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Bronchopleural Fistula Closure by Intrathoracic Transposition of the Omentum

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posted on 2023-03-23, 14:19 authored by Carlos Guerrero, Abel Gomez-Caro

Complex chest and lung infections with bronchial fistula are life-threatening situations with a mortality rate of up to 20 percent. If medical treatment fails, these patients require aggressive surgical procedures to heal. Transposition of the omentum is a valuable option in these complex cases with aggressive infection involving the pleural space, with or without a bronchial fistula, when medical treatment is unsuccessful.

The Patient

The patient is a sixty-seven-year-old man with no comorbidities who is a twenty pack-years ex-smoker, diagnosed with pulmonary adenocarcinoma and submitted to right pneumonectomy. This procedure was complicated with a bronchopleural fistula and managed through thoracostomy. After three years of local treatment, he was seen in the outpatient clinic for surgical closure of thoracostomy and total bronchial fistula. The patient complaints were a weak voice, chronic infection, and insufficient quality of life linked to painful local cures.

Preoperative Imaging

A chest computed tomography scan showed postoperative changes secondary to pneumonectomy, main bronchus fistulae, and right thoracostomy. A positron emission tomography ruled out hypermetabolic foci suggestive of locoregional or distant tumor disease.

The Surgery

Using a rigid bronchoscope, surgeons observed the bronchopleural fistula involving the right main bronchus and placed a tracheal left bronchial stent, through which a simple orotracheal tube was inserted for intraoperative ventilation.

Next, the team made a supraumbilical median laparotomy incision to access the peritoneal space. The omentum was exposed to clearly identify its structures. The greater curvature of the stomach and the right and left gastroepiploic arteries were identified. The origin of the right artery had to be preserved, since this keeps the omentum irrigated. Surgeons began by sectioning the gastro omental arteries until reaching the origin of the left gastroepiploic artery and the short gastric arteries, which were sectioned close to the spleen. The pulse of the right gastroepiploic artery was frequently checked to detect injuries during the dissection. The objective was to achieve a pedicle long enough to be able to move the omentum freely.

Then, the omentum was separated from the transverse colon. This maneuver has the objective of obtaining the largest possible volume of omentum. In this patient, the greater omentum presented a dissection plane with the transverse colon and the mesocolon that was difficult to identify, so a small section of the omentum was produced without affecting its vascularization.

The falciform ligament was freed and a gauze was sutured at once and placed in the hepatophrenic recess. This allowed surgeons to more easily identify the omentum from the thorax.

With the patient in left lateral decubitus, surgeons approached by means of an iterative right thoracotomy on the thoracostomy and expanded through a Paulson-type incision. The dorsal and trapezius muscles were then sectioned and the second to tenth right ribs were dissected and sectioned at the anterior chondrocostal level and vertebral detachment. Pleural curettage was then performed to facilitate healing.

Next, an incision at the anterior diaphragmatic muscle level was made to allow intrathoracic epiploic transposition. The margins of the incision were sutured with PDS 4/0 to prevent future tears of the diaphragm. The omentum was also sutured to the diaphragm to prevent it from slipping.

Circular mattress-type suture on the margins of the fistula in the right main bronchus to the omentum with double-needle PDS 4-0 was then performed for closure. Suturing was also performed at the vertex and homogeneously in the pleural space, managing to obliterate it. Aerostasis was then checked and found to be correct.

The team then performed careful hemostasis and TachoSil was placed in conjunction holes. Four chest drains were placed—two argyle type 28F and two blake type 19F placed intra- and extra-pleural. In order to gain the largest possible volume of subcutaneous tissue and facilitate its correct healing, a fragment of skin was deepithelialized at the level of the invagination of the thoracostomy. The muscular and subcutaneous planes were closed with vicryl and the skin with staples.

Postoperative Course

A postoperative chest computed tomography scan showed postsurgical changes secondary to omentoplasty and demolition thoracomyoplasty, and scant left pleural fluid.

The patient was readmitted to the ICU on the fourth postoperative day because of respiratory failure in the context of respiratory infection, requiring intravenous antibiotic therapy. No reintubation was needed. During his stay in the ICU, he suffered from acute kidney failure, anemia that required two packed red blood cell transfusions, and several episodes of pulmonary atelectasis that required a cleaning fiberoptic bronchoscopy. The tracheal prosthesis was removed on postoperative day fourteen. Negative pleural cultures were obtained before the drains were removed. The patient was discharged on the twentieth postoperative day. One and a half years after follow-up, no complications were presented.

Reference(s)

1. Puskas JD, Mathisen DJ, Grillo HC, Wain JC, Wright CD, Moncure AC. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg. 1995 May;109(5):989–95; discussion 995-6.

2. Thakur B, Zhang CS, Cao FM. Use of greater omentum in thoracic onco-surgery. Kathmandu Univ Med J (KUMJ). 2007 Jan-Mar;5(1):129–32.

3. Shrager JB, Wain JC, Wright CD, Donahue DM, Vlahakes GJ, Moncure AC, et al. Omentum is highly effective in the management of complex cardiothoracic surgical problems. J Thorac Cardiovasc Surg. 2003 Mar;125(3):526–32.

4. Billè A, Giovannetti R, Calarco G, Pastorino U. Tailored stent for bronchial stump fistula closure and omentoplasty for infection control: a combined approach with low morbidity. Tumori. 2014 Jul-Aug;100(4):157e–9e.

5. Zhou J, Sun J, Yao X, Zhao G, Sun F, Sheng W, et al. Laparoscopic omental flap for the treatment of thoracic aortic graft infection: report of two cases and review of the literature. J Cardiothorac Surg. 2020 May 29;15(1):120.

6. Guerrero C, Berthet JP, Gómez-Caro A. Intrathoracic transposition of the omentum. Multimed Man Cardiothorac Surg. 2021 Jun 4;2021. doi: 10.1510/mmcts.2021.033. PMID: 34143577.

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