Ann Thorac Surg 2009;88:212-215. doi:10.1016/j.athoracsur.2009.04.025
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Transdiaphragmatic Harvesting of the Omentum Through Thoracotomy for Bronchial Stump Reinforcement
Antonio D'Andrilli, MDa,*,
Mohsen Ibrahim, MDa,
Claudio Andreetti, MDa,
Anna Maria Ciccone, MDa,
Federico Venuta, MDb,
Erino A. Rendina, MDa
a Department of Thoracic Surgery, "Sant'Andrea" Hospital, University of Rome "La Sapienza," Rome, Italy
b Department of Thoracic Surgery, Policlinico "Umberto I," University of Rome "La Sapienza," Rome, Italy
Accepted for publication April 9, 2009.
* Address correspondence to Dr D'Andrilli, Department of Thoracic Surgery, Sant'Andrea Hospital, Via di Grottarossa 1035, Rome, 00189, Italy (Email: adandrilli{at}hotmail.com).
Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
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Abstract
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Background: We present our technique of omental flap transposition performed through a thoracotomy for bronchial stump protection, and employed over 11 years.
Methods: 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).
Results: 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.
Conclusions: 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.
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Introduction
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Bronchopleural fistula (BPF) represents one of the most serious life threatening complications after pneumonectomy with an incidence of 1% to 12% [1, 2]. Reinforcement of the bronchial stump by viable tissue flaps has been proven to reduce postpneumonectomy BPF rate for patients considered at high risk for bronchial stump dehiscence, especially when the flap is well-vascularized and provides a large amount of tissue [1, 3, 4].
Among the different biologic tissues employed with prophylactic intent in this setting (pleura, intercostal muscle, pericardium, major thoracic muscles, and diaphragm), pedicled omental flaps have been widely used showing optimal results, mainly due to the abundance of viable tissue and excellent vascularization.
However, omental flap transposition has the disadvantage of extending the thoracic operation into the abdomen. This aspect has partially limited its preference among surgeons and acceptance by patients. Therefore, we devised a transdiaphragmatic harvesting technique of the greater omentum which avoids a separate abdominal incision and is performed through the usual thoracotomy. We have used the omental flap to cover postpneumonectomy bronchial stumps in patients considered at increased risk for dehiscence. The same technique has been also used, more recently, in a few selected patients for the treatment of early BPF occurring after pneumonectomy. We present our 11-year experience with this newly devised surgical technique.
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Material and Methods
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Between February 1997 and January 2008, the transdiaphragmatic harvesting of an omental flap for bronchial stump reinforcement was performed through our standard thoracotomy approach in 45 patients, out of a total of 204 having undergone pneumonectomy for lung cancer at our institution. Informed consent for the omentoplasty procedure and for inclusion in a prospective database was obtained before surgery from all the patients who were candidates for pneumonectomy and considered at high risk for bronchial dehiscence. The Ethics Committee approved this study and waived the requirement for individual patient consent for the retrospective study. In 43 patients (29 males, 14 females) considered at high risk for dehiscence, the omentoplasty was performed at the end of pneumonectomy with prophylactic intent. There were 28 right pneumonectomies and 15 left pneumonectomies. In 2 patients (1 male, 1 female) the omental flap transposition was employed for the treatment of a BPF developing early in the postoperative period. Both these patients had undergone right pneumonectomy.
The 43 patients, in whom the omentoplasty was used prophylactically, were considered at significantly increased risk for bronchial dehiscence because of the following conditions: previous irradiation (> 4,000 cGy) in 6 patients, high dose steroid therapy in 6, recent chemotherapy resulting in marked immunosuppression in 19, diabetes and right side pneumonectomy in 9, and recent chemotherapy and previous surgical exploration in 3 patients. The 3 patients who had undergone previous surgical exploration were considered unresectable at thoracotomy performed in other centers. In these patients we utilized the same incision from the previous operation. All the other operations were performed through a lateral muscle-sparing thoracotomy in the fifth intercostal space.
Bronchial stump closure was performed with a mechanical stapler (thoracoabdominal, 30 or 45 mm) in all the cases. Resection margins were free of tumor in all patients.
The only contraindication for this omentoplasty technique was a previous abdominal intervention. Candidates for a right pneumonectomy with significant hepatomegaly on computed tomography (CT) were not offered a transdiaphragmatic omental harvest, as the enlarged liver would limit access to the abdomen.
In the 2 patients receiving the omental flap transposition to treat an early right BPF, the operation was performed 5 and 8 days after pneumonectomy, respectively, within a few hours after the detection of the bronchial stump dehiscence. At the time of discharge, detailed information about the procedure was included in the clinical report supplied to all patients as our procedure may impact future abdominal operations.
Duration of follow-up ranged between 6 and 102 months (median, 46). Besides periodic clinical and radiologic surveillance, bronchoscopic examination of the bronchial stump was performed in all living patients once a year for the first 5 years.
Technique
Through our routine muscle sparing thoracotomy, lung resections were performed in the standard fashion. The diaphragm was than incised radially between its anterior insertion and the central tendon. The length of the incision is tailored in order to allow the surgeon's hand to slide through the diaphragm into the abdominal cavity (Fig 1). The hand is introduced into the abdomen and the greater omentum is identified by gentle palpation. When the most distal portion of the omentum is identified and recognized to be free of adhesions, this is gently retracted through the diaphragm into the chest. During this maneuver the transverse colon is identified and its omental insertion is divided as extensively as possible. In the chest the most distal omental extremity is identified by gentle traction and is subsequently isolated carefully respecting its vascular supply (Fig 2). After assuring that the flap reaches the bronchial stump (Fig 3) with no traction on the colon or stomach, the omentum is sutured to the bronchial stump in the usual fashion. The diaphragmatic incision is then closed with heavy silk sutures leaving a wide enough opening to prevent strangulation of the omentum. Tension on the omental flap is further relieved fixing it to the diaphragmatic opening with fine interrupted sutures (Fig 4). It is important to point out that the omentum harvested by this technique is only appropriate to reinforce the bronchial stump and can never be large enough to fill the pleural cavity.
