T postlobectomy empyema, postpneumonectomy empyema,

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1 Use of Pedicled Omental Flap in Treatment of Empyema Takayuki Shirakusa, MD, Hitoshi Ueda, MD, Shinichi Takata, MD, Satoshi Yoneda, MD, Koji Inutsuka, MD, Nobuo Hirota, MD, and Masatoshi Okazaki, MD Division of Thoracic Surgery, Second Department of Surgery, and Department of Radiology, School of Medicine, Fukuoka University, and National Minami Fukuoka Hospital, Fukuoka, Japan Omental pedicle flaps were used in the treatment of patients with acute and chronic empyema with bronchopleural fistula. In 5 patients (group 1) with postoperative acute empyema owing to bronchial stump fistula, an omental covering was applied as a reinforcement to close the fistula. Six patients in group 2 with chronic tuberculous or Aspergillus empyema with multiple fistulas initially underwent open-window thoracostomy or cavernostomy and secondarily had omental transposition. In all patients, the right gastroepiploic vessels were used to provide the blood supply for the flap. Successful closure of the bronchial stump was obtained in all patients in group 1, but 2 of them died of recurrence of their underlying lung carcinoma within 1 year. Five of the 7 patients in group 2 had a favorable outcome, but 2 patients had partial recurrence after omental plombage. From our experience with these patients, we believe that the omental flap is effective for closing fistulas due to postoperative or chronic empyema but has only limited success in patients whose lungs are severely damaged by persistent infection. (Ann Thorac Surg 1990;50:420-4) reatment of acute and chronic empyema, including T postlobectomy empyema, postpneumonectomy empyema, and tuberculous or nontuberculous empyema, has been a major concern of thoracic surgeons [1-4]. Despite the decreasing use of resection as a treatment method for intrapulmonary tuberculosis, chronic tuberculous empyema must often be treated surgically. Although several operative procedures have been developed with varying degrees of success [l-3, 581, the method of treating empyema, and in particular empyema associated with fistula, remains controversial. The omentum has been used for management of complicated problems in various fields of general surgery and cardiovascular surgery [ It has also been used in repair or reconstruction of organs with ischemic damage and as an aid in the healing or closing of various types of fistulas [7, 10, 12, 161. Some successful results have been achieved by use of the omentum in patients with thoracic empyema resulting from bronchial fistula [7, 161. We have performed operations using the omentum in 12 patients with acute and chronic empyema and achieved favorable results in 10. We report our series of patients and discuss the value of the omental flap in the surgical treatment of thoracic empyema, its indications, and its limitations. Material and Methods Since January 1980, 12 patients have undergone omental transposition in our departments. The 9 men and 3 Accepted for publication April 4, 1990 Address reprint requests to Dr Shirakusa, Division of Thoracic Surgery, Department of Surgery, School of Medicine, Fukuoka University, 45-1, Nanakuma, Fukuoka, , Japan. women were divided into two groups (Tables 1, 2). Group 1 consisted of 5 patients who had postoperative acute empyema (4 had postpneumonectomy empyema, and 1 had empyema after right middle and lower lobectomy). The 7 patients in group 2 had chronic empyema: 5 had tuberculous empyema, and 2 had Aspergillus empyema. The underlying disease of the 5 patients in group 1 was lung carcinoma (see Table 2). Chronic empyema due to tuberculous or aspergillosis in group 2 was discovered after the development of symptoms related to bronchopleural fistulas. A single-stage operation was performed in all patients in group 1 and in 1 patient in group 2. Two-stage procedures (open-window thoracostomy or cavernostomy and then omental plombage) were performed in the remaining 6 patients with chronic empyema (see Tables 1, 2). In these patients, two or three segments of rib were resected and the empyema space was fully exposed at the initial operation. Postoperatively, daily gauze dressings were applied until fresh granulations appeared in the open space (a period of 1 to 9 months). Omental plombage was performed as a secondary procedure. Staphylococcus uureus was detected in the empyema space in 6 patients with postpneumonectomy empyema. In the chronic empyema group, only 1 patient (patient 8) was positive for tuberculous bacilli, whereas Aspergillus was demonstrated in 2 patients by culture. Tuberculous or mycotic lesions were histologically confirmed in all resected specimens in group 2. For transposition of the omentum, a short median incision was made in the upper abdomen and the greater omentum was freed from the greater curvature of the stomach proceeding from left to right. In all patients, the by The Society of Thoracic Surgeons /90/$3.50

