Scand J Thor Cardiovasc Surg 9: 287-290, 1975
USE OF OMENTAL PEDICLE FOR TREATMENT OF BRONCHIAL FISTULA AFTER LOWER LOBECTOMY Report of Two Cases
Lauri Virkkula and Seppo Eerola
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Otago on 01/08/15 For personal use only.
From the Department of Thoracic Surgery, University Central Hospital, Helsinki, Finland
(Submitted for publication December 28, 1973)
Abstract. Postoperative bronchopleural fistula in two patients was successfully closed by omental pedicle flap. The primary operation in both cases was left lower lobectomy for bronchiectasis. The technique of the operation is described and the cases are reported.
The omental pedicle has been used earlier for arterial revascularization of ischaemic organs (Casten & Alday, 1971; Goldsmith, 1967; Goldsmith, 1968; Pifarr6 & Hufnagel, 1968; Susset & MacKinnon, 1963) and for decompression of portal hypertension by creating neogenic venous communications between the portal and systemic veins (Berman, Waite, Gerig & Bakemier, 1963). Omental transposition has been presented as a method for the treatment of lymphoedema of the extremities (Goldsmith, 1969; Goldsmith & de 10s Santos, 1967; Goldsmith, de 10s Santos & Beattie, 1968). In reconstructions of areas of poor healing and in closing fistulae, omental pedicle graft has been helpful. The omentum has been used for this purpose in reconstruction of the perineum (Ruckley, Smith & Balfour, 1970) and chest wall (Dupont & Menard, 1972), in closing rectovesical and vesicovaginal fistulae (Kiricuta, 1965), in reconstruction of the urinary tract (TurnerWanvick, Wynne & Handley-Ashken, 1967) and in the protection of intrathoracic anastomoses (Barnes, Redo & Ogata, 1972; Goldsmith, Kiely & Randal, 1968) and vascular prostheses (Goldsmith & Beattie, 1970; Goldsmith, de 10s Santos, Vanamee & Beattie, 1968). We have used the omental pedicle for closing of the bronchial fistula and for filling the adjoining cavity after lower lobe lobectomy.
OPERATIVE TECHNIQUE In both of our cases the bronchial fistula developed after left lower lobectomy. A short upper midline incision was used to expose the omentum. It was dissected free from the stomach just along the greater curvature without injuring the gastro-epiploic vessels. The right gastro-epiploic vessels were tied and cut near the gastroduodenal artery. The omentum was freed from the transverse colon and mesocolon. The base of the pedicle was near the hilum of the spleen containing intact left gastro-epiploic vessels. One of the patients (case 1) had already had an open thoracostoma made for treatment of the empyema. For the other patient (case 2) a short thoracotomy was made at the site of the earlier thoracotomy incision. A hole admitting two fingers was made through the diaphragm above the spleen and the omental pedicle was taken into the pleural cavity (Fig. 1). It was fixed by Dexon sutures to the bronchial fistula and also to the edges of the opening in the diaphragm, avoiding compression of the vessels of the pedicle. A drainage tube was left in the pleural cavity and a soft rubber drain in the abdominal cavity.
CASE REPORTS Case I The patient was a 51-year-old woman who over the last 10 years had suffered from continuous cough and profuse sputum and had had pneumonia 12 times. Bronchiectasis was found, and left lower lobectomy and lingulectomy was carried out on February 12,1973. For postoperative empyema and bronchopleural fistula a tube thoracostomy was made on February 28, 1973. Because the empyema and air leakage did not cease, an open window thoracostomy was made on March 7, 1973 (Fig. 2a). The adherent upper lobe remained satisfactorily wide. The bronchial fistula was made airtight with saline tampons. An operation for haemostasis was performed on March 8, 1973, and another, on March 11, 1973, for postoperative haemorrhage from the pericardial artery. When the suppuration had decreased, the patient Scand J Thor Cardiovasc Surg 9
288
L. Virkkula and S . Eerola clinical symptoms and signs. The chest X-ray showed that there was still a 2 x 3 cm air-filled cavity above the diaphragm in the posterior pleura.
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Otago on 01/08/15 For personal use only.
