominal hernial repair are to reconstruct the structural integrity of the abdominal wall while minimizing morbidity. Current techniques include primary closure, staged repair, and the use of prosthetic materials. Techniques for abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. By incorporating these aspects into hernial repairs, the procedures are made safer and the results are improved. The medical records were reviewed of 123 consecutive patients who underwent hernial repair. Seventy-six of these patients underwent a total of 82 herniorrhaphies using an abdominoplasty approach. This included using a transverse lower abdominal incision with or without extending it into an inverted-T incision. The hernial defect was then identified and isolated. Repair was obtained with primary fascial closure and plication, primary fascial approximation and reinforcement with absorbable Vicryl mesh, or placement of permanent mesh with or without fascial approximation. Overall, 8 of 82 hernias recurred. Most complications were minor and could be managed with local wound care only. Major complications included one enterocutaneous fistula, one occurrence of skin flap necrosis requiring operative debridement and skin grafting, and one delayed permanent mesh extrusion 2 years after repair. The abdominoplasty approach isolates the incision from the hernial defect and repair. This technique is safe with a low risk of complications and a low rate of recurrence. It is particularly helpful in obese patients, in patients with multiple hernias, and in those patients with recurrent hernias.

Utility of the omentum in the reconstruction of complex extraperitoneal wounds and defects: donor-site complications in 135 patients from 1975 to 2000

OBJECTIVE

To examine donor-site complications after omental harvest for the reconstruction of extraperitoneal wounds and defects.

SUMMARY BACKGROUND DATA

The omentum, with its immunologic and angiogenic properties, is a versatile organ with well-documented utility in the reconstruction of complex wounds and defects. However, the need for laparotomy and the potential for intraabdominal complications have been cited as relative contraindications to the use of the omentum as a reconstructive flap. Further, few series have assessed long-term results, and no reports have focused on donor-site complications.

METHODS

Patients who underwent reconstruction of extraperitoneal defects with the omentum at a single university healthcare system were identified by searching discharge databases and office records. Charts were reviewed to determine patient demographics, surgical indications and technique, postoperative complications, and outpatient follow-up. Patients with donor-site complications were compared with patients who had no complications using the Student t test and chi-square analysis. Statistical significance was defined at P <.05.

RESULTS

From 1975 to 2000, the authors successfully harvested 135 omental flaps (64 pedicled, 71 free transfer) for reconstruction of the following defects: scalp (n = 16), intracranial (n = 1), orbitofacial (n = 33), neck (n = 8), upper extremity (n = 7), lower extremity (n = 4), intrathoracic (n = 3), sternal (n = 34), breast (n = 3), chest wall (n = 18), abdominal wall (n = 1), and perineal (n = 7). Donor-site complications in 25 patients (18.5%) included abdominal wall infection (n = 9), fascial dehiscence (n = 8), symptomatic hernia (n = 8), unplanned reexploration (n = 6), postoperative ileus (n = 3), gastrointestinal hemorrhage (n = 2), delayed splenic rupture (n = 1), gastric outlet obstruction (n = 1), and late partial small bowel obstruction (n = 1). Factors associated with increased donor-site complications included the use of pedicled flaps (compared with free tissue transfer), mediastinitis, advanced age, and pulmonary failure. Of note, 53 patients had undergone previous abdominal surgery; of these, 26 patients required extensive adhesiolysis and 4 patients sustained enterotomies. Eleven patients (8.1%) had partial flap loss and three patients (2.2%) had total flap loss. Mean length of stay was 28 days. Average follow-up was 2.4 years. The death rate was 5.9%.

CONCLUSIONS

The omentum can be safely harvested and reliably used to reconstruct a diverse range of extraperitoneal wounds and defects. Donor-site complications can be significant but are usually limited to abdominal wall infection and hernia. Risk factors associated with complications include the use of pedicled flaps, mediastinitis, and pulmonary failure. This low rate of donor-site complications strongly supports the use of the omentum in the reconstruction of complex wounds and defects.

Management of postpneumonectomy bronchopleural-cutaneous fistula with a single free flap

A variety of local flaps have been described for chest wall and bronchopleural fistula reconstruction. When local options cannot be used because of previous surgery, trauma, radiation, or body habitus, free flaps become an acceptable option. The authors report a case of persistent bronchopleural-cutaneous fistula treated with a free latissimus dorsi musculocutaneous flap that obliterated the right chest cavity, closed the site of empyema drainage, and aided healing of a bronchopleural fistula. Surgical technique including anastomosis to the innominate vein is described.