2 Ann Thorac Surg 1990;50:420-4 SHIRAKUSA ET AL 421 Table 1. Patients With Postoperative Empyema Who Underwent Omental Transposition (Group 1) Patient Age No. Sex (y) Underlying Disease Type of Fistula Operation Outcome 1 M 71 Right lung carcinoma Bronchial stump fistula TD, OC Successful closure; died 2 M 52 Right lung carcinoma Bronchial stump fistula TD, OC after 3 mo of tumor recurrence Successful closure; died after 1 y of tumor 3 M 56 Right lung carcinoma Bronchial stump fistula TD, OC recurrence Successful closure; alive 4 M 63 Right lung carcinoma after middle and lower lobectomy Bronchial stump fistula TD, carinal resection 1 y 3 mo postop Successful closure; alive and OC 1 y 3 mo postop 5 M 56 Right lung carcinoma Bronchial stump fistula TD, OC Successful closure; alive 1 y 3 mo postop OC = omental covering; Successful closure = successful closure of bronchial fistula; TD = tube drainage. omental flap was supplied by the right gastroepiploic vessels. A hole admitting two or three fingers was made in the diaphragm below the sternum, and the omental flap was generally brought up into the lower thoracic space without difficulty through this hole. In the patients with chronic empyema in the upper thorax (patients 9 and 10, Table 2), however, intrathoracic transfer of the omentum was difficult because the adhesions between lung and chest wall or diaphragm were very firm. In those patients, we made a subcutaneous tunnel and passed the omentum through it to bring it up into the empyema space (Fig 1). For closure of the fistulas in most patients in group 2, we sutured individual fistulas except for the smallest ones, which were left to close spontaneously. In patient 8, in whom the dissection and suturing of a larger fistula proved difficult, we pushed a part of the omentum into the fistula while covering the lung with omentum. In all patients, the omental flap was fixed to the bronchial wall with Dexon sutures, and fibrin glue was poured into the space around the omentum. In 4 patients with chronic empyema, we performed additional plombage using the surrounding chest wall muscles (pectoralis major and serratus anterior muscles for anterior lesions and latissimus dorsi for posterior lesions), because in those patients Table 2. Patients With Chronic Empvema Who Underwent Omental Plornbaxe (Group 2) Location of Patient Age Empyema in No. Sex (Y) Cause of Empyema Thoracic Space Operation Outcome ~ ~~~ 6 F 65 Tuberculous empyema Right lower 7 F 32 Aspergillus empyema Right upper 8 M 74 Tuberculous empyema Left lower M 68 Tuberculous empyema Right upper M 76 Aspergillus empyema Left upper F 66 Tuberculous empyema Right lower 12 M 72 Tuberculous empyema Right total OWT = open-window thoracostomy. OWT, decortication, and omental transposition transposition Open-window cavernostomy, omental and transposition No recurrence at 3 y 5 mo; alive and well No recurrence at 2 y 9 mo; alive and well 2 y 5 mo; alive 2 y 5 mo; alive 2 y 2 mo; alive 6 mo postop 6 mo postop

3 422 SHIRAKUSA ET AL Ann Thorac Surg 1990;50:420-4 the omentum was of insufficient volume to cover the entire surface of the damaged lung. In patients with postoperative bronchial stump fistulas, tube drainage and irrigation was performed initially. Next, the pleural space was opened and the entire surface of the empyema cavity was irrigated thoroughly. After exposing healthier tissue belonging to the bronchial stump as far as possible, we performed repeat resection and closed the stump. Finally, we bunched the transferred omentum and sutured it to the bronchial stump in some areas. Results We obtained favorable postoperative results in 5 patients in group 2 with chronic empyema (patients 6, 7,8,11, and 12); 2 had partial recurrence (patients 9 and 10) (see Table 2). Patient 6 had a right chronic empyema. Long-term management with tube drainage was a failure, but omental transposition was subsequently performed successfully (Fig 2). Patient 7 was a very short and thin woman. She had undergone long-term medical therapy for pulmonary tuberculosis, but an intracavitary aspergilloma subsequently developed. An open-window cavernostomy was performed. At the closure of this large open space, sufficient chest wall muscle was not available for plombage; therefore, only the omentum was placed Fig 2. A celiac angiogram performed 3 months after omental transposition in patient 6 shows the patency of the right gastroepiploic vessels that run into the left thorax. - / Fig 1. Method of transposing the omentum in a patient whose empyemu space is located in the upper thorax and whose residual lung has tight adhesions to the thoracic