Omental Flap Transposition Research Articles

Multifaceted surgical approach of combined thoracoretroperitoneal incision and midline abdominal incision for a secondary aortoenteric fistula

BackgroundWe report a one-stage surgery to the case of secondary aortoenteric fistula (sAEF) after prosthetic reconstruction of abdominal aortic aneurysm, by multifaceted approach.Case presentationA 63-year-old male was admitted to our unit under diagnosed of sAEF after prosthetic reconstruction of abdominal aortic aneurysm, and a pseudoaneurysm of thoracoabdominal aorta due to infection. The patient underwent emergency operation. Firstly, we placed the patient in a modified right lateral decubitus position and performed thoracoabdominal aortic replacement with retroperitoneal approach by thoracoretroperitoneal incision which combined thoracotomy and pararectal incision, and secondly, we changed to a supine position and performed closure of the duodenal fistula and omental flap transposition by midline abdominal incision. The patient was doing well without complications.ConclusionsA one-stage, multifaceted surgical approach covering both prosthetic reconstruction of thoracoabdominal aorta and closure of sAEF with omentopexy is reasonable and useful strategy.

Robotically-harvested, thoracoscopically-tunneled transdiaphragmatic omental pedicle flap for obliteration of radiated empyema cavity

Intra-thoracic defects continue to pose a challenge for the reconstructive surgeon. Stable soft tissue coverage and obliteration of dead space can be particularly challenging when complicated by infection or previous radiation. These cases may require a less conventional method of reconstruction. We describe a case in which vacuum-assisted closure followed by pedicled omental flap transposition was successfully used to reconstruct a complicated intra-thoracic wound following pneumonectomy, radiation therapy, and recurrent wound dehiscences secondary to chronic infection.

Clinical Outcomes of Left Ventricular Assist Device Pump Infection.

Few studies have focused on the clinical outcomes and risk factors of left ventricular assist device (LVAD) pump infection, and no standard treatment for LVAD pump infection has been established. Therefore, we used a therapeutic flowchart to manage LVAD pump infections. We retrospectively evaluated 220 patients who underwent continuous-flow LVAD implantation between January 2005 and March 2021 at Osaka University, Japan. First, we performed wound debridement, negative-pressure wound therapy, antibiotic treatment, and omental flap transposition. Subsequently, we administered conservative treatment, scheduled implantable LVAD exchange, or emergent removal of the implantable LVAD and exchange for extracorporeal LVAD or percutaneous LVAD (IMPELLA). Pump infections occurred in 32 patients. The survival rates of patients with pump infections during LVAD support were 93%, 74%, and 61% at 180 days, 1 year, and 2 years after LVAD pump infection, respectively. Fifteen patients underwent successful heart transplantation. Bridge-to-bridge surgery, preoperative use of venoarterial extracorporeal membrane oxygenation or percutaneous LVAD, high lactate dehydrogenase levels, and driveline infection were significantly associated with pump infection. Our study reveals that poor preoperative condition and driveline infection were significant risk factors for LVAD pump infection.

Mortality after sternal reconstruction with pectoralis major flap vs omental flap for postsurgical mediastinitis: A systematic review and meta-analysis.