Successful treatment of sternal osteomyelitis after pneumonectomy using a pedicled omental flap

We report here the case of a 64-year-old man with sternal osteomyelitis after pneumonectomy through a median sternotomy who was successfully treated using a pedicled omental flap. This is the first report in the literature to describe sternal osteomyelitis and mediastinitis after pneumonectomy. In this case, the visceral pleura of the remnant right lung was located just under the infected sternum. Careful management is recommended because empyema pleurae can be a fatal complication.

Thoracic reconstruction with the omentum: indications, complications, and results

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.

Chest wall resection and reconstruction

Chest wall reconstruction has been refined and expanded in recent years so that almost any defect may be repaired with an excellent cosmetic and physiological result. The first step in a good reconstruction is an appropriate and thorough resection that leaves healthy, viable margins to which the materials and tissues used in a reconstruction may be anchored securely. In most instances, chest wall stabilization will not be necessary. In some cases in which large areas of chest wall will be removed or a lateral aspect of a chest wall needs to be resected, stabilization may be necessary. Stabilization may also be required in patients who suffer from debilitating lung disease and need a chest wall resection and reconstruction. Soft tissue coverage completes the reconstruction by moving healthy, viable tissue to fill the defect. In most instances, pedicled muscular, musculocutaneous, and omental flaps will provide adequate soft tissue coverage. Very infrequently, a free flap will be necessary to achieve total closure of a chest wall defect. The soft tissue coverage is completed by using meshed, split thickness skin grafts to provide epithelialization of any exposed muscle or omentum.

Reconstruction of a large thoracoabdominal wall defect with a flow-through forearm flap and a latissimus dorsi-groin flap

We report a case of a 45-year-old man with a recurrent, large, invasive dermatofibrosarcoma protuberans over the left lower chest and abdomen. Wide surgical excision of the tumor created a major thoracoabdominal wall defect. Wound coverage was achieved by using a flow-through forearm flap and an inferiorly based latissimus dorsi-groin flap. Follow-up at 1 year revealed no local recurrence or herniation.

A technique for management of bite wounds of the thoracic wall in small dogs

Bite wounds of the chest wall in small dogs can extend into the thorax and can be associated with severe damage to chest wall muscles, ribs, and lungs. Two major problems associated with the management of these wounds are lack of sufficient muscle tissue for chest wall reconstruction, and difficulty draining the extensive dead space created in the chest wall. We describe a simple method to overcome these problems. The bite wound areas were surgically explored and all devitalized soft tissue was debrided. The pleural cavity was explored, intrathoracic injuries repaired, and a thoracic drainage tube was placed. Ribs in the injured area were stabilized in anatomic position by means of heavy gauge sutures passed around pairs of adjacent ribs, thus creating a scaffolding for soft tissues. Viable muscle and subcutaneous tissues were apposed as much as possible and the skin closed over the defect. Eleven small dogs were treated using this technique. All dogs had severe injuries to the thoracic wall muscles and eight dogs had multiple rib fractures. There was no evidence of chest wall instability in any of the dogs after surgery. Nine dogs survived the injury and were reevaluated 3 to 32 months after surgery. All were clinically normal. One dog developed wound infection and pyothorax, caused by insufficient debridement of injured muscle tissue, and died 10 days after surgery. A second dog died 24 hours postoperatively of undetermined causes.

Sternal resection and reconstruction

Twenty-one patients underwent sternal resection and reconstruction. Surgical indications included sternal infection in 9 patients, recurrent breast cancer in 6, metastatic carcinoma from an unknown primary in 2, pectus excavatum in 2, and osteogenic sarcoma and eosinophilic granuloma in 1 each. Management included partial sternectomy in 10 patients (group 1) and complete sternectomy in 11 (group 2). Chest wall reconstruction was by various flaps and mesh repairs. Blood transfusions averaged 2 units in group 1 versus 5.5 units in group 2 (p = 0.02). Average number of days until extubation was 2.6 in group 1 versus 7.3 in group 2 (p = 0.04). Average number of intensive care unit days was 4.4 for group 1 versus 9.4 for group 2 (p = 0.03). The number of days until discharge was 14 days for group 1 versus 20 days for group 2. Complications occurred in 40% of group 1 and 82% of group 2 patients. Overall mortality was 9.5%. Sternal resection and reconstruction, particularly complete sternal resections, are a major undertaking with substantial morbidity. Using a multidisciplinary approach (cardiothoracic, plastic and reconstructive, critical care medicine, and infectious disease) and aggressive pulmonary support, acceptable cosmetic and functional results are possible.