Omental Free Flap Coverage for Extracavitary Vascular Bypass Graft Salvage.
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ABSTRACT: Background
Prosthetic vascular graft infection is a serious complication associated with significant morbidity and mortality often requiring graft excision and numerous additional operations. Pedicled flaps are often used for the coverage of exposed deep tissue or hardware for graft salvage. In the absence of pedicled options, the properties of omentum make it an excellent choice for free flap tissue coverage, particularly in cases involving implanted prostheses.Methods
A 63-year-old woman developed a mycotic right subclavian arterial aneurysm requiring ligation and extra-anatomic bypass grafting to restore right-sided intracranial and right upper extremity arterial perfusion. Subsequent wound breakdown and poor healing left the grafts exposed, resulting in contamination. Given the profound risks associated with graft excision in this patient, salvage was attempted with IV antibiotics, serial wound/graft washouts, and graft coverage with an omental free flap.Results
The patient tolerated the procedure well. The remainder of her hospital course was uneventful, and she was discharged home in good clinical condition. She will remain on long-term suppressive antibiotics per Infectious Disease recommendations.Conclusions
Contemporary literature reporting novel and effective applications of omental free flap coverage is rare. This report demonstrates that omental free flap coverage is safe and can provide healthy tissue to protect implanted grafts and even aid in the salvage of infected extra-anatomic bypass grafts.
SUBMITTER: Robinson JN
PROVIDER: S-EPMC8245108 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Free omental tissue transfer is a versatile reconstructive option for trunk, head and neck, and extremity reconstruction. Its utility is due to the length and caliber of the vascular pedicle and the malleability and surface area of the flap. We report our experience with omental free flap coverage of complex upper-extremity defects. A retrospective analysis of eight omental free-tissue transfers in seven patients with complex upper-extremity defects between 1999 and 2008 was performed. Indications, operative technique, and outcome were evaluated. Patient age ranged from 12 to 59 years with five male and two female patients. Indications included tissue defects due to crush-degloving injuries, pitbull mauling, or necrotizing soft tissue infection. All patients had prior operations including: revascularization, debridement, tendon repair, skin grafts, and/or fixation of associated fractures. One patient sustained severe bilateral crush-degloving injuries requiring free omental hemiflap coverage of both hands. The mean defect size was 291 cm(2) with all patients achieving complete wound coverage. No flap loss or major complications were noted. Laparoscopic-assisted omental free flap harvest was performed in conjunction with the general surgery team in three cases. Mean follow-up was 2 years. The omental free flap is a valuable, often overlooked reconstructive option. The long vascular pedicle and large amount of pliable, well-vascularized tissue allow the flap to be aggressively contoured to meet the needs of complex three-dimensional defects. In addition, laparoscopic-assisted harvest may aid with flap dissection and may result in reduced donor-site morbidity.
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Project description:Radial forearm free flap is the most reliable flap for intraoral soft tissue reconstruction after cancer ablation surgery. However, unesthetic scar of the donor site and the need for a second donor site for skin graft are major disadvantages of the forearm flap. The purpose of this study was to report the clinical results of double-layered collagen graft to the donor site of the forearm free flap without skin graft.Twenty-two consecutive patients who underwent oral cancer ablation and forearm reconstruction between April 2010 and November 2013 were included in this study. Male to female ratio was 12:10, and average age was 61.0 years old (27-84). Double-layered collagen was grafted to the donor site of the forearm free flap and healed for secondary intention. Upper silicone had been trimmed at the periphery during secondary intention, and dry dressing was used. Postoperative scar healing and esthetic results and function were evaluated.An average follow-up period was 34.9 months. The scar area was decreased to 63.9 % in average. The complete healing was obtained between 1.5 and 3 months according to the defect size. There was no functional defect or impairment 3 months after operation. All patients were satisfied with the esthetic results. Three patients died of recurred cancer.Double-layered collagen graft was successfully performed in this study. Without the thigh skin graft, patients had experienced less painful postoperative healing periods and discomfort.
