Abstract Cavernostomy and fenestration were performed in a patient who developed a lung abscess and empyema in the left lung, which was damaged after multimodality therapy for advanced thymoma. The hospitalized patient suddenly experienced cardiopulmonary arrest due to major bleeding from the left main pulmonary artery. We immediately performed the main pulmonary arterial embolization, and the patient was resuscitated. Subsequently, the patient underwent supercharged free omental flap plombage performed in the following manner: first, laparoscopic harvesting of the omentum was performed in the supine position. Then, the right gastroepiploic artery and vein were anastomosed with the left axillary artery and vein, respectively. The lung cavity, bleeding point of the pulmonary artery and the surface of the artificial pericardium were filled and covered by the supercharged omentum, and the skin was closed. The postoperative course was uneventful. The patient has had no bleeding, recurrence of empyema and thymoma or skin abnormalities at 36 months postoperatively. Supercharged free omental flap plombage was a useful option for treatment of an intractable chest infection involving an artificial pericardium. Omental plombage, Supercharging technique, Empyema, Artificial material INTRODUCTION Sufficient omental plombage cannot be performed in some cases when there is a long distance between the abdomen and the infected site. This problem can be solved by using the ‘supercharging’ technique, similar to that used in oesophageal reconstruction , which involves anastomosing the right gastroepiploic artery and vein of free omentum with other vessels. This is the first report of a patient with an intractable lung abscess and empyema involving an artificial pericardium that was successfully treated by plombage using supercharged free omentum [supercharged free omental flap plombage (SFOFP)]. CASE PRESENTATION The patient was a 67-year-old man. Nine years ago, the patient underwent preoperative chemoradiotherapy for Masaoka Stage IVa thymoma, followed by extended thymectomy and combined partial resection of the left upper lung, pericardium, pleura and diaphragm. The pericardium was extensively reconstructed with an expanded polytetrafluoroethylene (Gore-Tex®: LW. L. Gore & Associates, Inc., AZ, USA) patch. As pleural recurrence occurred, the patient subsequently underwent repeated chemotherapy and radiotherapy. The residual left upper lobe of the lung was gradually damaged, and a cavity emerged inside it. Purulent discharge from the skin of the upper left anterior chest at the cavity site was observed. Staphylococcus was identified in the pus. Chest computed tomography revealed fluid collection in the cavity of the damaged lung (Fig. 1A). It also revealed that the discharge site and the cavity were connected (Fig. 1B). We performed cavernostomy and fenestration along the fistula of the discharge because pus was found between the chest wall and the surface of the artificial pericardium. Figure 1: View largeDownload slide (A) Fluid collection in the lung cavity. (B) The infected cavity and discharge site of the skin were connected. (C) The pulmonary artery bleeding point (arrow) could be pressed down from the fenestration site. (D) Coil embolization of the left main pulmonary artery (arrow). Figure 1: View largeDownload slide (A) Fluid collection in the lung cavity. (B) The infected cavity and discharge site of the skin were connected. (C) The pulmonary artery bleeding point (arrow) could be pressed down from the fenestration site. (D) Coil embolization of the left main pulmonary artery (arrow). The patient’s general condition was stable with no fever, and there was no recurrence of thymoma. Therefore, we planned to perform plombage using the patient’s own biological tissues after the infection had been controlled. However, major bleeding from the left main pulmonary artery occurred suddenly after 1 month of fenestration during his hospitalization. Accordingly, we immediately performed coil embolization of the left main pulmonary artery after resuscitation (Fig. 1C and D). The patient recovered without any damage, and there were no symptoms of lung necrosis or infection for 3 months after pulmonary artery embolization. In addition, no infection was found within the pericardium. Hence, we attempted SFOFP. SURGICAL TECHNIQUE Laparoscopic harvesting of the omentum was performed with the patient in the supine position. Systemic heparinization was then performed