Ann Thorac Surg 1999;68:269-271
© 1999 The Society of Thoracic Surgeons
How to Do It
Remnant omental transfer for the mediastinitis after coronary bypass surgery with right gastroepiploic artery
Hitoshi Yokoyama, MD, PhDa,
Mitsuaki Sadahiro, MDa,
Atsusi Iguchi, MDa,
Mikio Ohmi, MDa,
Koichi Tabayashi, MDa,
Shigeo Tanaka, MD, PhDb
a Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, Sendai, Japan
b Department of Cardiovascular Surgery, Aomori General Hospital, Aomori, Japan
Address reprint requests to Dr Yokoyama, Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai 980-8574, Japan
e-mail: hitoshiy{at}mail.cc.tohoku.ac.jp
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Abstract
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A one-stage procedure for the treatment of mediastinitis after coronary bypass surgery utilizing the right gastroepiploic artery is described. This procedure consists of thorough debridement of mediastinal pus and necrotic tissue, excision of infected sternal bone, mediastinal irrigation, and immediate transfer of the "remnant" omental pedicle based on the "left" gastroepiploic artery without postoperative drainage or irrigation. Recently, this procedure was applied to our patients followed by excellent results.
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Introduction
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Coronary bypass surgery utilizing the right gastroepiploic artery (RGEA) is an increasing practice because of the low surgical risk, high patency rate, and excellent patient outcome [1]. Poststernotomy mediastinitis after coronary revascularization is a rare, however, life-threatening complication. Omental transfer is known as an effective modality for this fatal complication [2, 3]. Recently, a successful one-stage procedure including mediastinal debridment and omental transfer without postoperative drainage or irrigation has been reported, which allows early ambulation and shortens the length of hospital stay [3]. The remnant omentum after RGEA harvest for coronary revascularization, however, may have disadvantages such as developed intraabdominal adhesion or decreased blood supply. Thus, a question raised is if such a remnant omentum is still useful for the one-stage operation for mediastinitis. We herein describe a technique for a one-stage procedure including remnant omental harvesting and transfer as well as encouraging results in our series.
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Technique
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Mediastinal debridment
After remedian sternotomy, the mediastinal pus and necrotic tissue are excised completely. The necrotic sternal edges are eradicated until red bone marrow is observed. The mediastinum is irrigated with 0.5% povidone-iodine and subsequently filled with povidone-soaked gauze until omental transfer.
Remnant omental harvest
After an upper median laparotomy through the previous incision, meticulous dissection of the remnant omentum is necessary if postoperative intraabdominal adhesion is developed, which is rare in the early postoperative period. The surgeon has to assess the remnant omentum, confirming it looks vascular rich without a pale ischemic scar. Peritoneal attachment of the omentum with the transverse colon is detached by cautery (Omento-colonolysis; Fig 1A), which allows the omentum to be only attached to the great curvature of the stomach, enhancing the mobility of the omentum. If further omental extension is necessary to fill the mediastinum, the surgeon must plan a procedure for extension based on the "left" gastroepiploic artery and its branches (Fig 1B), paying close attention to preserving the omental vessel arch. The surgeon can observe the vessel network of fatty omentum clearly by holding the omentum up to the light (translumination). Pulsation of the omental arteries are also helpful to determine which vessel should be sacrificed if multiple vessel supplies are observed. To confirm adequate blood supply even to the distal end of omental pedicle, it is helpful to amputate the pedicle end piece by piece until arterial bleeding is observed.
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Fig 1. (A) Omento-colonolysis. The arrow indicates the detachment line, which can be dissected by cautery. This procedure allows the omentum to be apart from the transverse colon, leaving the omentum merely attached to the stomach and enhancing omental transfer to the mediastinum. (B) Omental blood supply after harvesting the right gastroepiploic artery. The arrow indicates an example of the incision line that allows further omental extension, preserving the omental artery arch based on the "left" gastroepiploic artery.
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Omental transfer
The omentum is transferred to the mediastinum through a wide midline diaphragmatic opening to avoid omental ischemia. The transferred omentum should diminish all dead space in the mediastinum. Several stay stitches with monofilament sutures may avoid migration or kinking of the omentum. After hemostasis, the sternum is reapproximated followed by subcutaneous and skin closure with multiple monofilament stitches without mediastinal drainage.