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Project description:BackgroundTo present our experience with the "omental wrapping" technique in laparoscopic and robotic ureteroplasty using onlay flaps or grafts for the management of long proximal or middle ureteral strictures.MethodsThis is a retrospective review of 25 patients with long proximal or middle ureteral strictures who underwent laparoscopic and robotic onlay flaps or grafts ureteroplasty using an omental flap to reinforce an anastomosis site between August 2018 and November 2019. Perioperative and follow-up data were collected.ResultsSixteen laparoscopic procedures and nine robotic procedures were performed successfully. Sixteen patients underwent ureteroplasty with lingual mucosal graft (LMG), and nine patients with appendiceal onlay flap (AOF). The median stricture length was 4 cm (range, 2-6 cm). The mean operative time (OT) was 220.5±50.6 min, the estimated blood loss (EBL) was 66.0±38.9 mL, and the length of hospital stay (LHS) was 8.0±3.6 days. In the LMG group, four patients had tongue numbing and one had an oral ulcer, which relieved itself gradually without intervention. Two patients in the LMG group and four patients in the AOF group experienced urinary tract infection, and all responded well to antibiotic treatment. There were no complications attributed to "omental wrapping". The mean follow-up was 16.3±4.8 months. According to the standards regarding improvement in clinical symptoms, relief of obstruction radiologically and a stable estimate glomerular filtration rate, our surgical success rate was 100%.ConclusionsThe "omental wrapping" technique in laparoscopic and robotic onlay flaps or grafts ureteroplasty for long proximal or middle ureteral strictures is an efficient, safe, reproducible and simple technique.
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Project description:Chronic osteomyelitis is difficult to resolve and usually requires radical debridement, filling of dead space, and a well-vascularized tissue to cover the involved bone. In the tibia, this is frequently accomplished with free vascularized muscle transfer and success rates over 90% for cases of limited involvement but lower success for diffuse involvement. Elbow joints, with advanced arthritis but ineligible for total joint replacement, have been treated with interposition arthroplasty and varying degrees of success limited primarily by instability. A 46-year-old male presented with diffuse osteomyelitis of all three bones at the elbow joint and advanced articular destruction from septic arthritis. He had undergone more than ten previous surgeries without resolution of the osteomyelitis or restoration of elbow function over a 2-year period. Radical debridement followed by a latissimus dorsi free muscle flap interposed to the dead space and layered onto the bones as an interposition membrane was able to solve both of his problems. At 3 years postoperatively, there is no evidence of recurrent osteomyelitis, and the patient declares satisfaction with the daily functional performance of his elbow joint.
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Project description:Myocardial restoration using tissue-engineered grafts to regenerate the ischemic myocardium offers improved donor cell retention, yet a limited cell survival resulting from poor vascularization needs to be addressed. A cell type derived from the subamnion, namely, cord-lining mesenchymal stem cells (CL-MSC), has recently been identified. Here we present a restorative strategy that combines a fibrin graft containing human CL-MSC and omental flap providing, thereby, cell-, structural-, and angiogenic support to the injured myocardium. The graft consisted of a mixture of 2×10(6) CL-MSC-GFP-Fluc and fibrin. Myocardial infarction (MI) was induced in nude rats and following confirmation of ensued heart failure with echocardiography 2 weeks after injury, therapeutic intervention was performed as follows: untreated (MI, n=7), CL-MSC graft (CL-MSCG, n=8), CL-MSCG and omental flap (CL-MSCG+OM, n=11), and omental flap (OM, n=8). In vivo bioluminescence imaging at 1, 3, 7, and 14 days post-treatment indicated comparable early donor cell viability between the CL-MSCG and CL-MSCG+OM. Treatment with CL-MSCG+OM improved the myocardial function as assessed by the measurement of end-diastolic left ventricular (LV) pressure (3.53±0.34 vs. 5.21±0.54?mmHg, p<0.05), contractility (+dP/dt, 3383.8±250.78?mmHg vs. 2464.9±191.8?mmHg, p<0.05), and the relaxation rate (-dP/dt, -2707.2±250.7?mmHg vs. 1948.7±207.8?mmHg, p<0.05), compared to MI control 6 weeks after ischemic injury. Furthermore, evidence of a 20.32% increase in the ejection fraction was observed in CL-MSCG+OM rats from week 2 to 6 after injury. Both CL-MSCG and CL-MSCG+OM led to an enhanced cardiac output (p<0.05), and attenuated the infarct size (35.7%±4.2% and 34.7%±4.8%), as compared to MI (60.7%±3.1%; p<0.01 and p<0.001, respectively). All treated groups had a higher arteriole density than controls. Yet, a higher amount of functional blood vessels, and a 20-fold increase in arteriole numbers were found in CL-MSCG+OM. Altogether, CL-MSCGs supplemented with vascular supply have the potential to repair the failing, chronically ischemic heart by improving myocardial revascularization, attenuating remodeling, and ameliorating cardiac dysfunction.