before treating the right gastroepiploic artery and vein. The left axillary skin was incised to expose the axillary artery and vein. The right gastroepiploic artery and vein were anastomosed with the left axillary artery and vein, respectively, and sufficient blood flow was confirmed with a rheometer. The skin and the infected chest wall around the infected cavity were resected as much as possible. The lung cavity, bleeding point of the pulmonary artery and the surface of the artificial pericardium were filled and covered by the supercharged omentum. The omentum was secured to surrounding tissues to prevent it from kinking. Three drains were placed under the skin, and the skin was closed. The operation time was 326 min, and the amount of bleeding was 560 ml (Video 1). The postoperative course was uneventful. Good blood flow in the omentum was confirmed by computed tomography (Fig. 2A). The patient has had no bleeding, recurrence of empyema or thymoma, or abnormality in the skin at 36 months postoperatively (Fig. 2B) and is currently receiving outpatient treatment with an anticoagulant agent. Figure 2: View largeDownload slide (A) The most recent postoperative computed tomography scan image. (B) The most recent appearance of the anterior chest. Figure 2: View largeDownload slide (A) The most recent postoperative computed tomography scan image. (B) The most recent appearance of the anterior chest. Video 1 Supercharged free omental flap plombage for empyema in a patient with an artificial pericardium. Video 1 Supercharged free omental flap plombage for empyema in a patient with an artificial pericardium. Close COMMENTS Treatment is always difficult when empyema occurs after surgery using an artificial material. In addition, fatal bleeding can occur if patients with a lung abscess or empyema are treated only by cavernostomy or fenestration. Generally, infected artificial materials must be removed. However, there are some reports of thoracic aortic prosthetic graft infections being successfully managed by autologous tissue, frequently from the omentum . The activated omentum releases a potent mixture of growth factors including vascular endothelial growth factor, basic fibroblast growth factor and stromal cell-derived 1α, which facilitate adhesion and growth of new blood and lymphatic vessels, ensuring a fresh blood supply that protects the tissue from ischaemic damage and infection . In our case, the infected cavity was located between the left clavicle and the nipple. Therefore, it was deemed advantageous to use free omentum rather than the pedicled omentum to fill the infected cavity and cover the artificial pericardium because the distance from the left axilla was closer than that from the stomach. Shimizu et al.  reported that SFOFP was useful after cavernostomy for the treatment of an intractable lung abscess. Thus, we used SFOFP and consequently succeeded in controlling the infection and bleeding. In addition, the residual lung did not develop necrosis or infection after pulmonary artery embolization. This is presumably because the blood flow of the bronchial artery and the pulmonary vein was sustained. CONCLUSION In conclusion, SFOFP was a useful option for treatment of intractable chest infection involving an artificial pericardium. Conflict of interest: none declared. REFERENCES 1 Ascioti AJ , Hofstetter WL , Miller MJ , Rice DC , Swisher SG , Vaporciyan AA et al. . Long-segment, supercharged, pedicled jejunal flap for total esophageal reconstruction . J Thorac Cardiovasc Surg 2005 ; 130 : 1391 – 8 . Google Scholar CrossRef Search ADS PubMed 2 Tossios P , Karatzopoulos A , Tsagakis K , Sapalidis K , Grosomanidis V , Kalogera A et al. . Treatment of infected thoracic aortic prosthetic grafts with the in situ preservation strategy: a review of its history, surgical technique, and results . Heart Lung Circ 2014 ; 23 : 24 – 31 . Google Scholar CrossRef Search ADS PubMed 3 Vernik J , Singh AK. Omentum: power to heal and regenerate . Int J Artif Organs 2007 ; 30 : 95 – 9 . Google Scholar CrossRef Search ADS PubMed 4 Shimizu J , Arano Y , Adachi I , Ikeda C , Ishikawa N , Ohtake H. Intractable lung abscess successfully treated with cavernostomy and free omental plombage using microvascular surgery . Gen Thorac Cardiovasc Surg 2009 ; 57 : 616 – 21 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Interactive CardioVascular and Thoracic Surgery – Oxford University Press
Published: Feb 2, 2018
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