GUE
OMENTAL TRANSFER FOR RADIONECROSIS
Omental Transfer for the Treatment of Radionecrosis of the Chest Wall S . GUE Broken Hill, N.S.W. A technique is described f o r the treatment of non-healing deep ulcers of the chest wall following radiotherapy. These ulcers are avascfular and m a y involve the costal cartilages. T h e skin around them is stretched and fixed, so that covering and healing them has been a challcnging problem to surgeons. T h e method used in this patient utilizes the transfer of the whole of the greater omenturn attache to the greater curve of the stomach, which provides a clean, vascular bed f o r the skin grajt, and has been nature's best help to surgeons.
OMENTUMhas been used outside the abdomen as early as 1961 by Kiricuta for sealing bronchial and bladder fistula TWO years later, he advocated its use as a split skin graft bed in the treatment of radionecrosis of the chest wall.
His technique, using omenturn pedicled upon the gastroepiploic vessels, has been used in four cases by Dupont and Menard in 1972, and the operative technique is well documented.
FIGURE 2 : Area of skin excised, with the ulcers. FIGUREI : Two deep ulcers are seen over the parasternal area, exposing the costal cartilages. Reprints : Mr S. Gue, F.R.C.S., Senior Specialist Surgeon, Broken Hill and District Hospital, Broken Hill, N.S.W. 2880.
390
Seven further successful cases have been reDorted by these two workers. Omentum has alio been k e d for treating lymphcedema, and fevasculization Of the myocardiun1 and inferior extremity.
for
AUST.N.Z. J. SURG., VOL.45-No.
4, NOVEMBER, 195
OMEXTAL TRANSFER FOR RADIONECROSIS Cort and Collis (1973) reported another case’ but
they used a transdiaphragmatic approach after opening the pleural cavity for retrosternal transposition of the omenturn. In the patient now reported omentum was transported extraabdominally through a subcutaneous tunnel to the chest wall, and no disadvantages were noted. Serial photographs the ‘peration, with two suggested modifications in the operative technique.
GUE CLINICAL RECORD In January 1974, a 74-year-old Australian woman presented with two large, deep ulcers over the left parasternal region (Figure I ) of two months’ duration. She had had a left radical mastectomy for carcinoma of breast in 1960, followed hy deep X-ray therapy five years later, but the reason for this has not been established. She was apparently well up till 1973, apart from arthritic problems and a chronic cough. There was a mention in her clinical notes of “two atrophic scabs” over the parasternal area on the left side, near the lower edge of the mastectomy scar, when she was seen a t a follow-up clinic in 1972.
3 : (upper) the greater omentum has been mobilized, and the length obtained is shown; (lower) FIGURE demonstration of subcutaneous tunnel, with assurance of its adequacy. AuST.
N.Z. J.
SURG., VOL.
45 - No. 4, NOVEMBER, 1975
391
OMENTAL TRANSFER FOR RADIONECROSIS
GUE
On examination, she was reasonably fit for her age. The two left parasternal ulcers, each about half an inch in diameter and of the same depth, were separated by a quarter-inch skin bridge. The base was fixed, and there was a whitish slough exposing the partly destroyed costal cartilage. The skin edges were not everted, but looked red. The rest of the skin on that side of the chest was thin and fixed. The old mastectomy scar was healthy, with no evidence of local recurrence, and there was no lymphadenopathy. Other clinical findings were normal.
Results of base-line investigations, including hzemoglobin level, white cell count and serum calcium level were normal, though the E S R was 30mm per hour, and she had an alkaline phosphatase level of 22 K.A. units. A swab from the ulcer grew Staphylococcus aureus. A chest X-ray film, right mammogram, and skeletal survey were normal. A provisional diagnosis of radionecrotic ulcer was made, and was confirmed by two consecutive biopsies from the ulcer edge in February and May, 1973. Five months of conservative treatment proved of no
FIGURE 4 : (upper) omentum has been laid over excised area, peritoneum being held by artery forceps; (lower) omentum has been anchored in place, and peritoneal cavity closed.
392
AUST.N.Z. J. SURG.,VOL.45 -No.
4, NOVEMBER, 1975
OMENTAL TRANSFER FOR RADIONECROSIS benefit. The ulcers were becoming larger, and the patient had a lot of discomfort and pain. An omental transfer with primary skin grafting was decided upon. Operative technique.-The two ulcers from the chest wall were widely excised, down to necrotic and partially destroyed costal cartilages and intercostal muscle, leaving a gap of approximately 12cm by n c m , and then the skin edges were slightly undermined (Figure 2 ) . The set of dirty instruments used for this procedure were then discarded. The abdomen was opened through an upper midline incision. There was no evidence of any intraperitoneal metastasis. The greater omentum was then separated from the transverse colon and mesocolon, and a length was obtained (30cm) which was considered would reach the excised ulcer bed (Figure 3, upper). l t was found unnecessary to separate it from the greater curvature of the stomach and make a pedicle on the left or the right gastro-epiploic vessels (Dupont and Menard, 1972). A subcutaneous tunnel was made (Figure 3, lower) from the top of the abdominal incision to the lower end of the ulcer-excised area, then the omentum was
GUE The omentum was anchored to the underlying tissue with a few interrupted z / o catgut stitches (Figure 4). A thick split skin graft was taken from the right thigh and spread over the defect to cover it, two large pieces of skin being used. The edges of the graft were first fixed a t the corners by pullout 5 / 0 Nylon, passed through the deep fascia so as to minimize any graft movement with respiration and posture, and each of these was anchored with a bead and collar. The rest of the
FIGURE 6 : Appearance on 25th day, when patient was seen a t outpatient clinic. Graft has taken well and remains healthy.
FIGURE 5 : Skin graft in place, corners being fixed with pull-out Nylon beads and collar. Ends of sutures between these corners have been left long, to be tied over dressing. brought out of the abdomen through the upper portion of the incision and was passed through the subcutaneous tunnel, making sure that it was not rotated or constricted so as to impair its blood supply, and was spread over the whole area of the excision. Ausr. N.Z. J. SURG.,VOL.45-No.
4, NOVEMBER, 1975
stitches were placed approximately z cm apart, the ends being left long. A Zimmer drain was inserted between the omentum and the graft (Figure 5 ) . The stay sitches were tied over the tie over the dressing so as to keep the whole area as immobile as possible, then the whole wound was covered with Elastoplast. The abdomen was closed in layers with I/O Proline, making sure not to strangulate the omentum at the top. A subcuticular 3/0 Dexon stitch was used for the skin closure. Postoperative progress.-Her postoperative phase was complicated by chest infection and sputum retention, despite preoperative and postoperative physiotherapy. She responded well, however, to intravenous Keflin therapy, which was combined for ten days with intensive physiotherapy. On the fifth day, the Redivac drain was removed, as drainage had
393
TRANSFER FOR RADIONECROSIS
GUE
decreased from 100 ml to 5 ml in 24 hours. On the tenth day, the dressings were removed, and it was found that the graft had taken well, though there was some bruising of the top left corner. The stitches were removed on the 12th postoperative day. Mobilization was slow, but no other problems were encountered, and she went home on the 20th postoperative day. Since then, she has been seen in the outpatient clinic, and now, after five months, the graft remains healthy (Figure 6 ) , not tender, and with good cutaneous sensation. Histological examination of the excised ulcer confirmed the presence of radionecrosis, with no evidence of mammary carcinoma.
establishing a retrosternal route for the passage of omentum. They claimed that this reduced the risk of omental strangulation. This method was considered, but was not used, because it would cause more surgical trauma and prolong the operation, which could increase the morbidity in a poor-risk patient. A thicker skin graft was deliberately used in this case to get a better and more permanent skin cover, and because it would be resistant to trauma, both from mechanical and sensory reasons. No difficulty was encountered, and this is recommended. It is important to drain the area between the omentum and the skin graft, as the omentum produces a significant amount of transudate, which if not removed, will lift the graft off the bed (McLean and Buncke, 1972). The anchoring of the wound margins with the deep fascia is very important in order to try and reduce the respiratory and postural movement of the graft as much as possible, and also hzematoma formation, which in turn can cause graft loss. The bead and collar with pull-out Nylon stitches were found very satisfactory. I t is realized that the follow-up period has been short, but no abdominal or local complications have been noted. It is suggested that the method described should be ideal for reconstruction of radionecrotic ulcers of the chest wall and should be used more frequently, and early, which saves time, affords a permanent cover, and reduces morbidity.
OMENTAL
DISCUSSION Many methods have been reported in the past for treatment of radionecrotic ulcers of the chest wall, and these were taken into consideration. First, thoughts of a rotation advancement flap or a transposition flap from the abdomen were discarded, as these would not survive because of poor bed and distance. A tubed pedicle flap was also rejected, because of multiplicity of stages and long hospital stay. Omental transfer with primary skin grafting was therefore carried out. Because of its simplicity, the method described by Dupont and Menard in I972 was used in this case, and no disadvantages were, seen during or after operation. Special omental mobilization in terms of use of a gastroepiploic pedicle was not necessary, and this made the operation more simple and less time-consuming. This possibility, however, must be kept in mind, especially when one finds a small and fixed omentum, as described by Dupont and Menard in 1972. Recently, Cort and Collis (1973) reported a similar case, in which instead of using the subfascial route, they detached the diaphragm from the anterior costal margin, moving the free edge cephalad, and suturing it to the muscle and periosteum, the defect created by removal of affected costal cartilage thus
394
REFERENCES COKT,D. F. and COLLIS,J. L. (1973), Brit. J. .%rg., 60: 581. DUPONT,C. and MENARD, Y. (1972), Plast. reconsir. Surg., 49: 263. KIRICUTA,I. (1963), Press. mid., 71: 15. MCLEAN,D. H. and BUNCKE,H. L. ( r g ? ~ ) ,P h t . reconstr. Surg., 49 : 268.
AUST. N.Z. J.
SURG., VOL.45 - NO. 4, NOVEMBER, 1975
OMENTAL TRANSFER FOR RADIONECROSIS
Omental Transfer for the Treatment of Radionecrosis of the Chest Wall S . GUE Broken Hill, N.S.W. A technique is described f o r the treatment of non-healing deep ulcers of the chest wall following radiotherapy. These ulcers are avascfular and m a y involve the costal cartilages. T h e skin around them is stretched and fixed, so that covering and healing them has been a challcnging problem to surgeons. T h e method used in this patient utilizes the transfer of the whole of the greater omenturn attache to the greater curve of the stomach, which provides a clean, vascular bed f o r the skin grajt, and has been nature's best help to surgeons.
OMENTUMhas been used outside the abdomen as early as 1961 by Kiricuta for sealing bronchial and bladder fistula TWO years later, he advocated its use as a split skin graft bed in the treatment of radionecrosis of the chest wall.
His technique, using omenturn pedicled upon the gastroepiploic vessels, has been used in four cases by Dupont and Menard in 1972, and the operative technique is well documented.
FIGURE 2 : Area of skin excised, with the ulcers. FIGUREI : Two deep ulcers are seen over the parasternal area, exposing the costal cartilages. Reprints : Mr S. Gue, F.R.C.S., Senior Specialist Surgeon, Broken Hill and District Hospital, Broken Hill, N.S.W. 2880.
390
Seven further successful cases have been reDorted by these two workers. Omentum has alio been k e d for treating lymphcedema, and fevasculization Of the myocardiun1 and inferior extremity.
for
AUST.N.Z. J. SURG., VOL.45-No.
4, NOVEMBER, 195
OMEXTAL TRANSFER FOR RADIONECROSIS Cort and Collis (1973) reported another case’ but
they used a transdiaphragmatic approach after opening the pleural cavity for retrosternal transposition of the omenturn. In the patient now reported omentum was transported extraabdominally through a subcutaneous tunnel to the chest wall, and no disadvantages were noted. Serial photographs the ‘peration, with two suggested modifications in the operative technique.