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Results
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Recently, we applied this procedure in two cases, a 71-year-old man (case 1) in Aomori General Hospital and 64-year-old diabetic woman (case 2) in Tohoku University Hospital, who both underwent four-vessel coronary bypass on cardiopulmonary bypass. Bypass grafts were left internal thoracic artery (ITA), RGEA, and saphenous vein for case 1, and bilateral ITA, RGEA, and radial artery for case 2. Both cases had postoperative events before development of mediastinitis. Case 1 had a hemorrhagic peptic ulcer on the 7th operative day, which was treated by endoscopic hemostasis and blood transfusion. Case 2 required an intraaortic balloon pump for 2 days due to low cardiac output. Regarding the onset of mediastinitis, case 1 presented a spiky high fever and pus discharge from the skin incision on the 21st postoperative day. Case 2 suddenly presented with a high fever on the 13th postoperative day. An emergent computed tomography (CT) showed an anterior mediastinal oval mass with circumferential enhancement, which was interpreted as an mediastinal abscess. Neither case showed leukocytosis. Both cases underwent the emergent one-stage operation described herein to prevent further extension of mediastinitis associated with septic shock. Intraoperatively, case 1 presented full sternal dehiscence, with dense pus observed around the right ventricle. Case 2 presented anterior mediastinum filled with dense pus. In both cases, the remnant omenta showed minimal adhesion and could fill the entire mediastinum after omento-cononolysis. The bacteriological study revealed Methicillin-resistant Staphylococcus aureus in case 1 and S. epidermidis in case 2. Both cases received appropriate antibiotics for a couple of weeks until serum C-reactive protein returned to the normal level. They were discharged 4 weeks after this procedure and have been doing well after 4 years and 1 year of follow-up, respectively.
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Comment
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In our experience with the cases described herein, the remnant omentum showed no ischemic change such as shrinkage or fibrosis, bearing enough volume to fill the mediastinum. In addition, there was minimal intraabdominal adhesion in the early postoperative period, without severe adhesion between RGEA pedicle and remnant omentun, which might enhance the risk of graft injury at omental harvest. However, adhesion between any part of the omentum and the major curvature of the stomach might develop after RGEA harvest. Therefore, reattachment of the resected edge of the omentum to the great curvature of the stomach after RGEA harvest during the coronary bypass surgery is recommended to avoid unexpected omental adhesion that would mislead the remnant omental harvest later.
The omentum is known to be so rich in lymphatic and blood vessels that it can absorb inflammatory exudate rapidly and prevent further extension of local infection. The results in our series convinced us that the remnant omentum after harvesting RGEA still has ample blood supply and lymphatic drainage, which are able to force the postoperative purulent mediastinitis to subside rapidly even in a one-stage fashion without postoperative drainage or irrigation. Furthermore, this procedure was still effective in a diabetic case that had undergone bilateral ITA harvest (case 2).
The importance of prompt diagnosis of postoperative mediastinitis and emergent operation can not be over-emphasized. Any delay in making the diagnosis and surgical treatment often results in septic shock followed by multiple organ failure or fatal hemorrhage from the surgical suture line on the heart or great vessels. We recommend emergent chest CT [4] when the patient develops any subtle sign that indicates mediastinitis, such as a spiky high fever after an afebrile postoperative period, even without any wound signs, or leukocytosis, which occurred in case 2. We also believe that prompt diagnosis and surgical procedure without delay are both imperative for the accomplishment of a one-stage procedure, because a delay allows extensive mediastinitis that compromises complete mediastinal debridment.
In summary, the one-stage procedure including mediastinal debridment and remnant omental transfer is an effec-tive modality for the selected patients with postoperative mediastinitis after coronary revascularization utilizing the right gastroepiploic artery.
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References
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Suma H., Wanibuchi Y., Terada Y., Fukuda S., Takayama T., Furuta S. The right gastroepiploic artery. J Thorac Cardiovasc Surg 1993;105:615-623.[Abstract]
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Mathisen D.J., Grillo H.C., Vlahakes G.J., Daggett W.M. The omentum in the management of complicated cardiothoracic problems. J Thorac Cardiovasc Surg 1988;95:677-684.[Abstract]
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Heath B.J., Bagnato V.J. Poststernotomy mediastinitis treated by omental transfer without postoperative irrigation or drainage. J Thorac Cardiovasc Surg 1987;94:355-360.[Abstract]
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Misawa Y., Fuse K., Hasegawa T. Infectious mediastinitis after cardiac operations. Ann Thorac Surg 1998;65:622-624.[Abstract/Free Full Text]
Accepted for publication March 23, 1999.
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Abstract
Introduction