DISCUSSION
Fig. 1. The drawing shows the omental pedicle in the left pleural cavity. The base of the pedicle covers the spleen.
was transferred to a sanatorium for 3 months. The bronchial fistula remained open. On July 5, 1973, a n omental pedicle operation was done by the above technique, the edges of the open window thoracostoma were refreshed and it was closed. Air leakage stopped immediately. The closed thoracostoma wound produced some secretion, but healed without suppuration (Fig. 26). The abdominal incision healed at the first attempt. Examination on October 23, 1973, revealed a slight deformity of the lower part of the left thoracic cage, due to ribs resected in connection with the open window thoracostomy. The chest X-ray showed no cavity, and the upper lobe was satisfactorily wide (Fig. 3). Contrast X-ray examination of the (oesophagus and stomach gave normal findings.
Case 2 The patient was a 35-year-old woman who had had pleurisy 15 years earlier. She now had fever and haemoptysis. Bronchiectasis was confirmed by bronchography, and Ieft lower lobectomy and lingulectomy were performed on June 26, 1973. Postoperatively there was continuous air leakage from the posterior drain. This did not seem to decrease. The chest X-ray showed a 5 x 10 cm wide air-filled cavity in the pleura. When the drain was closed the patient had breathing difficulties and a feeling of tension in the left thoracic area. There were no signs of inflammation. Because the air leakage continued and the cavity existed after suction drainage for 6 weeks, an omental pedicle operation was performed on August 8, 1973. Air leakage stopped immediately and the drains could be removed after 2 days. At the examination on October 2, 1973, the patient felt well and was without any Scand J Thor Cardiouasc Surg 9
Bronchial fistulae heal poorly, which is evidently due to insufficient blood circulation and infection of the area. Thoracoplasty with or without myoplasty results in considerable deformity of the thoracic cage. A thoracoplasty is even less suitable after lower lobectomy than in the treatment of cavities and bronchial fistulae resulting from upper lobectomy. Complete obliteration of the cavity by thoracoplasty is not possible without partial collapse of the remaining lung tissue. Having earlier treated bronchial fistulae connected with postpneumonectomy empyema (Virkkula & Eerola), we were convinced of the usefulness of pedicle surgery for fistula closure. The omental pedicle is suitable for intrathoracic use. If necessary, it can easily be extended even to the neck and to the extremities (Alday & Goldsmith, 1972). The omentum has a good tendency to adhere to the inflammatory area. The pedicle is easy to prepare so that its blood circulation is maintained. The omentum is also suitable for filling the cavity after a lower lobectomy, as a method of avoiding thoracic deformity. In this respect, the omentum is obviously better than the muscle pedicle available because of its greater mass. Preparation of the omental pedicle requires a laparotomy and there is a potential danger of the infection spreading to the abdominal cavity. This did not occur in the two cases presented here, but for the present we have no experience of tuberculous patients. Since the omental pedicle must be taken through the diaphragm, there is also a risk of herniation of the abdominal organs. Therefore, in both patients the opening to the diaphragm was made at the site of the spleen. In our opinion, there is no objection to taking the omental pedicle also into the right pleural cavity. Judging by the limited experience obtained so far, we regard the use of the omental pedicle as a promising method for treatment of bronchial fistula after lower lobectomy. ACKNOWLEDGEMENT This study was supported by a grant from the Paavo Nurmi Foundation.
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Otago on 01/08/15 For personal use only.
Use of omentalpedicle for treatment of bronchialfistula 289
Fig. 2. (a) (Case 1) Open-window thoracostoma just before the omental pedicle operation. (b) (Case 1) Two weeks after
the omental pedicle operation and closing of the openwindow thoracostoma.
REFERENCES
Barnes, W. J., Redo, S. F. & Ogata, K. 1972. Replacement of portion of canine esophagus with composite prosthesis and greater omenturn. Thoroc cardiov surg 64, 892. Berman, E. J., Waite, B., Gerig, E. L. & Bakemier, R. E. 1963. Omentocavopexy. Archiv Surg 86, 150. Casten, D. F. & Alday, E. S. 1971. Omental transfer for revascularization of the extremities. Surg Gynec Obstet 132, 301. Dupont, C. & Menard, Y. 1972. Transposition of the greater omentum for reconstruction of the chest wall. PIast Reconstr Surg 49, 263. Goldsmith, H. S. 1967. Omental transposition for peripheral vascular insufficiency. Review Surg 23-24, 319. - 1968. Pedicled omentum versus free omental graft for myocardial revascularization. Dis Chest 54, 37. - 1969. The treatment of postsurgical lymphedema. Surg Clin North Am 49, 407. Goldsmith, H. S. & Beattie, E. J. Jr. 1970. Carotid artery protection by pedicled omental wrapping. Surg Gynec Obstet 130, 57. Goldsmith, H. S. & de 10s Santos, R. 1967. Omental transposition in primary lymphedema. Surg Gynec Obste r125, 607. Goldsmith, H. S., de 10s Santos, R. & Beattie, E. J. Jr. 1968. Omental transposition in the control of chronic lymphedema. J A M A 203, 117. Goldsmith, H. S., de 10s Santos, R., Vanamee, P. & Beattie, E. J. Jr. 1968. Experimental protection of vascular prosthesis by omentum. Arch Surg 97, 872. Goldsmith, H. S., Kiely, A. A. & Randal, H. T. 1968. Protection of intrathoracic esophageal anastomoses by omentum. Surg 63, 464.