Deep sternal wound infections are rare but severe complications after median sternotomy and can be managed with sternal reconstruction. The use of pectoralis major flap (PMF) has traditionally been the first-line approach for flap reconstruction but the advantage in patients' survival when compared to the omental flap (OF) transposition is still not clear. We performed a study-level meta-analysis evaluating the association of the type of flap on postoperative outcomes. A systematic search of the literature was performed to identify all studies comparing the postoperative outcomes of PMF versus OF for sternal reconstruction. The primary outcome was postoperative mortality. Secondary outcomes were the occurrence of sepsis, pneumonia, operative time, and length of stay. Binary outcomes were pooled using an inverse variance method and reported as odds ratio (OR) with corresponding 95% confidence interval (CI). Continuous outcomes were pooled using an inverse variance method and reported as standardized mean difference (SMD) with corresponding 95% CI. Four studies with a total of 528 patients were included in the analysis. Overall, 443 patients had PMF reconstruction, and 85 patients had OF reconstruction. Baseline characteristics were similar in both groups. There were no statistically significant differences between PMF patients and OF patients in mortality (OR 0.6 [0.16; 2.17]; p = .09), sepsis (OR 1.1 [0.49; 2.47]; p = .43), pneumonia (OR 0.72 [0.18; 2.8]; p = .11), length of stay (SMD -0.59 [-2.03; 0.85]; p < .01), and operative time (SMD 0.08 [-1.21; 1.57]; p < .01). Our analysis found no association between the type of flap and postoperative mortality, the incidence of pneumonia, sepsis, operation time, and length of stay.

Utilização de flap de omento para indução da cicatrização de enxertos cutâneos

ABSTRACT The objective of this study was to assess healing induction of free skin grafts following transposition of omental flap through a subcutaneous tunnel to the recipient bed. Macroscopic and microscopic evaluations were performed. Nineteen piglets were used. Two surgical wounds were created of each subject. The graft removed from the left side (LS) was placed on the right side (RS) without the omental flap in the graft-bed (control group-CG). On the LS, an omental flap was placed between the graft removed from the RS and the recipient bed (omentum group-OG). Macroscopic evaluations showed edema, which gradually decreased on both groups. Suture dehiscence was highest at day 10 compared to other days in both groups. The CG had a higher incidence of unvitalized tissue compared to OG, although no difference was found among days of postoperative evaluation. The presence of unvitalized tissue was seen on 32% on OG and 53% on CG. Microscopic evaluations revealed higher collagenization, reepithelization, keratinization and less swelling in the OG compared to CG. In conclusion, mesh skin grafts evolved satisfactorily in swine even in newly created bedding without granulation tissue, but with appropriate vascularization. The omentum flap provided better macroscopic and microscopic outcomes regarding graft integration.

Ten-year experience with laparoscopic pedicled omental flap for cerebral revascularization in patients with Moyamoya disease

BackgroundThe omental flap has numerous extraperitoneal applications in reconstruction and revascularization given its favorable immunologic and angiogenic properties. In patients with Moyamoya disease, cerebral revascularization using a pedicled omental flap has proven to be a viable option following direct revascularization procedures. Historically, harvesting omentum involved laparotomy with the associated risk of complications; herein we describe outcomes from a 10-year experience of laparoscopic harvesting of pedicled omental flap for cerebral revascularization in Moyamoya patients. MethodsA retrospective chart review was performed of all patients with Moyamoya disease who underwent laparoscopic omental cerebral transposition between 2011 and 2021. Intraoperative and postoperative complications, length of stay (LOS), and outcomes at follow-up were analyzed. ResultsTwenty-one patients underwent the procedure during the study period. Three intraoperative complications occurred (one segmental transverse colectomy for mesenteric injury, one converted to omental free flap, and one requiring micro anastomosis). Average overall LOS was 6 ± 6 days, with 3 ± 3.5 days in the ICU (mean±SD). Following discharge, complications included epigastric incisional hernia at the graft fascial exit site, recurrent neck pain at subcutaneous tunneling site, and partial scalp necrosis. One patient required subsequent direct bypass seven months after the initial procedure owing to the progression of the disease. All other patients had partial or complete resolution of symptoms. ConclusionOur retrospective observational study indicates that laparoscopic pedicled omental flap mobilization and transposition is a safe and effective method of indirect cerebral revascularization in patients with Moyamoya disease. Level of evidenceN/A.