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Project description:The morbidly obese patient has few reliable options if a single free flap is required for large surface area coverage. Usually, a latissimus dorsi muscle would be the primary option. If unavailable, a transverse-oriented abdominal flap based on deep inferior epigastric perforators as either a perforator flap or a muscle sparing type 2 transverse rectus abdominis musculocutaneous flap would be an alternative. A central panniculectomy type approach allows primary donor site closure by the cephalad advancement of the intentionally retained ptotic portion of the panniculus. Inclusion of the umbilicus with the free flap, which in this patient subgroup often is at risk for complications if excluded, mitigates against the need for undermining of the upper abdomen. The umbilicus free flap, as part of a panniculectomy, not only minimizes intrinsic flap risks, but also those of the abdominal donor site.
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Project description:Due to the significant morbidity and mortality associated with pharyngocutaneous fistula in pharyngoesophageal reconstruction following cancer resection, the purpose of this retrospective study is to examine the selection of tubed skin flaps that impact anastomotic integrity. The flaps evaluated included radial forearm flap versus anterolateral thigh flap, and fasciocutaneous anterolateral thigh flap versus chimeric anterolateral thigh flap. The outcome of interest is the incidence of pharyngocutaneous fistula. The radial forearm group had a significantly higher rate of fistula than the anterolateral thigh group (56.6% vs. 30.2%, p = 0.03). No significant difference in the incidence of fistula was demonstrated between fasciocutaneous and chimeric anterolateral thigh flap (36.8% vs. 25%, p = 0.51). The anastomotic integrity in pharyngoesopharyngeal reconstruction is affected by choice of skin flaps. Anterolateral thigh flap appears to be a viable option for pharyngoesophageal reconstruction. The more technical demand of the anterolateral thigh flap must be weighed against an easily harvested radial forearm flap.
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Project description:The increasing frequency of early breast cancer cases has driven an increasing number of patients to choose immediate reconstruction with an autologous flap. Omentum-flap-based breast reconstruction is a unique strategy that is highly suitable for repairing moderate tissue defects. However, all available evidence comes from individual reports with small numbers of cases, and the overall effectiveness and safety of the procedure have yet to be reported. Here, we reported 7 cases of laparoscopically harvested omental free flap breast reconstruction and performed a systematic review to assess the applicability and safety of this approach. The data were gathered from MEDLINE, Ovid, Google Scholar and the China Knowledge Resource Integrated Database. In total, we combined 15 articles (410 cases) for analysis. The data revealed that almost all patients (87.6%) were reported to have undergone laparoscopy instead of laparotomy; pedicle flaps were used in 90.9% of the cases, while only 5 (37 cases) used free flaps for reconstruction; and 96.6% (396/410) of all reconstruction procedures were immediate. Almost all of these cases had a small tumour burden (T0/Tis/T1 59.8%; T2 36.8%), and the distribution of tumour location was similar among the four quadrants. The cosmetic outcomes were desirable in most cases (83.9%). There were 41 complications identified in the dataset: partial graft necrosis accounted for the largest percentage (41.5%) of all events, followed by skin necrosis (19.5%), haematoma (12.2%) and wound infection (9.8%). During the follow-up period, which had a short median duration, 2 cases of tumour recurrence were reported. Overall, our systematic review found that omentum-flap-based breast reconstruction could achieve a satisfactory aesthetic outcome, especially for small breasts and tissue replacement after breast-conserving surgery, and the safety of the procedure was also acceptable.
