Outcome following Sternal Reconstruction with the Omental Flap
12 August 2018 (online)
The article by Kolbenschlag et al is a significant contribution to the limited literature available on this topic for several reasons.
The omental flap, in carefully selected patients and properly executed, saves lives as this cohort demonstrates. Yet, half of the cohort had had one or more failed reconstructive attempts with an alternative flap. Had preference been given to an omental flap earlier mortality may have been lower still. In patients with poststernotomy mediastinitis, the omentum is sadly still widely regarded as the ultimum refugium. Yet, a recent and first study to combine the level of evidence with the level of recommendation, showed the omentum to be eminently suitable for a delayed primary reconstruction in early cases.
Another valuable observation emanating from the current study is, it demonstrates that, in due course, the vascular pedicle of the transposed omentum becomes independent. Knowledge of dependence is relevant where re-entry for either reoperative cardiac surgery or repair of a hernia is ineluctable. Whether the vascular pedicle of the omental flap can be safely divided on re-entry of the chest has so far been inadequately addressed. Various other types of flap have been shown to maintain long-term dependence on the vascular pedicle. The author's cohort of 6 patients provides further evidence of the safety of transecting the vascular pedicle to the intrathoracic omental flap and lends valuable support to a previous study.
The authors seem to suggest that bleeding from the upper GI tract early in the postoperative course may have been related to the severance of one of the gastroepiploic vessels during harvesting of the omentum. This is possible, yet unlikely. Gastric ischemic conditioning studies have shown that only the microcirculation of the fundus decreases but recovers within 4 to 5 days. Also, if there is indeed a relationship between temporary reduction of the gastric microcirculation and an early bleeding, one would have expected it to be reported in one or more of the larger series as a potential complication of harvesting of one of the gastroepiploic vessels for coronary artery bypass grafting—which is not the case.
Vascular severance is one issue and vascular compromise is another. Wound healing problems following omental flap reconstruction necessitated a subsequent debridement in 44% of the current cohort. The most likely cause was vascular pedicle compromise. High-resolution, gray-scale, and color Doppler ultrasonography in the immediate postoperative setting could assist in the early diagnosis of such compromise.
Finally, herniation can be a serious problem. Prevention of a sliding hernia is more challenging than an abdominal wall herniation. Complete release of the omentum from the colon, transdiaphragmatic rather than subcutaneous routing, and intrathoracic anchoring of the omentum, may assist in prevention. So could splitting and wrap-around of either a sliver of omentum or the ligamentum teres.
Cure is not the same as healing. One in five patients in the current series suffered “intense pain” and/or remained in poor health. Of course, this is no cause to curse the cure. Without an omental flap, none would likely have survived. Attention to detail will mitigate accompanying technique-related problems. The authors should be complimented for complementing our current knowledge of a useful procedure.
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