A Case of Aortoesophageal Fistula Treated by Aortic Graft with Omental Flap Transposition on Condition that Two-stage Esophageal Reconstruction was Followed

A Case of Aortoesophageal Fistula Treated by Aortic Graft with Omental Flap Transposition on Condition that Two-stage Esophageal Reconstruction was Followed

PREOPERATIVE RADIOLOGIC EVALUATION OF BRONCHO-PLEURAL FISTULA AS PREPARATION FOR TRANSSTERNAL MAIN BRONCHIAL STUMP OCCLUSION

Objective:retrospective assessment of preoperative radiologic evaluation of patients with chronic pleural empyema and bronchopleural fistula after pneumonectomy and its influence on the choice of transsternal main bronchial stump occlusion as definitive surgical treatment.Methods.From April 2005 to December 2016 in A.V. Vishn evsky Institute of Surgery 25 patients with chronic pleural empyema (&gt;12 weeks from the onset of the disease) and bronchopleural fistula (BPF) after pneumonectomy were treated. The main methods of preoperative diagnosis were fibrobronchoscopy and multispiral computed tomography. The results of treatment of BPF after pneumonectomy by transsternal bronchial occlusion as a method of choice were retrospectively analyzed.Results.Depending on the length of the bronchial stump and the diameter of the BPF, evaluated with CT, patients were divided into two groups. In 9 (36%) patients with bronchial stump length ≥20 mm and BPF diameter ≥3mm performed transsternal bronchial closure. In 16 patients (64%) with short (less than 20 mm) bronchial stump BPF was covered with muscle flap (87.5%) or omental flap transposition (12.5%) was done. Perioperative mortality rate was 2 (8 %) of 25 (95% CI: 2.2–24.9) cases due to ARDS and severe sepsis in muscleflap group. Recurrence rate was 2 (12.5%) of 16 (95% CI: 3.5–36) patients in control group vs no recurrence rate in basic group according to 18–110 months follow up.Conclusion. Radiologic methods are the gold standard in the diagnosis of pleural empyema with BPF. A differential approach based on the assessment of risk factors (the etiology of empyema, length of the stump of the main bronchus, diameter of bronchial fistula and initial state of residual pleural cavity) makes it possible to reduce morbidity and mortality in patients with BPF.

Laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection

To present an experience of laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection. It was made a prospective analysis of 14 patients aged 39-85 years after laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for the period December 2014 - November 2016. Men/women ratio was 10/4. All patients had deep sternal wound infection grade IV (Oakley-Wright classification). Postoperative complications were observed in 2 (14.3%) of 14 (95% CI: 4.0-39.9%) cases that did not require re-operation. There were no 30-day postoperative mortality and significant complications as acute intestinal obstruction, postoperative ventral herniation and transplant rejection. Mean postoperative hospital-stay was 10.5 (9; 13) days. Laparoscopic-assisted harvesting of omental flap is safe method for chest wall reconstruction in patients with severe sternal wound infection associated with soft tissue deficiency and high risk of local complications (bleeding, etc.). Laparoscopy significantly reduces incidence of postoperative complications after omental flap transposition and is feasible in majority of patients.

Experience of Successful Treatment for an Intractable Advanced Ureter Cancer with Extra ureteral Extension using Omental Flap Transposition: A Case Report

We report on a 61-year-old female case of advanced ureter cancer using omental flap transposition (OFT) with tumor reduction surgery before adjuvant pelvic irradiation to prolong survival and to prevent pelvic complication from irradiation, resulting in a stable disease state for one year without serious major morbidity. The patient presented with growing pelvic pain and constipation for three months without gross hematuria or flank pain. She was diagnosed with stage IV (T4N2M0) left distal ureter cancer extending to the left iliac vessels. After three cycles of neoadjuvant combination chemotherapy of gemcitabine-cisplatin, left nephroureterectomy with a resection of the bladder cuff and ipsilateral salphingo-oophorectomy with lymph node dissection, and segmental colon resection with OFT were performed. Then, 30 adjuvant radiations at a fractionated dose of 6880 cGy on left-sided pelvic areas enabled the patient to remain in a stable disease state without progression or loco-regional recurrence, and no severe complications occurred during follow-up. Therefore, owing to the OFT with surgical reduction of tumor burden, adjuvant high dosing radiotherapy was performed effectively and safely in advanced ureter cancer without occurrence of severe radiation-related complications.

Single-stage repair of the anterior chest wall following sternal destruction complicated by mediastinitis

Although various techniques have been described, the ideal reconstructive procedure for treating massive sternal fragmentation and necrosis is still a matter of debate. Sometimes, reconstruction is so challenging that repetitive operations are required, particularly when complicated by mediastinitis and sternal osteomyelitis. Five patients (three males, two females, median age 66) with severe osteomyelitis and sternal destruction after receiving myocardial revascularization underwent partial or radical sternal resection, omental flap transposition, titanium mesh implantation and rectus abdominis muscle flap transposition. The final procedure involved single-stage closure. One patient died 9days after the final procedure due to pneumonia and septicemia. The other patients received antibiotics for at least 6weeks postoperatively. The mean hospital stay was 36days. Optimal wound healing was observed, with acceptable cosmetic disorders. Although lateral sternal support is the first-line surgical treatment for sternal dehiscence, performing primary closure of complicated defects is often impossible. Aggressive treatment modalities are required in such cases for anterior chest wall defects. This technique provides the ability to perform rigid and stable sternal closure in complicated cases.

Mediastinitis and sternal prosthesis infection successfully treated by minimally invasive omental flap transposition

Purulent mediastinitis is a possible serious complication after mediastinal surgery. We report the case of a localized sternal plasmocytoma treated by sternectomy and prosthetic repair, who needed a second surgery for a fistulizing mediastinitis. Five months earlier, in another Hospital, the patient underwent sternal resection and reconstruction with a “sandwich” prosthesis (Methyl-methacrylate and Marlex mesh). Suppurative mediastinitis occurred and septic shock resolution was observed after the spontaneous opening of a mediastinal cutaneous fistula. After referring to our Unit the patient underwent extensive local and systemic preparation and nutritional support; the infected prosthesis was then removed and the gap filled by a laparoscopically-prepared omental flap. Adequate preoperative management, removal of any infected material and minimally invasive omental flap transposition allowed the successful treatment of this life-threatening condition.

Transomental Titanium Plates for Sternal Osteomyelitis in Cardiac Surgery

Wound infection is a devastating complication resulting in a high mortality rate from 7% to 80%. The risk of recurrences depends on the depth and the extension of the infection. We present our experience of omentoplasty using transomental sternal plates. Five patients (two females, mean age 61.2 ± 8.3 years) had severe osteomyelitis requiring radical sternectomy and omental flap transposition. In three cases (60%), the sternal manubrium was completely removed: in case of upper sternectomy, chest wall stability was achieved without metallic bars; in two cases chest wall stability required the use of three metallic plates for each patient (STRATOS SYSTEM) fixed on the second, third, and fourth ribs. The plates were passed through the omental flap to obtain a partial cover of the devices. No patient had abdominal complications. One patient had postoperative dehiscence of the superficial wound that was treated by VAC therapy for 30 days. The length of hospital stay was 65.2 ± 45.2 days. All patients had complete wound healing and are alive after 24.0 ± 21.4 months. Omental flap transposition represents a good option in the treatment of sternal osteomyelitis. Partial or total sternal manubrium preservation and fixation are essential for the restoration of sternal stability. The use of transomental titanium plates provides chest wall stabilization when extensive sternal resection is required.

Vacuum-assisted closure therapy with omental transposition for salvage of infected prosthetic femoral–distal bypass involving the femoral anastomosis

Vascular graft infections are associated with the potential for devastating sequelae, including hemorrhage, septicemia, amputation, and death. Graft excision and debridement of the infected bed with revascularization via an extra-anatomic site or orthotopic vein bypass has been the traditional treatment of choice. Because the morbidity of these operations is substantial, less radical graft preservation techniques are desirable, such as myoplasty, omental flap transposition, and vacuum-assisted closure therapy. We report a patient with infection involving a prosthetic graft that was treated with vacuum-assisted closure and transposition of an omental tongue to enable coverage of the exposed graft.

Single-stage omental flap transposition: modality of an effective treatment for deep sternal wound infection

Deep sternal wound infection (DSWI) is an uncommon life-threatening complication of cardiac surgery performed through median sternotomy. Surgical treatment is considered complicated and challenging. We report our experience with a single-stage omental flap transposition in the treatment of the 14 consecutive patients who were diagnosed with DSWI within 3-16days after the primary cardiac surgery, between August 2001 and January 2008. The single-stage omental flap transposition was achieved within 70-135min, at four to eight hours after diagnosis of DSWI. The single-stage omental flap transposition was successfully applied and all 14 patients survived. They displayed a shortened intensive care unit stay (one to nine days) and hospital stay (19-36days). Follow-up was 100% complete (26-92months) and demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. However, the very few complications found were slight numbness of anterior chest and minor paradoxical chest movement. We obtained satisfactory outcomes when treating the patients with DSWI by a single-stage omental flap transposition. Based on our solid experience, we recommend this procedure as an option for patients with DSWI, especially those who are not in a state of severe low cardiac output or malnutrition.

The role of omental flap transposition in patients with locoregional recurrent rectal cancer treated with reirradiation

We performed reirradiation after omental flap transposition (OFT) in patients with locoregional recurrent rectal cancer (LRRC) and evaluated the effect of OFT on the irradiated small bowel by comparing the displacement of the small bowel from the radiation field before and after OFT. Between October 2005 and October 2008, this study included 12 patients with LRRC who had previously received radiotherapy. To evaluate the effect of OFT on the irradiated volume of the small bowel and bladder, we measured the closest distances between the small bowel and the tumor or tumor bed (distance(SB)) and between the bladder and tumor or tumor bed (distance(BL)) before and after OFT, respectively. The median distance(SB) before and after OFT was 5 and 30 mm, respectively (P < 0.001). The median distance(BL) before and after OFT was 10 and 23 mm, respectively (P = 0.002). The respective overall survival and local control rates at 3 years were 50.9% and 54.6%, respectively. No severe complication occurred of grade 3 or higher involving the small bowel or bladder. In our study, OFT effectively excluded small bowel from the radiation field. In addition, selective reirradiation after OFT was feasible for patients with LRRC.

Omental flap – a highly effective procedure for recurrent sternal wound infection and mediastinitis after cardiac surgery

Background: Therapy failure after surgical treatment of deep sternal wound infection (DSWI) and postcardiotomy mediastinitis may lead to sepsis, multi-organ failure and death. Seeding of suture lines may result in dehiscence, a life threatening complication. Omental flap transposition (OFT) may be in this situation the "ultima ratio" therapy.

Laparoscopic repair of iatrogenic diaphragmatic hernias after sternectomy and pedicled omentoplasty

During sternectomy and pedicled omental flap transposition for the treatment of deep sternal wound infections, an ectopic diaphragmatic aperture is created. This may be the site of an iatrogenic diaphragmatic hernia, which may result in the herniation of intra-abdominal organs, and is difficult to repair. Although this complication was described as early as 1991, no effective treatment for this condition has been described previously. The defect in poststernectomy diaphragmatic hernias has features similar to other incisional abdominal wall hernias, as well as to parastomal hernias and hiatal diaphragmatic hernias. We describe our laparoscopic approach developed from experience with these other types of hernias. We use an intraperitoneal flat mesh without keyhole. Fixation of the mesh to the anterior abdominal wall and to the diaphragm is done with a combination of sutures and spiral tackers. The omental pedicle is lateralised, fixed to the diaphragm and covered with the mesh. Special caution is needed when spiral tackers are applied to the diaphragm, because fatal complications of pericardial and cardiac injury have been described in laparoscopic hiatal diaphragmatic hernia repair. We used this technique in four patients who presented with a symptomatic poststernectomy diaphragmatic hernia. No procedure-related intra-operative or postoperative complications occurred. With a follow up of at least 12 months, no clinical or radiographic recurrence of diaphragmatic herniation has been encountered. We describe a laparoscopic technique to repair this difficult diaphragmatic hernia used in four patients, with a good clinical and computed tomographic outcome at 12 months.