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Project description:BackgroundMale genital skin loss is a common disease in urology. However, male genital skin loss accompanying a penile urethra defect is rarely reported. Herein, we describe a novel surgical technique using a composite local flap and oral mucosal graft to reconstruct the penis, which may provide a new solution for patients with similar conditions.Case presentationA 36-year-old male with a penile urethra defect and a large area of genital skin loss required urethral reconstruction. The meatus had descended to the penoscrotal junction. This procedure was divided into three stages. The first stage of the surgery involved burying the nude penile shaft beneath the skin of the left anteromedial thigh for coverage of the skin defect. The second stage consisted of releasing the penis and expanding the size of the urethral plate for further urethroplasty. The third stage consisted of reconstruction of the anterior urethra 6?months later. Postoperatively, the patient reported satisfactory voiding. The maximal flow rate (MFR) was 22.2?ml/s with no postvoiding residual urine at the 24-month follow-up visit. No edema, infection, hemorrhage, or cicatricial retraction were observed. The patient's erectile function was satisfactory, and his international index of erectile function-5 score (IIEF-5 score) was 23 at the 24-month follow-up visit. Additionally, the presence of nocturnal penile tumescence demonstrated that he had normal erectile function.ConclusionsThis procedure is an effective surgical option for men with complete foreskin and penile urethra defects. It could also be extended as a treatment strategy when composite local or pedicle transposition flaps and free grafts are needed for specific patients.
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Project description:BackgroundThe radial forearm free flap (RFFF) serves as a workhorse for a variety of reconstructions. Although there are a variety of surgical techniques for donor site closure after RFFF raising, the most common techniques are closure using a split-thickness skin graft (STSG) or a full-thickness skin graft (FTSG). The closure can result in wound complications and function and aesthetic compromise of the forearm and hand. The aim of the planned systematic review and meta-analysis is to compare the wound-related, function-related and aesthetics-related outcome associated with full-thickness skin grafts (FTSG) and split-thickness skin grafts (STSG) in radial forearm free flap (RFFF) donor site closure.MethodsA systematic review and meta-analysis will be conducted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be followed. Electronic databases and platforms (PubMed, Embase, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI)) and clinical trial registries (ClinicalTrials.gov, the German Clinical Trials Register, the ISRCTN registry, the International Clinical Trials Registry Platform) will be searched using predefined search terms until 15 January 2024. A rerun of the search will be carried out within 12 months before publication of the review. Eligible studies should report on the occurrence of donor site complications after raising an RFFF and closure of the defect. Included closure techniques are techniques that use full-thickness skin grafts and split-thickness skin grafts. Excluded techniques for closure are primary wound closure without the use of skin graft. Outcomes are considered wound-, functional-, and aesthetics-related. Studies that will be included are randomized controlled trials (RCTs) and prospective and retrospective comparative cohort studies. Case-control studies, studies without a control group, animal studies and cadaveric studies will be excluded. Screening will be performed in a blinded fashion by two reviewers per study. A third reviewer resolves discrepancies. The risk of bias in the original studies will be assessed using the ROBINS-I and RoB 2 tools. Data synthesis will be done using Review Manager (RevMan) 5.4.1. If appropriate, a meta-analysis will be conducted. Between-study variability will be assessed using the I2 index. If necessary, R will be used. The quality of evidence for outcomes will eventually be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.DiscussionThis study's findings may help us understand both closure techniques' complication rates and may have important implications for developing future guidelines for RFFF donor site management. If available data is limited and several questions remain unanswered, additional comparative studies will be needed.Systematic review registrationThe protocol was developed in line with the PRISMA-P extension for protocols and was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 17 September 2023 (registration number CRD42023351903).
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