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Fig 1. Right lateral thoracotomy: enlargement of the radial incision on the diaphragm; the liver is visible through the diaphragm.
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Fig 2. Right lateral thoracotomy: The omentum is retracted into the chest and dissected from the colon (arrow).
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Fig 4. Postoperative computed tomography, showing the omental flap (arrows) covering the right main stem bronchus after right pneumonectomy.
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Results
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There were no complications related to the omentoplasty procedure. None of the patients reported digestive or abdominal symptoms. No herniation of abdominal organs into the chest occurred in any patient.
Major complications related to pneumonectomy occurred in 4 patients (9%). These included respiratory insufficiency due to pulmonary edema in 2 patients, myocardial infarction in 1 patient, and massive hemorrhage resulting in death in 1 patient. The perioperative mortality rate was 2.1% (1 of 45). Minor complications included atrial fibrillation in 3 patients, subcutaneous emphysema in 1 patient, and temporary renal failure in 1 patient. The non-life threatening complication rate was 11.1% (5 of 45). There was no recurrence of tumor on the bronchial stump and no development of late fistula was found during the follow-up period. In the 2 patients developing early BPF, there was no evidence of empyema and the microbiologic analysis of the pleural fluid revealed no bacterial colonization. Repair of the fistula was successful in both patients and no recurrence was observed. Primary closure of the chest at the end of the operation was possible in both cases. Postoperative hospital stay ranged between 5 and 21 days (median, 8.3) in the 43 patients undergoing prophylactic omentopexy, while it was 11 and 14 days, respectively, in the 2 patients undergoing omentoplasty to reinforce closure of a BPF.
Pathologic stage was the following: IB in 3 patients; IIA in11; IIB in 17; IIIA in 11; and IIIB in 3. At the date of last follow-up (30 June 2008), 21 patients had died as a result of their tumor, 4 patients had died of other causes, 18 patients are alive with no evidence of disease, and 2 are alive with distant recurrence.
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Comment
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The use of greater omental flaps has proven to be effective in the management of several complex thoracic surgical problems [3, 5–9]. It has been particularly successful in aiding the healing of bronchial stumps considered at high risk for dehiscence after pneumonectomy or as a means to reinforce the repair of a BPF especially in the presence of empyema. Although very satisfactory results have been obtained also with the use of muscular [4, 10, 11], pericardial [1, 12], and diaphragmatic [13] flaps, the omental tissue shows some peculiarities that promote its utilization in this setting. First, the omentum has a rich vascular supply assuring adequate oxygen and antibiotic delivery. Additionally, the omentum delivers potent angiogenic factors [14–16], which have been proven to improve neovascularization of the bronchial suture lines in animal models [17]. No such factors have been found in the muscle.
The immunologic action of the greater omentum is also well-known to increase local lymphocyte and other immunocompetent elements counts. Moreover, the omental transposition does not have the disadvantage of producing chest wall deformities and impairing the muscle function as seen with the use of major muscles flaps. Its amorphous shape and pliability allows perfect adaptation of the flap to the bronchial stump and hilar structures. However, omental flap transposition has the disadvantage of extending the surgical procedure into the abdomen requiring additional laparotomic access or enlargement of the thoracic incision.
Most often, the omentum is mobilized through an upper midline abdominal incision [3, 5–7] and transposed into the chest through an anterior transdiaphragmatic [3, 5–7] or substernal route [3, 5]. More rarely a paravertebral transdiaphragmatic route has been employed [3]. In the case of sternotomy, the midline thoracic incision is extended into the upper abdomen [3, 8]. Rare cases of omental transposition through a thoracoabdominal incision or subcostal incision have also been described [3].
The need for an additional surgical access into the abdomen and the concern for the potentially related additional complications (ileus, laparotomic dehiscence, herniation) have limited the proliferation of the omentoplasty among thoracic surgeons as well as its acceptance by the patients. Our technique, proven over a long period of time, allows the harvest of a sufficient amount of vascularized omental tissue without an additional laparotomy, by simply performing a radial incision in the diaphragm through the standard thoracotomy. For this reason our procedure is better accepted by patients and reduces operative time and trauma without increased morbidity. In particular, no associated abdominal and gastrointestinal complications or diaphragmatic herniation have been observed in our patients. We believe that fixing the omentum to the diaphragmatic opening is the most effective way to prevent potential intrathoracic herniation of abdominal organs.
It is important to point out that the amount of omental tissue harvested with this technique is not sufficient to fill the entire pleural cavity as required for the treatment of a postpneumonectomy empyema. This procedure is therefore not indicated in the presence of concomitant established infection. In these cases a standard laparotomy or videolaparocoscopic preparation of the omentum is required.
In conclusion, our technique, utilized over an 11-year period, allows omental harvesting safely through the thoracotomy without an additional laparotomy and provides excellent results whether employed prophylactically or for the treatment of early BPFs without associated empyema.
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References
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Abstract
Introduction