Submucosal injection of the silver–human albumin complex for the treatment of bronchopleural fistula

Postoperative bronchopleural fistula (BPF) is a serious complication and a therapeutic challenge in thoracic surgery. The purpose of this study is to assess the efficacy of the use of the silver-human albumin (SHA) complex injected in the bronchial submucosa for the treatment of BPF. From January 2005 to March 2008, we treated 11 patients with BPF (seven post-pneumonectomy and four post-lobectomy) by endoscopic injection of the SHA complex into the bronchial submucosa. In all patients a chest drain was positioned and employed for antibiotic pleural irrigation. Simultaneously, the endoscopic treatment including repeated injection of the SHA complex was started. In 10 patients the diameter of the fistulas was equal to or smaller than 5mm (range: 3-5mm) and in one it was larger than 5mm (8mm). There was no morbidity or mortality related to the procedure. Permanent closure of the fistula was achieved in all 10 patients with a BPF of 3-5mm. In four of these patients (post-lobectomy fistula), the good general condition allowed early discharge with the Heimlich valve before the completion of treatment. Two other patients with a fistula smaller than 5mm presented persisting empyema and compromised general conditions after closure of the post-pneumonectomy BPF. These patients underwent fast-track treatment of the empyema achieving definitive cure. In the patient with a BPF larger than 5mm, the conservative treatment was not sufficient and an omental flap transposition was necessary. The SHA complex submucosal injection is easy, safe and inexpensive. It can be considered a valid therapeutic option in selected patients presenting an early fistula with a size equal to or smaller than 5mm. Early diagnosis, simultaneous insertion of a chest drain and achievement of a sterile pleural cavity are fundamental conditions for the final success of the procedure.

Transdiaphragmatic Harvesting of the Omentum Through Thoracotomy for Bronchial Stump Reinforcement

We present our technique of omental flap transposition performed through a thoracotomy for bronchial stump protection, and employed over 11 years. Between February 1997 and January 2008, the transdiaphragmatic harvesting of the omentum was performed, using an original technique through a thoracotomy approach, in 45 patients. Forty-three patients (29 male, 14 female), considered at high risk for bronchial dehiscence, simultaneously underwent pneumonectomy and 2 patients (1 male, 1 female) were treated for an early postpneumonectomy bronchopleural fistula by the standard thoracotomy route. The omental flap was mobilized through a radial incision in the diaphragm avoiding an additional laparotomy. The only contraindication for this technique was a previous abdominal intervention. Duration of follow-up ranged between 6 and 102 months (median, 46). There were no complications related to the omentoplasty. Major complications related to pneumonectomy occurred in 4 patients (9%). Perioperative mortality rate was 2.1% (1 of 45). The non-life threatening complication rate was 11.1% (5 of 45). Postoperative hospital stay ranged between 5 and 21 days (median, 8.3) in the 43 patients undergoing prophylactic omentoplasty and was 11 and 14 days, respectively, in the 2 patients receiving omentoplasty after bronchial dehiscence. No neoplastic recurrence on the bronchial stump or late fistula occurred during follow-up. This technique of omental flap transposition for bronchial stump coverage through a thoracotomy is an effective method for the prevention and treatment of postpneumonectomy bronchopleural fistula. The amount of omentum obtained by this technique is appropriate for bronchial reinforcement but not for filling the pleural cavity. This procedure can be performed safely through thoracotomy access avoiding an additional laparotomy.