GUE CLINICAL RECORD In January 1974, a 74-year-old Australian woman presented with two large, deep ulcers over the left parasternal region (Figure I ) of two months’ duration. She had had a left radical mastectomy for carcinoma of breast in 1960, followed hy deep X-ray therapy five years later, but the reason for this has not been established. She was apparently well up till 1973, apart from arthritic problems and a chronic cough. There was a mention in her clinical notes of “two atrophic scabs” over the parasternal area on the left side, near the lower edge of the mastectomy scar, when she was seen a t a follow-up clinic in 1972.
3 : (upper) the greater omentum has been mobilized, and the length obtained is shown; (lower) FIGURE demonstration of subcutaneous tunnel, with assurance of its adequacy. AuST.
N.Z. J.
SURG., VOL.
45 - No. 4, NOVEMBER, 1975
391
OMENTAL TRANSFER FOR RADIONECROSIS
GUE
On examination, she was reasonably fit for her age. The two left parasternal ulcers, each about half an inch in diameter and of the same depth, were separated by a quarter-inch skin bridge. The base was fixed, and there was a whitish slough exposing the partly destroyed costal cartilage. The skin edges were not everted, but looked red. The rest of the skin on that side of the chest was thin and fixed. The old mastectomy scar was healthy, with no evidence of local recurrence, and there was no lymphadenopathy. Other clinical findings were normal.
Results of base-line investigations, including hzemoglobin level, white cell count and serum calcium level were normal, though the E S R was 30mm per hour, and she had an alkaline phosphatase level of 22 K.A. units. A swab from the ulcer grew Staphylococcus aureus. A chest X-ray film, right mammogram, and skeletal survey were normal. A provisional diagnosis of radionecrotic ulcer was made, and was confirmed by two consecutive biopsies from the ulcer edge in February and May, 1973. Five months of conservative treatment proved of no
FIGURE 4 : (upper) omentum has been laid over excised area, peritoneum being held by artery forceps; (lower) omentum has been anchored in place, and peritoneal cavity closed.
392
AUST.N.Z. J. SURG.,VOL.45 -No.
4, NOVEMBER, 1975
OMENTAL TRANSFER FOR RADIONECROSIS benefit. The ulcers were becoming larger, and the patient had a lot of discomfort and pain. An omental transfer with primary skin grafting was decided upon. Operative technique.-The two ulcers from the chest wall were widely excised, down to necrotic and partially destroyed costal cartilages and intercostal muscle, leaving a gap of approximately 12cm by n c m , and then the skin edges were slightly undermined (Figure 2 ) . The set of dirty instruments used for this procedure were then discarded. The abdomen was opened through an upper midline incision. There was no evidence of any intraperitoneal metastasis. The greater omentum was then separated from the transverse colon and mesocolon, and a length was obtained (30cm) which was considered would reach the excised ulcer bed (Figure 3, upper). l t was found unnecessary to separate it from the greater curvature of the stomach and make a pedicle on the left or the right gastro-epiploic vessels (Dupont and Menard, 1972). A subcutaneous tunnel was made (Figure 3, lower) from the top of the abdominal incision to the lower end of the ulcer-excised area, then the omentum was
GUE The omentum was anchored to the underlying tissue with a few interrupted z / o catgut stitches (Figure 4). A thick split skin graft was taken from the right thigh and spread over the defect to cover it, two large pieces of skin being used. The edges of the graft were first fixed a t the corners by pullout 5 / 0 Nylon, passed through the deep fascia so as to minimize any graft movement with respiration and posture, and each of these was anchored with a bead and collar. The rest of the
FIGURE 6 : Appearance on 25th day, when patient was seen a t outpatient clinic. Graft has taken well and remains healthy.
FIGURE 5 : Skin graft in place, corners being fixed with pull-out Nylon beads and collar. Ends of sutures between these corners have been left long, to be tied over dressing. brought out of the abdomen through the upper portion of the incision and was passed through the subcutaneous tunnel, making sure that it was not rotated or constricted so as to impair its blood supply, and was spread over the whole area of the excision. Ausr. N.Z. J. SURG.,VOL.45-No.
