Omental Flap Transposition Research Articles

Omental Flap for Recurrent Deep Sternal Wound Infection and Mediastinitis after Cardiac Surgery

Unsuccessful surgical treatment of deep sternal wound infection (DSWI) and mediastinitis may lead to sepsis, multiorgan failure and death. Omental flap transposition (OFT) may, in this situation, be the only effective therapy. Twenty-seven patients with DSWI and mediastinitis after one or more unsuccessful surgical attempts to cure the infection were treated by OFT. Forty-one interventions (1.5/patient) consisting of closed irrigation technique, bilateral pectoralis flap reconstruction and vacuum-assisted therapy were performed before carrying out OFT. Operative mortality was 0. Mean postoperative ventilation time was 1.38 days and mean time in the intensive care unit was 4.7 days. Hospital mortality was 7.4 % (n = 2). Mean follow-up time was 2 years. One patient (4 %) died one year after discharge. During follow-up, abdominal wall hernia occurred in one patient (4 %) and presternal fistula resection was necessary in another patient (4 %). OFT is, in our experience, the most effective procedure for the treatment of recurrent DSWI and mediastinitis after cardiac surgery. Early mortality is acceptable, morbidity is low and late results are very good.

Omental Transposition: The Final Solution for Major Sternal Wound Infection

Sternal osteomyelitis after median sternotomy for cardiac surgery is associated with considerable morbidity and mortality. The ideal reconstruction after sternal debridement is still debated. From 2000 to 2004, we treated 15 patients for sternal osteomyelitis (type IIIB, IVA, IVB) after median sternotomy for cardiac surgery. Total or partial resection of the sternum and extensive debridement were performed in all cases. The defect was covered by omental transposition. In 11 cases, a single-stage operation took place, and a two-stage procedure was employed in 4. All patients had antibiotics postoperatively. There were 3 (20%) deaths due to cardiac failure. Hospital stay ranged from 21 to 45 days. Transient paradoxical movement of the anterior chest wall disappeared within one month. No recurrence was observed during 6 to 24 months of follow-up. Radical debridement along with omental flap transposition provides definitive control of the infection in cases of failure of other semi-conservative or surgical interventions. Prognosis depends on the general condition of the patient.

Anterior Mediastinal Herniation of the Transverse Colon after an Omental Flap Transposition

Poststernotomy mediastinitis continues to be an infrequent but serious complication after cardiac surgery. We present a case of a 59-year-old man who developed a deep sternal wound infection after an emergency cardiac surgery. Omental transposition flap was used to cover the sternal defect. Several days later, the patient developed a transverse colon herniation into the anterior mediastinum that required emergency exploration and colon resection. The patient survived after a difficult hospital course. Indications, technical points, and possible complications of using omental flap transposition are discussed.

Omental flap for recurrent deep sternal wound infection and mediastinitis after cardiac surgery

Aims: 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 produce dehiscence, a life threatening complication. Omental flap transposition (OFT) may be in this situation the „ultima ratio“ therapy.

High-pressure irrigation and gentian-violet application for mediastinitis following replacement of ascending aorta and aortic valve

Mediastinitis following ascending aortic replacement is intractable and potentially fatal, and the feature is characterized as having both high mortality and morbidity when its causation pathology is methicillin-resistant Staphylococcus aureus (MRSA). Possible treatments for the condition, which include debridement, irrigation, and healthy tissue transposition, often result in failure. We report a case of MRSA mediastinitis after replacement of the ascending aorta and the aortic valve successfully treated by continuous saline lavage and drainage, debridement, high-pressure irrigation, and gentian-violet application, and delayed omental-flap transposition. The application of gentian violet and high-pressure irrigation may provide an additional option to the standard therapy for intractable mediastinitis after ascending aortic replacement.

Omental Transposition Flap for Salvage of Ventricular Assist Devices

The use of ventricular assist devices for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. Ventricular assist devices improve the longevity and the quality of life for these patients. In addition, they serve as a bridge to cardiac allograft transplantation until a donor heart is found. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Clinical infection and sepsis can critically threaten these patients with ventricular assist devices. Infection can delay immediate transplantation and potentially require the removal of the device for definitive treatment of the problem. Patients who underwent insertion of a ventricular assist device at the University of Pittsburgh Medical Center were identified through accessing the medical records archives of the hospital. Review of patients' medical records was conducted to obtain patient demographics, preoperative diagnosis and disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, infectious organism identified, timing of omental flap procedure after the initial insertion, duration of ventricular assist device support before cardiac transplantation, and patient follow-up. There were 76 patients who underwent a ventricular assist device insertion procedure during the 4-year period between January of 2000 and January of 2004. Of the 76 patients who received a device, 11 (14 percent) had evidence of clinical infection secondary to insertion. Two of these 11 patients died before surgical intervention, four had their devices explanted, and the remaining five underwent omental flap transposition with bilateral pectoralis major advancement flaps in surgically addressing their infections. Of the five patients with infections who received omental transposition flaps, two went on to undergo successful transplantation, two continue to await cardiac allograft transplantation, and one died as a result of an unknown cause. The authors present their experience with five patients who received omental transposition flaps to cover infected ventricular assist device pumps and the associated tubing in large, open sternoabdominal wounds. Treatment included the direct application of an omental transposition flap over the infected device with use of a bilateral pectoralis advancement flap to aid in complete sternal and skin closure of the sternal wound defect. In each of these cases, the use of the omental flap was followed by resolution of the mediastinal infection. In addition, the treatment with an omental flap prevented the removal of infected devices in patients who were otherwise pump dependent during their waiting periods for transplantation. The use of omental transposition flaps can be an effective technique in salvaging infected ventricular assist devices and preserving this valuable device for patients awaiting a cardiac transplant.