wall. The omentum is brought up through a subcutaneous tunnel. over the openings of the fistulas. Postoperatively, the dead space slowly decreased with time (Figs 3 and 4). Patients 6 and 12 also did not undergo - additional plombage using chest wall muscles. In patients with successful results, pulmonary symptoms resolved completely and there has been no recurrence during follow-up. Patients 9 and 10 had recurrence of symptoms about 1 month after omental plombage. Both of them were malnourished elderly patients with large empyemas and persistent infection of the lung parenchyma in whom pleuropneumonectomy was impossible because of their poor general condition and reduced lung function. In patient 9, after an open-window thoracostomy, the omentum and chest wall muscles were used to cover many fistulas of various sizes. Postoperative bronchography showed, however, that obliteration of the fistulas was only partially successful. In patient 10 a recurrent free space developed 1 month after operation and repeat cavernostomy showed partial recurrence of the fistulas even though the omentum was viable and tightly adherent to the top of the empyema space. Patients 11 and 12 are alive and well 6 months after operation, but it is too early to assess the long-term results in these patients. In all patients with postoperative acute empyema (group l), we successfully achieved closure of the bronchial fistula by using the omental covering (Table 1). Four of the 5 patients in this group had stage I11 lung carci-

4 Ann Thorac Surg 1990;50:42&4 SHIRAKUSA ET AL 423 Fig 3. A celiac angiogram performed 3 weeks after omental transposition in patient 4 shows thin ornental vessels farrows) covering the surface of the bed of a large empyema space. previously performed open-window thoracostomy followed by myoplasty in select patients, using methods reported previously [ 1-3, 5, 81. For empyema with fistula, pleuropneumonectomy is a potentially curative operation, but it may be too invasive for patients at risk. Bronchial fistulas generally heal poorly owing to an inadequate blood supply and persistent infection [7]. The omentum has a rich blood supply and tends to adhere well to inflammatory tissue [7, 151. In 21 empyemic patients, Hankins and colleagues [6] reported six recurrences and unsuccessful treatment in 4 patients; in 2 others, treatment was partially successful but myoplasty had to be repeated. Myoplasty is a safer procedure than pleuropneumonectomy or extended thoracoplasty, but myoplasty does not always provide satisfactory results in elderly or thin, malnourished patients. The remarkable power of the omentum to aid tissue repair may result from its encouragement of cellular proliferation and fibrous tissue formation, as well as its adhesion to surrounding organs [10,16, 181. Furthermore, both the rich omental lymphatic system and the revascularization promoted by the omentum permit rapid reabsorption of inflammatory exudates, with little local infection [3, 151. Miller and co-workers [20] reported good results in 2 patients who underwent closure of a postpneumonectomy empyema space with use of both extrathoracic muscle flaps and omental grafts. In this series, we also added plombage with chest wall muscles in a few patients in whom the thin omental tissue was not suffi- noma, and 1 had a stage I tumor. Patient 1 died of recurrence of carcinoma in the early postoperative period. Comment In empyema without fistula, decortication or extrapericostal air plombage usually is used; the former procedure is performed for a localized and the latter for an extensive empyema. However, the treatment of empyema with fistula is more varied because it often is difficult. The mortality in patients with a bronchial stump fistula after pneumonectomy is considerable. In the treatment of acute empyema resulting from bronchial fistula, we have performed an open-window thoracostomy as an emergency procedure. After daily irrigation with antibiotics, we then performed repeat closure of the bronchial stump and. The results, however, were sometimes not favorable. In elderly patients with bronchial carcinoma, the bronchial stump may be at risk of ischemia because of the dissection of surrounding tissues. Accordingly, in the case of a large bronchial stump with dehiscence due to ischemia, covering the fistula with a muscle flap alone will be inadequate because muscle lacks the ability of fat to promote angiogenesis [19]. For this reason, we used the omentum for closing bronchial stump fistulas in this series and obtained good results. Several surgical techniques have been introduced for the treatment of chronic empyema with fistula. We have Fig 4. A chest roentgenogram performed 6 months after operation in patient 4 S ~OZUS the rtiarked decrease in the right apical dead space (arrows).