Alday, E. S . 8~Goldsmith, H. S . 1972. Surgical technique for omental lengthening based on arterial anatomy. Surg Gynec Obstet 135, 103.
Fig. 3. (Case 1) Chest X-ray 15 weeks after the omental pedicle operation shows a satisfactorily wide upper lobe and n o deformity in the thoracic cage.
Scand J Thor Cardiovasc Surg 9
293 L. Virkkula and S. Eerola
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Otago on 01/08/15 For personal use only.
Kiricuta, I. 1965. L'utisation du grand dpiploon dans le traitement des fistules post-radiothdrapeutiques rectovdsico-vaginales et dans les cystoplasties. J Chir 89, 177. Pifarrd, R. & Hufnagel, C. A. 1968. Epicardiectomy and omental graft in acute myocardial infarction. Am J Surg 115, 589. Ruckley, C. V., Smith, A. M. & Balfour, T. W. 1970. Perineal closure by omental graft. Surg Gynec Obstet 132, 300. Susset, J. G. & MacKinnon, K. J. 1963. fitude experimentale de la revascularisation du rein ischdmie a l'aide du grand dpiploon. Un Med Can 92, 746.
Scand J Thor Cardiouasc Surg 9
Turner-Wanvick, R. T., Wynne, E. J. C. & HandleyAshken, M. 1967. The use of the omental pedicle graft in the repair and reconstruction of the urinary tract. Brit J Surg 54, 849. Virkkula, L. & Eerola, S. Use of pectoralis skin pedicle flap for closure of large bronchial fistula connected with postpneumonectomy empyema. Scand J Thor Cardiouasc Surg, in print.
USE OF OMENTAL PEDICLE FOR TREATMENT OF BRONCHIAL FISTULA AFTER LOWER LOBECTOMY Report of Two Cases
Lauri Virkkula and Seppo Eerola
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Otago on 01/08/15 For personal use only.
From the Department of Thoracic Surgery, University Central Hospital, Helsinki, Finland
(Submitted for publication December 28, 1973)
Abstract. Postoperative bronchopleural fistula in two patients was successfully closed by omental pedicle flap. The primary operation in both cases was left lower lobectomy for bronchiectasis. The technique of the operation is described and the cases are reported.
The omental pedicle has been used earlier for arterial revascularization of ischaemic organs (Casten & Alday, 1971; Goldsmith, 1967; Goldsmith, 1968; Pifarr6 & Hufnagel, 1968; Susset & MacKinnon, 1963) and for decompression of portal hypertension by creating neogenic venous communications between the portal and systemic veins (Berman, Waite, Gerig & Bakemier, 1963). Omental transposition has been presented as a method for the treatment of lymphoedema of the extremities (Goldsmith, 1969; Goldsmith & de 10s Santos, 1967; Goldsmith, de 10s Santos & Beattie, 1968). In reconstructions of areas of poor healing and in closing fistulae, omental pedicle graft has been helpful. The omentum has been used for this purpose in reconstruction of the perineum (Ruckley, Smith & Balfour, 1970) and chest wall (Dupont & Menard, 1972), in closing rectovesical and vesicovaginal fistulae (Kiricuta, 1965), in reconstruction of the urinary tract (TurnerWanvick, Wynne & Handley-Ashken, 1967) and in the protection of intrathoracic anastomoses (Barnes, Redo & Ogata, 1972; Goldsmith, Kiely & Randal, 1968) and vascular prostheses (Goldsmith & Beattie, 1970; Goldsmith, de 10s Santos, Vanamee & Beattie, 1968). We have used the omental pedicle for closing of the bronchial fistula and for filling the adjoining cavity after lower lobe lobectomy.