Postoperative mediastinitis following hemiarch replacement

Although various strategies have been advocated for mediastinitis following cardiac operations, surgical results for this complication remain a significant concern. The condition would be more complicated with replacement of the ascending aorta using a prosthetic graft. We present the case of a 50-year-old female patient with acute aortic dissection who underwent hemiarch replacement using a prosthetic graft and concomitant coronary artery bypass grafting, and developed periprosthetic purulent collection 2 months later. Successful treatment involved debridement ofìnfected tissues and omental flap transposition. Postoperative chest computed tomography revealed no sign of perigraft infection. Omental flap transposition can be effective for treating mediastinitis following prosthetic graft replacement of the ascending aorta. The patient has remained in good health for 1 year, with no signs of recurrent graft infection or pseudoaneurysm formation.

Successful treatment of Novacor pump pocket infection by omental transposition

Device-related infection remains a major factor restricting the long-term use of left ventricular assist systems. Severe pocket infection is especially difficult to manage and removal of the device has been the only curative treatment in most cases. We report a case of a Novacor device pocket infection treated successfully with continuous local irrigation and transposition of omental flap. This procedure provides another option for the management of pocket infection, which is mandatory for destination therapy the permanent usage of LVAS for the purpose of circulatory supports in patients with end–stage heart failure, who are not indicated for heart transplantation.

Radical surgery with omental flap for uncontrolled locally recurrent breast cancer.

Uncontrolled chest wall disease due to breast cancer is a highly morbid condition causing pain, ulceration, malodour and the need for frequent dressings. Aggressive surgical approaches are rarely justified because most patients will succumb to metastatic breast cancer within a short period. A highly selected group of patients with minimal or no evidence of metastatic disease and good performance status may benefit from radical chest wall surgery. Omental transposition flaps are ideal for reconstructing extensive surgical defects following chest wall surgery. A retrospective review was carried out of 61 female patients treated consecutively between 1980 and 1995. The surgical technique is described herein. All patients were symptomatic preoperatively. Symptoms included ulceration (80%), pain (44%) and malodour (40%). Twenty-nine patients had uncontrolled local recurrence following initial treatment for locally advanced breast cancer and 32 patients developed uncontrolled recurrence after treatment for operable breast cancer by mastectomy or conservation surgery. Median survival following chest wall surgery was 21 months and the median local recurrence-free interval was 20 months. Morbidity was -limited. There were no cases of major flap loss. Twenty-nine patients (48%) had no further local disease. Eighteen patients (30%) developed soft-tissue recurrence at the edge of the omental flap or in surrounding skin and 14 (23%) developed recurrence beneath the flap. In a highly selected group of patients with symptomatic uncontrolled chest wall recurrence who are fit and have an expectation of at least moderate-term survival, radical chest wall surgery and omental flap transposition offers excellent palliation and local control in the majority of patients

Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery.

Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery.

Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery.

Our experience with omental flap transposition in the treatment of deep sternal wound infections is reviewed here with an emphasis on efficacy, risk factors for in-hospital mortality rates, and long-term results. Even with improvements in muscle and omental flap transposition, the timing of closure and the surgical strategy are controversial. Forty-four consecutive patients with deep sternal wound infections were treated using the omental flap transposition from 1985 through 1994. The strategies included debridement with delayed omental flap transposition or single-stage management, which consisted of debridement of the sternal wound and omental flap transposition. Methicillin-resistant Staphylococcus aureus was cultured from more than 50% of the wounds. A logistic regression analysis was used to identify the predictors of in-hospital death after omental flap transposition. There were seven (16%) in-hospital deaths. Univariate analysis demonstrated that hemodialysis and ventilatory support at the time of omental flap transposition were significantly associated with in-hospital mortality rates (p = 0.0023 and p = 0.0075, respectively). Thirty-seven patients whose wounds healed well were discharged from the hospital. Two patients with cultures positive for methicillin-resistant Staphylococcus aureus had recurrent sternal infections. Patients without positive methicillin-resistant Staphylococcus aureus cultures had good long-term results after reconstructive surgery. Transposition of an omental flap is a reliable option in the treatment of deep sternal wound infections, unless the patients require ventilatory support or hemodialysis at the time of transposition.