The healing process of bronchial wound was compared among wrapping tissues such as pedicled omentum, pericardium, and parietal pleura in terms of the degrees of revascularization of the bronchial artery interrupted by bronchoplasty itself by microangiography, including the circumstances of performing a procedure of esophagectomy. The development of neovascularity was marked and facilitated by omentopexy. The procedure of wrapping by pedicled pericardium and pleura was not so useful for promoting neovascularity as would be expected, and it was almost the same as non-wrapping one. Meanwhile, recanalization by wrapping with free pleura was delayed. When esophagectomy was combined with bronchoplasty, revascularization was apparently retarded. In conclusion, wound healing at bronchial anastomosis was markedly impaired so that omentopexy was recommended for facilitating wound healing at anastomosis

Ayabe Hiroyoshi

Honda Hirotake

Kawahara Katsunobu

Kimino Koji

Nakasone Tomonori

Okada Daikichi

Sha Kamei

Taniguchi Hideki

Tomita Masao

Yasutake Tohru

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Acta Med. Nagasaki 33 : 87-90Benefit from omentopexy on bronchial wound healing      in performing concurrent esophagectomyMasao TOMITA, Hiroyoshi AYABE, Katsunobu KAWAHARA,      Koji KIMINO, Kamei SHA, Hideki TANIGUCHI, Tomonori NAKASONE, Hirotake HONDA, Tohru YASUTAKE                  Daikichi OKADA  The First Department of Surgery Nagasaki University School of Medicine Received for publication, May 23, 1988ABSTRACT : The healing process of bronchial wound was compared among wrapping tissues such as pedicled omentum, pericardium, and parietal pleura in terms of the degrees of revascularization of the bronchial artery interrupted by bron-choplasty itself by microangiography, including the circumstances of performing a procedure of esophagectomy.      The development of neovascularity was marked and facilitated by omentopexy. The procedure of wrapping by pedicled pericardium and pleura was not so useful for promoting neovascularity as would be expected, and it was almost the same as non-wrapping one. Meanwhile, recanalization by wrapping with free pleura was delayed. When esophagectomy was combined with bronchoplasty, revascularization was apparently retarded. In conclusion, wound healing at bronchial anastomosis was markedly impaired so that omentopexy was recommended for facilitating wound healing at anastomosis.       INTRODUCTION  It has been emphasized that satisfactory wound healing at bronchial anastomosis is en-sured by the adequate anastomosis that pro-vides sufficient blood supply at both edges of the bronchus without any tension. However, it is inevitable that bronchoplasty itself ensues the interruption of the bronchial artery and deteriorates wound healing by reduction of nu-tritional blood supply.  Furthermore, the posterior wall of the bron-chial tree was protected and supported by a presence of the esophagus which may also help to inflow the nutritional blood vessels into bi-lateral walls of the tracheobronchial tree. When thoracic esophageal cancer involves the trachea or the main bronchus, combined resec-tion of the trachea or main bronchus with esoph-agectomy is needed for ontological radicality. If combined resection with esophagectomy is made, tracheobronchial tree loses the posterior support. The wound healing at anastomosis will be also jeopardized by mediastinal dissec-tion which has often been used for enhancing oncologic radicality.  In fact, the wound healing at bronchial anas-tomosis performed with esophagectomy may have some danger, and our clinical experience is not yet satisfactory.  In this present study, usefulness of omentpexy is experimentally evaluated by using microangi-ography, in particular, under the condition thatesophagectomy was combined.     METHOD AND MATERIAL  Mongrel dogs (weighing from 10 to 15 kg) were anesthetized with intravenously adminit-trated pentobarbital sodium (25 mg per kg of body weight), tracheally intubated, and main-trained on position-pressure ventilation. Left thoracotomy was made in these dogs. The exper-imental groups of dogs were divided into 6 groups. Group I (G1) underwent left sleeve up-per lobectomy in 14 dogs, G2 received the same as G 1 with omentopexy in 12 dogs. G 3 was with pedicled.pedicardial wrapping in 13 dogs. G4 was with pedicled parietal pleural wrapping in 11 dogs, G5 was with free pleural wrapping in 11 dogs, G5 was the same as G1 combined with esophagectomy in 12 dogs, and G 6 was the same as G5 with omentopexy in 12 dogs respec-tively.  On day 3-5, 7, 10, 12 and 14 of postoperative period these dogs were rethoracotomized. A No 7 cut-down tube was introduced into the descend-ing aorta. The lung was infused with saline and contrast material was injected. The trachea-lung preparation was removed and microangio-gram was made by Softex (type EMB) using the specimen of the bronchial anastomosis which was longitudinally extended.   In the groups of omentopexy, laparotomy was made at the same time and recanalization with the omental artery was evaluated on mi-croangiogram.  The grades of recanalization on microangio-gram was analyzed and it was graded as follows (Fig. 1). Grade 0 (G - 0) : there was no com-munication by arterial regeneration. Grade I (G- I-) : A little arterial regeneration was seen on the part of a bronchial artery. Grade II (G-II ) : arterial regeneration was well seen in while the arterial wall. Grade III (G- III ): There were marked development of the neovassels more than in G- II.           RESULT  Omentopexy was effective to facilitate arte-rial recanalization at anastomosis. As shown in Fig. 2, microangiogram in which contrast mate-   Fig. 1. Schema of the grades of arterial      recanalization at anastomosis on mi-     croangiography. rial was infused from the celiac artery clearly displayed well developed vascular network orig-inated from the omental artery. It was observed from day three to day five, thereafter showing excellent blood supply.  With time after bronchial anastomosis, the . grades of bronchial artery regeneration were carefully observed on micronagiogram.  As indicated in Fig. 3, in the control group, arterial communication was initiated on day seven to day 14, showing a maximum of the Grade, II and then vascular network had become well developed more than G - II . On the con-trary, in the Group II (omentopexy group) the arterial regeneration occurred on day three and become dense on day five to seven. Meanwhile, in the Group III (wrapping with pedicled peri-cardium) the arterial regeneration began on day five to seven and gradually became developed. It was useful for facilitating arterial recanalization, although still more retard than that of omentopexy.Fig. 2. Microangiographic pattern with  omentopexy, showing arterial blood  supply from the omental vessels.* left sleeve lobectomy & esophagectomy (Group I ) •additional omentopexy at bronchial anastomosis                              (Group II)Aadditional pedicled pericardial wrapping(Group III)Fig. 3. Changes in the grades of arterial  recanalization at bronchial anastomosis  in each group in the course of postopera- tive period.  As already shown in Fig. 3, in the group of wrapping with pedicled pleura, recanalization of the bronchial artery was seen on day five to seven and it was not different from that of wrapping with pedicled pericardium. However, wrapping with free pericardium was not of benefit in enhancing arterial regeneration. It was inferior to that of the control at times. . Furthermore, when esophagectomy was com-bined, arterial recanalization was retarded and it started on day seven to 10, and on day 14, thereafter it developed well, although poor blood perfusion was demonstrated following combined esophagectomy.   However, even under the conditions of esoph-agectomy concurrently performed, omentopexy prompted arterial revascularization. It was seen on day five to seven and well developed on day seven to 10.         DISCUSSION  Advances in surgery of tracheobronchoplasty has been remarkable and the number of the ope-rative cases is now increasing. IsIUIIARA2) in 1978 reported a nationwide survey concerning tra-cheobronchial plastic surgery in Japan. Accord-ing to him, the number of trahheoplastic opera-tions was 195 and that of bronchoplastic one reached 288 cases. However, in MAEDA's review of the nationwide collection in 1986, in which 578 of the tracheoplastic operations and 944 of the bronchoplastic one were included, the re-sults were not yet satisfactory although the incidence of postoperative complications has been reduced with time.  The total incidence was 16.9%, 23.4% in the trachea and 12.0% in the bronchus, indicating that it is not necessarily low.  The contributing factors are that there is a limit to resect, blood flow of the bronchial artery is impaired 4)5 ), and an operative pro-cedure of mediastinal dissection itself gives an insult to the bronchial arterial flow. Continu-ous movement of the trachea in accordance with respiratory cycle may well delay wound healing at bronchial anastomosis.  It is evident that omentopexy plays an important role in promoting arterial blood flow 6)-8) and it has been used for drainageoperation in the treatment of ascitic fluid and lymph edema as well as for aiding elimination of bacterial infection by activated macrophage. MORGAN et al 9). cited that wrapping with the omentum around bronchial anastomosis is of benefit in preventing granulation production which results in bronchial stenosis as well as in eliminating irradiation injury when radia-tion would be applied. LIMA et al 10 ). also re-ported that bronchial blood flow is accerelated by omentopexy after lung autotransplantation.  In this present study, wrapping effects of the omentum on bronchial recanalization at anastomosis were compared with those of the pericardium and the pleura.  The omentum has a large amount of tissue volume as well as vessels. It is helpful to make arterial recanalization hasten on day three de-spite day five to seven in the pericardial and/ or pleural wrapping groups which was the same as that of non-wrapping group. However, wrapping with avascular free grafts such as pericardium and /or pleura aggravated arte-rial recanalization at bronchial anastomosis. Furthermore, combined esophagectomy made it retarded and deteriorated, and an initiation of arterial recanalization delayed behind seven to 10 days, providing the detrimental con-ditions to bronchial recanalization.  Therefore, if surgeons try to combine esopha gectomy with bronchoplastic operation, oment opexy at bronchial anastomosis is necessary for overcoming the handicap of wound healing at bronchial anastomosis.         REFERENCE  1) KAWAIIARA,K : Experimental study on bron-   chial recanalization in bronchoplasty.    Nagasaki Igakkai 55 : 199-229, 1980.  2) IsI-uxnRA, T et al. : Current clinical data con-   cerning tracheobronchoplasty in Japan. J.J.     Thorac. Ass. 26: 3) MAEDA, M et al : Statistical survey of trache-   obronchoplasty in Japan. J.J. Society for    Broncholagy 8 : 4) VIRKKULA, EEROLA S : Use of omental pedicle    for treatment of bronchial fistula after lower    lobectomy. Report of two cases. Scand. J.    Thorac. Cardiovase. Surg. 9 : 287-290, 1975. 5) DUPor.,, C.,MENARD, Y. : Transposition of the    greater omentum for reconstruction of the    chest wall. Plast. Reconst. Surg. 49 : 263-267,   1972.  6) COOPER, J. D : Experience with lung trans-   lantation at the Toronto General Hospital.    Transplantation Today 1 ; 26-27, 1984.  7) KIMINO, K : Experimental study on healing    process in bronchial anastomosis. Especially    availability of omental and pericardial    covering. Acta Med. Nagasaki. 30:34-46, 1985. 8) ISHIHARA T, NLMOTO E, KIKUCHI K et al. : Does    pleural bronchial wrapping improve wound    healing in right sleeve lobectomy ? J. Thorac.    Cardiovasc. Surg. 89 : 665-672, 1985. 9) MORGAN E, LIMA 0, GOLDBERG M et al. : Suc-   cessful revascularization of totally ischemic    bronchial autografts with omental pedicle    flaps in dogs. J. Thorac. Cardivasc. Surg. 84:    204-210, 1982. 10) LIMA 0, GOLDBERG M, PETERS WJ et al. : Bron-   chial omentopexy in canine lung transplanta-   tion. J. Thorac. Cardiovasc. Surg. 83 : 418-   421, 1982.

Benefit from omentopexy on bronchial wound healing in performing concurrent esophagectomy

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Benefit from omentopexy on bronchial wound healing in performing concurrent esophagectomy

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