Cranial transposition and revascularization of autologous omentum: a novel surgical technique for resection of recurrent glioblastoma multiforme.

Glioblastoma multiforme (GBM) patients continue to suffer a poor prognosis. The blood brain barrier (BBB) comprises one of the obstacles for therapy, creating a barrier that decreases the bioavailability of chemotherapeutic agents in the central nervous system. Previously, a vascularized temporoparietal fascial scalp flap (TPFF) lining the resection cavity was introduced in a trial conducted in our institution, in newly-diagnosed GBM patients in an attempt to bypass the BBB after initial resection. In this paper, we report on a new technique to bypass the BBB after re-resection and potentially to allow tumor antigens to be surveilled by the immune system. The study aims to assess the feasibility of performing a cranial transposition and revascularization of autologous omentum after re-resection of GBM. Laparoscopically harvested omental free flap was transposed to the resection cavity by a team consisting of neurosurgeons, otolaryngologists, and general surgeons. This was done as part of a single center, single arm, open-label, phase I study. Autologous abdominal omental tissue was harvested laparoscopically on its vascularized pedicle in 2 patients, transposed as a free flap, revascularized using external carotid artery, and carefully laid into the tumor resection cavity. Patients did well postoperatively returning to baseline activities. Graft viability was confirmed by cerebral angiogram. Omental cranial transposition of a laparoscopically harvested, vascularized flap, into the cavity of re-resected GBM patients is feasible and safe in the short term. Further studies are needed to ascertain whether such technique can improve progression free survival and overall survival in these patients.

Flowthrough Omental Flap for Vascularized Lymph Node Transplant of the Lower Extremity.

SUMMARY: Vascularized lymph node transplantation is a surgical approach for the treatment of chronic lymphedema. However, there is no clinical standard for flap placement nor vascular anastomoses. The authors propose a novel flowthrough configuration for an omental vascularized lymph node transplant in the popliteal space. To prepare the popliteal space for an omental free flap, the medial popliteal fat pad and medial head of the gastrocnemius muscle were debulked. Venous anastomoses were completed with vein couplers, joining the right gastroepiploic vein to the medial sural venae comitantes and the left gastroepiploic vein to the lesser saphenous vein. Arterial anastomoses were hand sewn, joining the right gastroepiploic artery to the proximal medial sural artery and the left gastroepiploic artery to the distal medial sural artery, to create the flowthrough configuration. A retrospective review of patients who underwent this procedure at a single institution was performed. Six patients with chronic lymphedema of the lower extremity underwent vascularized lymph node transplantation from June of 2019 to November of 2020. Five patients underwent at least 3 months of postoperative surveillance, with no postoperative complications reported. In this technique contribution, the authors describe a novel flowthrough configuration for an omental free flap to the popliteal space. The popliteal space offers an aesthetically favorable recipient location when appropriately prepared. The medial sural vessels are ideal recipient vessels for the flowthrough omental flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Homoinjerto de epiplón en paciente con quemadura eléctrica y exposición de hueso / Homograft of omentum in patient with electrical burn and exposure of bone

Introducción: las quemaduras son traumas ocasionados, generalmente por exposición térmica, radioactiva, eléctrica o química. Presentación del caso: paciente masculino de 17 años que sufre accidentalmente quemadura eléctrica de alto voltaje. En la mano derecha, por su evolución desfavorable y lesiones hipodérmicas con compromiso vascular fue necesaria la amputación de la mano. A nivel del pie derecho se eliminó el tejido necrótico quedando la falange distal del grueso artejo expuesta. Al lograr un tejido de granulación útil se realiza homoinjerto de epiplón. Discusión: el epiplón es un donador natural de factores de crecimiento. El injerto de epiplón mostró su utilidad para proteger pequeñas partes óseas expuestas, favoreciendo el mejoramiento del tejido de granulación, el control de la infección local y la cicatrización. Conclusiones: la utilización del homoinjerto de epiplón es una alternativa viable para cubrir zonas cruentas pequeñas con hueso expuesto, favoreciendo el tejido de granulación y la cicatrización(AU)