4, NOVEMBER, 1975
stitches were placed approximately z cm apart, the ends being left long. A Zimmer drain was inserted between the omentum and the graft (Figure 5 ) . The stay sitches were tied over the tie over the dressing so as to keep the whole area as immobile as possible, then the whole wound was covered with Elastoplast. The abdomen was closed in layers with I/O Proline, making sure not to strangulate the omentum at the top. A subcuticular 3/0 Dexon stitch was used for the skin closure. Postoperative progress.-Her postoperative phase was complicated by chest infection and sputum retention, despite preoperative and postoperative physiotherapy. She responded well, however, to intravenous Keflin therapy, which was combined for ten days with intensive physiotherapy. On the fifth day, the Redivac drain was removed, as drainage had
393
TRANSFER FOR RADIONECROSIS
GUE
decreased from 100 ml to 5 ml in 24 hours. On the tenth day, the dressings were removed, and it was found that the graft had taken well, though there was some bruising of the top left corner. The stitches were removed on the 12th postoperative day. Mobilization was slow, but no other problems were encountered, and she went home on the 20th postoperative day. Since then, she has been seen in the outpatient clinic, and now, after five months, the graft remains healthy (Figure 6 ) , not tender, and with good cutaneous sensation. Histological examination of the excised ulcer confirmed the presence of radionecrosis, with no evidence of mammary carcinoma.
establishing a retrosternal route for the passage of omentum. They claimed that this reduced the risk of omental strangulation. This method was considered, but was not used, because it would cause more surgical trauma and prolong the operation, which could increase the morbidity in a poor-risk patient. A thicker skin graft was deliberately used in this case to get a better and more permanent skin cover, and because it would be resistant to trauma, both from mechanical and sensory reasons. No difficulty was encountered, and this is recommended. It is important to drain the area between the omentum and the skin graft, as the omentum produces a significant amount of transudate, which if not removed, will lift the graft off the bed (McLean and Buncke, 1972). The anchoring of the wound margins with the deep fascia is very important in order to try and reduce the respiratory and postural movement of the graft as much as possible, and also hzematoma formation, which in turn can cause graft loss. The bead and collar with pull-out Nylon stitches were found very satisfactory. I t is realized that the follow-up period has been short, but no abdominal or local complications have been noted. It is suggested that the method described should be ideal for reconstruction of radionecrotic ulcers of the chest wall and should be used more frequently, and early, which saves time, affords a permanent cover, and reduces morbidity.
OMENTAL
DISCUSSION Many methods have been reported in the past for treatment of radionecrotic ulcers of the chest wall, and these were taken into consideration. First, thoughts of a rotation advancement flap or a transposition flap from the abdomen were discarded, as these would not survive because of poor bed and distance. A tubed pedicle flap was also rejected, because of multiplicity of stages and long hospital stay. Omental transfer with primary skin grafting was therefore carried out. Because of its simplicity, the method described by Dupont and Menard in I972 was used in this case, and no disadvantages were, seen during or after operation. Special omental mobilization in terms of use of a gastroepiploic pedicle was not necessary, and this made the operation more simple and less time-consuming. This possibility, however, must be kept in mind, especially when one finds a small and fixed omentum, as described by Dupont and Menard in 1972. Recently, Cort and Collis (1973) reported a similar case, in which instead of using the subfascial route, they detached the diaphragm from the anterior costal margin, moving the free edge cephalad, and suturing it to the muscle and periosteum, the defect created by removal of affected costal cartilage thus
394
REFERENCES COKT,D. F. and COLLIS,J. L. (1973), Brit. J. .%rg., 60: 581. DUPONT,C. and MENARD, Y. (1972), Plast. reconsir. Surg., 49: 263. KIRICUTA,I. (1963), Press. mid., 71: 15. MCLEAN,D. H. and BUNCKE,H. L. ( r g ? ~ ) ,P h t . reconstr. Surg., 49 : 268.
AUST. N.Z. J.
SURG., VOL.45 - NO. 4, NOVEMBER, 1975