OPERATIVE TECHNIQUE In both of our cases the bronchial fistula developed after left lower lobectomy. A short upper midline incision was used to expose the omentum. It was dissected free from the stomach just along the greater curvature without injuring the gastro-epiploic vessels. The right gastro-epiploic vessels were tied and cut near the gastroduodenal artery. The omentum was freed from the transverse colon and mesocolon. The base of the pedicle was near the hilum of the spleen containing intact left gastro-epiploic vessels. One of the patients (case 1) had already had an open thoracostoma made for treatment of the empyema. For the other patient (case 2) a short thoracotomy was made at the site of the earlier thoracotomy incision. A hole admitting two fingers was made through the diaphragm above the spleen and the omental pedicle was taken into the pleural cavity (Fig. 1). It was fixed by Dexon sutures to the bronchial fistula and also to the edges of the opening in the diaphragm, avoiding compression of the vessels of the pedicle. A drainage tube was left in the pleural cavity and a soft rubber drain in the abdominal cavity.
CASE REPORTS Case I The patient was a 51-year-old woman who over the last 10 years had suffered from continuous cough and profuse sputum and had had pneumonia 12 times. Bronchiectasis was found, and left lower lobectomy and lingulectomy was carried out on February 12,1973. For postoperative empyema and bronchopleural fistula a tube thoracostomy was made on February 28, 1973. Because the empyema and air leakage did not cease, an open window thoracostomy was made on March 7, 1973 (Fig. 2a). The adherent upper lobe remained satisfactorily wide. The bronchial fistula was made airtight with saline tampons. An operation for haemostasis was performed on March 8, 1973, and another, on March 11, 1973, for postoperative haemorrhage from the pericardial artery. When the suppuration had decreased, the patient Scand J Thor Cardiovasc Surg 9
288
L. Virkkula and S . Eerola clinical symptoms and signs. The chest X-ray showed that there was still a 2 x 3 cm air-filled cavity above the diaphragm in the posterior pleura.
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Otago on 01/08/15 For personal use only.
DISCUSSION
Fig. 1. The drawing shows the omental pedicle in the left pleural cavity. The base of the pedicle covers the spleen.
was transferred to a sanatorium for 3 months. The bronchial fistula remained open. On July 5, 1973, a n omental pedicle operation was done by the above technique, the edges of the open window thoracostoma were refreshed and it was closed. Air leakage stopped immediately. The closed thoracostoma wound produced some secretion, but healed without suppuration (Fig. 26). The abdominal incision healed at the first attempt. Examination on October 23, 1973, revealed a slight deformity of the lower part of the left thoracic cage, due to ribs resected in connection with the open window thoracostomy. The chest X-ray showed no cavity, and the upper lobe was satisfactorily wide (Fig. 3). Contrast X-ray examination of the (oesophagus and stomach gave normal findings.
Case 2 The patient was a 35-year-old woman who had had pleurisy 15 years earlier. She now had fever and haemoptysis. Bronchiectasis was confirmed by bronchography, and Ieft lower lobectomy and lingulectomy were performed on June 26, 1973. Postoperatively there was continuous air leakage from the posterior drain. This did not seem to decrease. The chest X-ray showed a 5 x 10 cm wide air-filled cavity in the pleura. When the drain was closed the patient had breathing difficulties and a feeling of tension in the left thoracic area. There were no signs of inflammation. Because the air leakage continued and the cavity existed after suction drainage for 6 weeks, an omental pedicle operation was performed on August 8, 1973. Air leakage stopped immediately and the drains could be removed after 2 days. At the examination on October 2, 1973, the patient felt well and was without any Scand J Thor Cardiouasc Surg 9
Bronchial fistulae heal poorly, which is evidently due to insufficient blood circulation and infection of the area. Thoracoplasty with or without myoplasty results in considerable deformity of the thoracic cage. A thoracoplasty is even less suitable after lower lobectomy than in the treatment of cavities and bronchial fistulae resulting from upper lobectomy. Complete obliteration of the cavity by thoracoplasty is not possible without partial collapse of the remaining lung tissue. Having earlier treated bronchial fistulae connected with postpneumonectomy empyema (Virkkula & Eerola), we were convinced of the usefulness of pedicle surgery for fistula closure. The omental pedicle is suitable for intrathoracic use. If necessary, it can easily be extended even to the neck and to the extremities (Alday & Goldsmith, 1972). The omentum has a good tendency to adhere to the inflammatory area. The pedicle is easy to prepare so that its blood circulation is maintained. The omentum is also suitable for filling the cavity after a lower lobectomy, as a method of avoiding thoracic deformity. In this respect, the omentum is obviously better than the muscle pedicle available because of its greater mass. Preparation of the omental pedicle requires a laparotomy and there is a potential danger of the infection spreading to the abdominal cavity. This did not occur in the two cases presented here, but for the present we have no experience of tuberculous patients. Since the omental pedicle must be taken through the diaphragm, there is also a risk of herniation of the abdominal organs. Therefore, in both patients the opening to the diaphragm was made at the site of the spleen. In our opinion, there is no objection to taking the omental pedicle also into the right pleural cavity. Judging by the limited experience obtained so far, we regard the use of the omental pedicle as a promising method for treatment of bronchial fistula after lower lobectomy. ACKNOWLEDGEMENT This study was supported by a grant from the Paavo Nurmi Foundation.
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Otago on 01/08/15 For personal use only.
Use of omentalpedicle for treatment of bronchialfistula 289
Fig. 2. (a) (Case 1) Open-window thoracostoma just before the omental pedicle operation. (b) (Case 1) Two weeks after
the omental pedicle operation and closing of the openwindow thoracostoma.
REFERENCES
Barnes, W. J., Redo, S. F. & Ogata, K. 1972. Replacement of portion of canine esophagus with composite prosthesis and greater omenturn. Thoroc cardiov surg 64, 892. Berman, E. J., Waite, B., Gerig, E. L. & Bakemier, R. E. 1963. Omentocavopexy. Archiv Surg 86, 150. Casten, D. F. & Alday, E. S. 1971. Omental transfer for revascularization of the extremities. Surg Gynec Obstet 132, 301. Dupont, C. & Menard, Y. 1972. Transposition of the greater omentum for reconstruction of the chest wall. PIast Reconstr Surg 49, 263. Goldsmith, H. S. 1967. Omental transposition for peripheral vascular insufficiency. Review Surg 23-24, 319. - 1968. Pedicled omentum versus free omental graft for myocardial revascularization. Dis Chest 54, 37. - 1969. The treatment of postsurgical lymphedema. Surg Clin North Am 49, 407. Goldsmith, H. S. & Beattie, E. J. Jr. 1970. Carotid artery protection by pedicled omental wrapping. Surg Gynec Obstet 130, 57. Goldsmith, H. S. & de 10s Santos, R. 1967. Omental transposition in primary lymphedema. Surg Gynec Obste r125, 607. Goldsmith, H. S., de 10s Santos, R. & Beattie, E. J. Jr. 1968. Omental transposition in the control of chronic lymphedema. J A M A 203, 117. Goldsmith, H. S., de 10s Santos, R., Vanamee, P. & Beattie, E. J. Jr. 1968. Experimental protection of vascular prosthesis by omentum. Arch Surg 97, 872. Goldsmith, H. S., Kiely, A. A. & Randal, H. T. 1968. Protection of intrathoracic esophageal anastomoses by omentum. Surg 63, 464.
Alday, E. S . 8~Goldsmith, H. S . 1972. Surgical technique for omental lengthening based on arterial anatomy. Surg Gynec Obstet 135, 103.
Fig. 3. (Case 1) Chest X-ray 15 weeks after the omental pedicle operation shows a satisfactorily wide upper lobe and n o deformity in the thoracic cage.
Scand J Thor Cardiovasc Surg 9
293 L. Virkkula and S. Eerola
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Otago on 01/08/15 For personal use only.
Kiricuta, I. 1965. L'utisation du grand dpiploon dans le traitement des fistules post-radiothdrapeutiques rectovdsico-vaginales et dans les cystoplasties. J Chir 89, 177. Pifarrd, R. & Hufnagel, C. A. 1968. Epicardiectomy and omental graft in acute myocardial infarction. Am J Surg 115, 589. Ruckley, C. V., Smith, A. M. & Balfour, T. W. 1970. Perineal closure by omental graft. Surg Gynec Obstet 132, 300. Susset, J. G. & MacKinnon, K. J. 1963. fitude experimentale de la revascularisation du rein ischdmie a l'aide du grand dpiploon. Un Med Can 92, 746.
Scand J Thor Cardiouasc Surg 9
Turner-Wanvick, R. T., Wynne, E. J. C. & HandleyAshken, M. 1967. The use of the omental pedicle graft in the repair and reconstruction of the urinary tract. Brit J Surg 54, 849. Virkkula, L. & Eerola, S. Use of pectoralis skin pedicle flap for closure of large bronchial fistula connected with postpneumonectomy empyema. Scand J Thor Cardiouasc Surg, in print.