Introduction: burns are trauma caused, usually by thermal, radioactive, electrical, or chemical exposure. Presentation of the case: a 17-year-old male patient accidentally suffers a high voltage electrical burn. In the right hand, due to its unfavorable evolution and hypodermic lesions with vascular compromise, the amputation of the hand was necessary. At the level of the right foot, the necrotic tissue was removed, leaving the distal phalanx of the thick exposed thick finger. Once a useful granulation tissue is achieved, omentum homograft is performed. Discussion: the omentum is a natural donor of growth factors. The omentum graft showed its usefulness to protect small exposed bone parts, favoring the improvement of the granulation tissue, the control of local infection and healing. Conclusions: the use of omental homograft is a viable alternative to cover small bloody areas with exposed bone, favoring granulation tissue and healing(EU)

The Application of an Omentum Graft or Flap in Spinal Cord Injury.

BACKGROUND: Spinal cord injury (SCI) causes a primary injury at the lesion site and triggers a secondary injury and prolonged inflammation. There has been no definitive treatment till now. Promoting angiogenesis is one of the most important strategies for functional recovery after SCI. The omentum, abundant in blood and lymph vessels, possesses the potent ability of tissue regeneration. METHODS: The present work examines the efficacy of autologous omentum, either as a flap (with vascular connection intact) or graft (severed vascular connection), on spinal nerve regeneration. After contusive SCI in rats, a thin sheath of omentum was grafted to the injured spinal cord. RESULTS: Omental graft improved behavior scores significantly from the 3rd to 6th week after injury (6th week, 5.5 ± 0.5 vs. 8.6 ± 1.3, p < 0.05). Furthermore, the reduction in cavity and the preservation of class III ß-tubulin-positive nerve fibers in the injury area was noted. Next, the free omental flap was transposed to a completely transected SCI in rats through a pre-implanted tunnel. The flap remained vascularized and survived well several weeks after the operation. At 16 weeks post-treatment, SCI rats with omentum flap treatment displayed the preservation of significantly more nerve fibers (p < 0.05) and a reduced injured cavity, though locomotor scores were similar. CONCLUSIONS: Taken together, the findings of this study indicate that treatment with an omental graft or transposition of an omental flap on an injured spinal cord has a positive effect on nerve protection and tissue preservation in SCI rats. The current data highlight the importance of omentum in clinical applications.

Intrathoracic transposition of the omentum.

Complex chest and lung infections with bronchial fistula are life-threatening situations with a mortality rate of up to 20%. If medical treatment fails, these patients require aggressive procedures to heal. Transposition of the omentum is a valuable, nonstandard option in these complex cases with aggressive infection involving the pleural space, with or without a bronchial fistula, when medical treatment is unsuccessful. We present a 29-year-old female patient diagnosed with primary immunodeficiency and invasive fungal infection with involvement of the left upper lobe and mediastinal and vertebral bodies treated with a lobectomy and intrathoracic transposition of the omentum.

Vascularized omental lymphatic transplant for upper extremity lymphedema: A systematic review.

BACKGROUND: Vascularized omental lymphatic transplant (VOLT) is an increasingly popular treatment of extremity lymphedema given its promising donor site. While the success of VOLT in the treatment of lymphedema has been reported previously, several questions remain. AIM: To further elucidate appropriate use of VOLT in the treatment of lymphedema, specifically addressing patient selection, harvest technique, and operative methods. METHODS AND RESULTS: A systematic review of VOLT for upper extremity lymphedema was performed. Of 115 yield studies, seven were included for analysis based on inclusion and exclusion criteria. Included studies demonstrated significant reductions in extremity circumference/volume (average volume reduction, 22.7%-39.5%) as well as subjective improvements using patient-reported outcomes. Though studies are heterogenous and limited, when analyzed in aggregate, suggest the efficacy of VOLT in lymphedema treatment. CONCLUSION: This is the largest systematic review of VOLT to date. VOLT continues to show promise as a safe and efficacious surgical intervention for lymphedema in the upper extremity. Further studies are warranted to more definitively identify patients for whom this technique is appropriate as well as ideal harvest and inset technique.

[Multi-component multi-stage treatment of a patient with infection of thoracic aorta prosthesis, deep sternal wound infection and soft tissue deficit of the chest]. / Mnogokomponentnoe, mnogoetapnoe lechenie patsientki s infektsiei proteza vsei grudnoi aorty, osteomielitom grudiny i defitsitom myagkikh tkanei grudnoi kletki.

We report a comorbid patient after redo Frozen Elephant Trunk procedure followed by recurrent infection of thoracic aortic prosthesis, deep sternal wound infection and extensive soft tissue defect. Closure with skin-muscle thoracodorsal flap and graft-sparing technique with omentoplasty is an alternative to total graft replacement for thoracic aortic graft infection in comorbid patients with concomitant extensive defect of the chest wall or recurrent infection in early postoperative period.

[Treatment of recurrent traumatic sternomediastinitis after cardiac surgery]. / Lechenie retsidivnogo travmaticheskogo sternomediastenita posle kardiokhirurgicheskikh operatsii.

OBJECTIVE: To assess the possibilities of omentoplasty for prevention of complications after redo sternum osteosynthesis for traumatic rupture. MATERIAL AND METHODS: The study included 53 patients with recurrent sternal diastasis. Greater omentum was additionally implanted in 19 (35.8%) cases to improve healing and reduce the risk of infectious complications. In 34 patients, redo osteosynthesis was carried out using a metal wire and deployment of irrigation-aspiration system. In 19 patients, omentoplasty was additionally used to close the wound. RESULTS: Omentoplasty was characterized by less duration of lavage (7.4±1.5 vs. 4.2±3.3 days, p<0.0001) and no cases of arrosive bleeding (p=0.04). CONCLUSION: Omentoplasty reduces duration of treatment and risk of arrosive bleeding.

Induced organoids derived from patients with ulcerative colitis recapitulate colitic reactivity.

The pathogenesis of ulcerative colitis (UC), a major type of inflammatory bowel disease, remains unknown. No model exists that adequately recapitulates the complexity of clinical UC. Here, we take advantage of induced pluripotent stem cells (iPSCs) to develop an induced human UC-derived organoid (iHUCO) model and compared it with the induced human normal organoid model (iHNO). Notably, iHUCOs recapitulated histological and functional features of primary colitic tissues, including the absence of acidic mucus secretion and aberrant adherens junctions in the epithelial barrier both in vitro and in vivo. We demonstrate that the CXCL8/CXCR1 axis was overexpressed in iHUCO but not in iHNO. As proof-of-principle, we show that inhibition of CXCL8 receptor by the small-molecule non-competitive inhibitor repertaxin attenuated the progression of UC phenotypes in vitro and in vivo. This patient-derived organoid model, containing both epithelial and stromal compartments, will generate new insights into the underlying pathogenesis of UC while offering opportunities to tailor interventions to the individual patient.

Omental patch versus gastric resection for perforated gastric ulcer: Systematic review and meta-analysis for an unresolved debate.

BACKGROUND: Perforated gastric ulcers are surgical emergencies with paucity of data on the preferred treatment modality of resection versus omental patch. We aim to compare outcomes with ulcer repair and gastric resection surgeries in perforated gastric ulcers after systematic review of literature. METHODS: A systematic literature search was performed for publications in PubMed Medline, Embase, and Cochrane Central Register of Controlled Trials. We included all studies which compared ulcer repair vesus gastric resection surgeries for perforated gastric ulcers. We excluded studies which did not separate outcomes gastric and duodenal ulcer perforations. RESULTS: The search included nine single-institution retrospective reviews comparing ulcer repair (449 patients) versus gastric resection surgeries (212 patients). Meta-analysis was restricted to perforated gastric ulcers and excluded perforated duodenal ulcers. The majority of these studies did not control for baseline characteristics, and surgical strategies were often chosen in a non-randomized manner. All of the studies included were at high risk of bias. The overall odds ratio of mortality in ulcer repair surgery compared to gastric resection surgery was 1.79, with 95% CI 0.72 to 4.43 and p-value 0.209. CONCLUSION: In this meta-analysis, there was no difference in mortality between the two surgical groups. The overall equivalence of clinical outcomes suggests that gastric resection is a potentially viable alternative to ulcer repair surgery and should not be considered a secondary strategy. We would recommend a multicenter randomized control trial to evaluate the surgical approach that yields superior outcomes. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

Enxerto pediculado de omento maior como adjuvante no tratamento de osteomielite de tíbia em cão - relato de caso / [Greater omentum pedicle flap as adjunctive treatment of tibial osteomyelitis in a dog - case report]

A osteomielite é um desafio terapêutico em ortopedia, capaz de retardar ou mesmo impedir a consolidação óssea. O omento, há anos, tem sido empregado como alternativa em diferentes procedimentos cirúrgicos, por sua capacidade, entre outras, de angiogênese, sendo aplicado na ortopedia veterinária quando há o risco de não união óssea. Neste caso, um cão Fila Brasileiro foi submetido à realização de enxerto com retalho pediculado de omento maior, após osteomielite resistente presente em osteossíntese de fratura múltipla de tíbia aberta grau II. Durante 16 dias, manteve-se a comunicação do retalho, mas, diante do risco de peritonite, o pedículo foi seccionado. Numa sequência de intervenções cirúrgicas, após 89 dias, houve cicatrização óssea e remissão da osteomielite, mesmo na presença de bactérias multirresistentes. Neste relato, o omento foi efetivo como terapia adjuvante no tratamento da osteomielite e garantiu o retorno da função do membro.(AU)

Osteomyelitis is a therapeutic challenge in orthopedics, capable of delaying or even preventing bone healing. The omentum has been used in different surgical procedures as an alternative for its capacity, among others, of angiogenesis, being applied in veterinary orthopedics, when there is a risk of non-union of bone. In this case, a Brazilian row dog was submitted to grafting with pedicle flap of greater omentum, after resistant osteomyelitis present in open fracture osteosynthesis of open tibia grade II. For 16 days the communication of the flap was maintained, but at the risk of peritonitis, the pedicle was sectioned. In a sequence of surgical interventions, after 89 days, there was bone healing and remission of osteomyelitis, even in the presence of multi-resistant bacteria. In this report, the omentum was effective as adjuvant therapy in the treatment of osteomyelitis and guaranteed the return of limb function.(AU)

Successful treatment of thoracic aortic graft infection by omental flap following vacuum-assisted closure therapy.

BACKGROUND: Postoperative thoracic aortic graft infection (TAGI) is a serious and potentially fatal complication. The classical approach is to replace the infected graft. However, this approach has a high mortality rate. Alternatively, treatment of TAGI without graft replacement can be performed METHOD: Herein, we present a 72-year-old case with mediastinitis and graft infection after type A aortic dissection operation and successful treatment using omental flap coverage following vacuum-assisted wound closure therapy without graft replacement. CONCLUSION: The patient had an uneventful postoperative course and remains infection-free to date.

Technical details for harvesting gastro-epiploic lymph node flaps via mini-laparotomy incision.

Laparoscopic harvest method to obtain gastro-epiploic lymph node flaps for lymphedema treatment has been previously described. In this article, the technical details of an alternative method - open approach via mini-laparotomy incision - for harvesting gastro-epiploic lymph node flaps and preparation of the flaps for the inset is presented. A total of 17 patients were included in this series of the mini-laparotomy approach. Blood loss was minimal during the surgery. The average duration of lymph node flap harvest was 65 min. The average length of hospital stay was 10 days. The period of the restricted diet was 1.5 days. The upper abdominal scar was acceptable, there were no postoperative hernia or bulging, and there were no complications related to bowel obstruction during the follow-up. The open approach harvest method via mini-laparotomy incision offers similar results to laparoscopic harvest method, and it is safe when applied with the right technique.

Use of Omental Flap for Treating Cardiocutaneous Fistula After Ventricular Aneurysm Repair.

Infection of an endoventricular patch used for left ventricular aneurysm repair with formation of cardiocutaneous fistula is a rare but potentially serious complication. We report an adult patient who developed a cardiocutaneous fistula 1 year after repair of a third left ventricular aneurysm. The patient was successfully treated with a redo operation using a bovine pericardial patch with omental flap coverage. He is alive and well 10 years later.

In-vivo regeneration of bladder muscular wall with whole decellularized bladder matrix: A novel hourglass technique for duplication of bladder volume in rabbit model.

OBJECTIVE: To determine histological aspects of decellularized bladder graft to achieve a double-sized bladder by novel hourglass technique; using rabbit models. METHODS: Sixteen rabbit bladders were decellularized and underwent laboratory investigations. After making a laparotomy incision and exposure of bladders in another 16 rabbits (partial detrusor myomectomy), they were separated into two groups. The fundus of the decellularized scaffold was anastomosed to the fundus of the native bladder via the serosal layer, and the omentum and a double-J stent were placed in the decellularized bladder by no direct contact with the urine (Group A, n=8). In group B (n=8), the bladder was augmented applying the decellularized bladder that was in contact with the urine. After 6 months, the omentum was brought out of the neck of the engineered bladder and the anastomosis was opened. Biopsies were taken at 1, 3, and 9 months postoperatively. RESULTS: Cell removal with preservation of extracellular matrix structure was confirmed in decellularized bladders. Histological examination after 1 month demonstrated few cells at the border of the grafts. After 3 months, the region of the graft was indistinguishable from the natural bladder with continuity of transitional epithelium of natural bladder on the decellularized grafted scaffolds. The organization of muscle layers was similar to native bladder muscle layers after 9 months. IHC staining markers were highly expressed after 9 months. Interestingly, bladders had a high fibrosis grade in group B compared with hourglass technique. CONCLUSION: We confirmed that decellularized bladder may be a reliable scaffold and viable material for bladder augmentation.

Treatment of a femoral septic nonunion in a dog with interlocking nail stabilization associated to corticospongious bone autograft and greater omentum flap: case report / Tratamento de não união séptica femoral em cão com estabilização com haste intramedular bloqueada associada a autoenxerto de osso corticoesponjoso e retalho do omento maior: relato de caso

Chronic septic bone nonunion requires a well-designed therapeutic planning, demanding a multimodal treatment to achieve bone consolidation and elimination of infection. A successful case of an association of the major omentum flap with surgical stabilization with an interlocking nail for treatment of a femoral septic nonunion in dog is reported. The patient had partial functional return of the limb 30 days after surgery, negative bacterial culture with radiographic signs of bone healing and total functional return of the limb at 90th days after the surgical procedure.(AU)

Não uniões ósseas associadas à osteomielite crônica necessitam de um planejamento terapêutico muito bem realizado, demandando tratamento multimodal para conseguir atingir a consolidação óssea e eliminar a infecção. Relatou-se um caso de sucesso do uso da associação de retalho do omento maior com estabilização cirúrgica com haste intramedular bloqueada para tratamento de uma não união séptica de fêmur em cão. O paciente apresentou retorno funcional parcial do membro com 30 dias após a cirurgia, cultura bacteriana estéril com sinais radiográficos de consolidação óssea e retorno funcional total do membro aos 90 dias de pós-operatório.(AU)

Free gastroepiploic lymph nodes and omentum flap for treatment of lower limb ulcers in severe lymphedema: Killing two birds with one stone.

BACKGROUND AND OBJECTIVES: In patients with lymphedema, the disruption of the lymphatic network increases skin turgor and fibrosis of subcutaneous tissue, delays wound healing, causing recurrent ulcerations and infections. In these cases, management of ulcers can be challenging. METHODS: Between January 2016 and June 2018, patients presenting with lymphedema were enrolled at our Institution. We selected patients with severe lymphedema and ulcers of lower limbs and we performed a surgical approach, involving free gastroepiploic lymph nodes and omentum flap, harvested through laparoscopy. RESULTS: We enrolled 135 patients presenting for lymphedema. Among them, 10 eligible cases underwent excision of the ulcer and reconstruction with omentum flap. Mean age was 57.8 years and average follow-up 24.1 months. Circumferences and skin tonicity significantly decreased from the preoperative period. Lymphoscintigraphy showed improvement of the lymphatic drainage and restoration of lymphatic network. No episodes of infection were recorded in the postoperative period. CONCLUSIONS: Our combined procedure merges free flap techniques and lymphedema surgery: omentum covers the defect while providing a new source of lymph nodes, improving the lymphatic networks of the affected limb. This technique can highly increase the quality of life of the patient in a single-stage operation with fast recovery and low donor site morbidity.