5 424 SHIRAKUSA ET AL Ann Thorac Surg 1990;50:42&4 cient to cover the empyema surface. We do not believe that complete closure of an empyema space is always needed, however, provided that the residual space is kept clean by daily gauze dressings and provided that omental coverage of the fistula openings is sufficient. The residual space decreases considerably in such cases with time, even though it does not become completely obliterated. In 3 patients with chronic empyema, additional muscle plombage was not performed. All are now alive and well despite having a residual pleural space. Based on their experience in chest wall reconstruction with omentum, Jurkiewicz and Arnold [ll] stressed that the right gastroepiploic artery is usually lager than the left and that omental flaps accordingly should be based on the right gastroepiploic vessels. We believe that either artery may be used, although in all our patients the right gastroepiploic vessels were used for the blood supply of the flap. Use of the omentum should be avoided in patients who have had any previous operation on the gastrointestinal tract or who have any kind of active abdominal disease. Regarding postoperative complications, subacute ileus with brief postoperative abdominal distention developed in only 1 patient. Although there is a theoretical risk of herniation of the abdominal organs, this complication did not occur in our series. When using an omental flap, one must be careful to avoid any kinking, compression, or rotation of the vascular pedicle [15]. Formation of larger hematomas in the omentum should also be avoided [12]. Infection may spread to the abdominal cavity because a passage is created surgically between the empyemic space and the abdomen, particularly in cases of pulmonary tuberculosis or aspergillosis. Therefore, to achieve sterilization of the empyema space, we recommend an openwindow thoracostomy followed by daily gauze dressings for several months before its closure is attempted. Two patients in our series had unsuccessful results. The cause of failure was considered to be that both patients were malnourished and had severe chronic infection of the airways and lung parenchyma. Thus, it appears that if the lung has foci of persistent infection connecting to the empyema space, omental plombage may not be successful. References 1. Cicero R, Vecchyo C, Porter JK, Carreno J. Open window thoracostomy and plastic surgery with muscle flaps in the treatment of chronic empyema. Chest 1986;89:36& Shaji FM, Ginsberg RJ, Cooper JD, Pearson FG. Open win- dow thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula. J Thorac Cardiovasc Surg 1983;86:81& Eerola S, Virkulla L, Vastela E. Treatment of postpneumonectomy empyema and associated bronchopleural fistula. Scand J Thorac Cardiovasc Surg 1988;22: Chicarilli ZN, Ariyan S, Glenn WL, Seashore JH. Management of recalcitrant bronchopleural fistulas with muscle flap obliteration. Plast Reconstr Surg 1985;75: Hankins JR, Miller JE, McLaughlin JS. The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients. Ann Thorac Surg 1978;25: Virkkula L, Eerola S. Use of omental pedicle for treatment of bronchial fistula after lower lobectomy. Scand J Thorac Cardiovasc Surg 1975;9: Rocha AG, Robertson GA. Sealing the postpneumonectomy space: use of a pectoralis major myodermal flap. Ann Thorac Surg 1984;38: Casten DF, Alday ES. Omental transfer for revascularization of the extremities. Surg Gynecol Obstet 1971;132: Dupont C, Menard Y. Transposition of the greater omentum for reconstruction of the chest wall. Plast Reconstr Surg 1972;49: Goldsmith HS, Beattie EJ. Carotid artery protection by pedicled omental wrapping. Surg Gynecol Obstet 1970;130: Jurkiewicz MJ, Arnold PG. The omentum: an account of its use in the reconstruction of the chest wall. Ann Surg 1977; 185: Lima 0, Goldberg M, Peters WJ, et al. Bronchial omentopexy in canine lung transplantation. J Thorac Cardiovasc Surg 1982;83:41% Morgan E, Lima 0, Goldberg M, et al. Successful revascularization of totally ischemic bronchial autografts with omental pedicle flaps in dogs. J Thorac Cardiovasc Surg 1982; 84: Segulin JR, Loisance DY. Omental transposition for closure of median sternotomy following severe mediastinal and vascular infection. Chest 1985;88: lverson LIG, Young JN, Ecker RR, et al. Closure of bronchopleural fistulas by an omental flap. Am J Surg 1986;:152: Dubois P, Choiniere L, Cooper JD. Bronchial omentopexy in canine lung allotransplantation. Ann Thorac Surg 1984;38: Heath BJ, Bagnato VJ. Postpneumonectomy mediastinitis treated by omental transfer without postoperative irrigation or drainage. J Thorac Cardiovasc Surg 1987;94: Mathiesen DJ, Grillo HC, Vlahakes GJ, Daggett WM. The omentum in the management of complicated cardiothoracic problems. J Thorac Cardiovasc Surg 1988;95: Miller J1, Mansour KA, Nahai F, et al. Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984;38: