Use of Pedicled Omental Flap in Treatment
of Empyema
Takayuki Shirakusa, MD, Hitoshi Ueda, MD, Shinichi Takata, MD, Satoshi Yoneda, MD,
Koji Inutsuka, MD, Nobuo Hirota, MD, and Masatoshi Okazaki, MD
Division of Thoracic Surgery, Second Department of Surgery, and Department of Radiology, School of Medicine, Fukuoka
University, and National Minami Fukuoka Hospital, Fukuoka, Japan
Omental pedicle flaps were used in the treatment of
patients with acute and chronic empyema with bron-
chopleural fistula. In 5 patients (group 1) with postoper-
ative acute empyema owing to bronchial stump fistula,
an omental covering was applied as a reinforcement to
close the fistula. Six patients in group 2 with chronic
tuberculous or Aspergillus empyema with multiple fis-
tulas initially underwent open-window thoracostomy or
cavernostomy and secondarily had omental transposi-
tion. In all patients, the right gastroepiploic vessels were
used to provide the blood supply for the flap. Successful
T reatment of acute and chronic empyema, including
postlobectomy empyema, postpneumonectomy em-
pyema, and tuberculous or nontuberculous empyema,
has been a major concern of thoracic surgeons [1-4].
Despite the decreasing use of resection as a treatment
method for intrapulmonary tuberculosis, chronic tubercu-
lous empyema must often be treated surgically. Although
several operative procedures have been developed with
varying degrees of success [l-3, 581, the method of
treating empyema, and in particular empyema associated
with fistula, remains controversial.
The omentum has been used for management of com-
plicated problems in various fields of general surgery and
cardiovascular surgery [9-181. It has also been used in
repair or reconstruction of organs with ischemic damage
and as an aid in the healing or closing of various types of
fistulas [7, 10, 12, 161. Some successful results have been
achieved by use of the omentum in patients with thoracic
empyema resulting from bronchial fistula [7, 161. We have
performed operations using the omentum in 12 patients
with acute and chronic empyema and achieved favorable
results in 10. We report our series of patients and discuss
the value of the omental flap in the surgical treatment of
thoracic empyema, its indications, and its limitations.
Material and Methods
Since January 1980, 12 patients have undergone omental
transposition in our departments. The 9 men and 3
Accepted for publication April 4, 1990
Address reprint requests to Dr Shirakusa, Division of Thoracic Surgery,
Department of Surgery, School of Medicine, Fukuoka University, 45-1,
Nanakuma, Fukuoka, 814-01, Japan.
0 1990 by The Society of Thoracic Surgeons
closure of the bronchial stump was obtained in all
patients in group 1, but 2 of them died of recurrence of
their underlying lung carcinoma within 1 year. Five of
the 7 patients in group 2 had a favorable outcome, but 2
patients had partial recurrence after omental plombage.
From our experience with these patients, we believe that
the omental flap is effective for closing fistulas due to
postoperative or chronic empyema but has only limited
success in patients whose lungs are severely damaged by
persistent infection.
(Ann Thorac Surg 1990;50:420-4)
women were divided into two groups (Tables 1, 2). Group
1 consisted of 5 patients who had postoperative acute
empyema (4 had postpneumonectomy empyema, and 1
had empyema after right middle and lower lobectomy).
The 7 patients in group 2 had chronic empyema: 5 had
tuberculous empyema, and 2 had Aspergillus empyema.
The underlying disease of the 5 patients in group 1 was
lung carcinoma (see Table 2). Chronic empyema due to
tuberculous or aspergillosis in group 2 was discovered
after the development of symptoms related to bron-
chopleural fistulas.
A single-stage operation was performed in all patients
in group 1 and in 1 patient in group 2. Two-stage
procedures (open-window thoracostomy or cavernos-
tomy and then omental plombage) were performed in the
remaining 6 patients with chronic empyema (see Tables 1,
2). In these patients, two or three segments of rib were
resected and the empyema space was fully exposed at the
initial operation. Postoperatively, daily gauze dressings
were applied until fresh granulations appeared in the
open space (a period of 1 to 9 months). Omental plom-
bage was performed as a secondary procedure. Staphylo-
coccus uureus was detected in the empyema space in 6
patients with postpneumonectomy empyema. In the
chronic empyema group, only 1 patient (patient 8) was
positive for tuberculous bacilli, whereas Aspergillus was
demonstrated in 2 patients by culture. Tuberculous or
mycotic lesions were histologically confirmed in all re-
sected specimens in group 2.
For transposition of the omentum, a short median
incision was made in the upper abdomen and the greater
omentum was freed from the greater curvature of the
stomach proceeding from left to right. In all patients, the
0003-4975/90/$3.50
Ann Thorac Surg SHIRAKUSA ET AL 421
1990;50:420-4 OMENTAL USE FOR SURGERY OF THORACIC EMPYEMA

Table 1. Patients With Postoperative Empyema Who Underwent Omental Transposition (Group 1 )
Patient Age
No. Sex (y) Underlying Disease Type of Fistula Operation Outcome

1 M 71 Right lung carcinoma Bronchial stump fistula TD, OC Successful closure; died
after pneumonectomy after 3 mo of tumor
recurrence
2 M 52 Right lung carcinoma Bronchial stump fistula TD, OC Successful closure; died
after pneumonectomy after 1 y of tumor
recurrence
3 M 56 Right lung carcinoma Bronchial stump fistula TD, OC Successful closure; alive
after middle and 1 y 3 mo postop
lower lobectomy
4 M 63 Right lung carcinoma Bronchial stump fistula TD, carinal resection Successful closure; alive
after pneumonectomy and OC 1 y 3 mo postop
5 M 56 Right lung carcinoma Bronchial stump fistula TD, OC Successful closure; alive
after pneumonectomy 1 y 3 mo postop

OC = omental covering; Successful closure = successful closure of bronchial fistula; TD = tube drainage.

omental flap was supplied by the right gastroepiploic
vessels. A hole admitting two or three fingers was made
in the diaphragm below the sternum, and the omental
flap was generally brought up into the lower thoracic
space without difficulty through this hole. In the patients
with chronic empyema in the upper thorax (patients 9 and
10, Table 2), however, intrathoracic transfer of the omen-
tum was difficult because the adhesions between lung and
chest wall or diaphragm were very firm. In those patients,
we made a subcutaneous tunnel and passed the omentum
through it to bring it up into the empyema space (Fig 1).
For closure of the fistulas in most patients in group 2,
we sutured individual fistulas except for the smallest
ones, which were left to close spontaneously. In patient 8,
in whom the dissection and suturing of a larger fistula
proved difficult, we pushed a part of the omentum into
the fistula while covering the lung with omentum. In all
patients, the omental flap was fixed to the bronchial wall
with Dexon sutures, and fibrin glue was poured into the
space around the omentum. In 4 patients with chronic
empyema, we performed additional plombage using the
surrounding chest wall muscles (pectoralis major and
serratus anterior muscles for anterior lesions and latissi-
mus dorsi for posterior lesions), because in those patients

Table 2. Patients With Chronic Empvema Who Underwent Omental Plornbaxe (Group 2)
Location of
Patient Age Empyema in
No. Sex (Y) Cause of Empyema Thoracic Space Operation Outcome
_______~ ~~~

6 F 65 Tuberculous empyema Right lower OWT, decortication, and No recurrence at 3 y

with fistulas omental transposition 5 mo; alive and
well
7 F 32 Aspergillus empyema Right upper OWT, omental No recurrence at 2 y
with fistulas transposition 9 mo; alive and
well
8 M 74 Tuberculous empyema Left lower OWT, omental Partial recurrence at
with fistulas transposition, and 2 y 5 mo; alive
muscle plombage
9 M 68 Tuberculous empyema Right upper OWT, omental Partial recurrence at
with fistulas transposition, and 2 y 5 mo; alive
muscle plombage
10 M 76 Aspergillus empyema Left upper Open-window Partial recurrence at
with fistulas cavernostomy, omental 2 y 2 mo; alive
and muscle plombage
11 F 66 Tuberculous empyema Right lower OWT, omental 6 mo postop
with fistulas transposition, and
muscle plombage
12 M 72 Tuberculous empyema Right total OWT, omental 6 mo postop
with fistulas transposition
OWT = open-window thoracostomy.
422 SHIRAKUSA ET AL Ann Thorac Surg
OMENTAL USE FOR SURGERY OF THORACIC EMPYEMA 1990;50:420-4

the omentum was of insufficient volume to cover the

entire surface of the damaged lung.
In patients with postoperative bronchial stump fistulas,
tube drainage and irrigation was performed initially.
Next, the pleural space was opened and the entire surface
of the empyema cavity was irrigated thoroughly. After
exposing healthier tissue belonging to the bronchial
stump as far as possible, we performed repeat resection
and closed the stump. Finally, we bunched the trans-
ferred omentum and sutured it to the bronchial stump in
some areas.

Results
We obtained favorable postoperative results in 5 patients
in group 2 with chronic empyema (patients 6, 7,8,11, and
12); 2 had partial recurrence (patients 9 and 10) (see Table
2). Patient 6 had a right chronic empyema with fistulas.
Long-term management with tube drainage was a failure,
but omental transposition was subsequently performed
successfully (Fig 2). Patient 7 was a very short and thin
woman. She had undergone long-term medical therapy
for pulmonary tuberculosis, but an intracavitary as-
pergilloma subsequently developed. An open-window
cavernostomy was performed. At the closure of this large
open space, sufficient chest wall muscle was not available
for plombage; therefore, only the omentum was placed
Fig 2 . A celiac angiogram performed 3 months after omental transpo-
sition in patient 6 shows the patency of the right gastroepiploic vessels
that run into the left thorax.

/-- - - --__-
over the openings of the fistulas. Postoperatively, the
dead space slowly decreased with time (Figs 3 and 4).
Patients 6 and 12 also did not undergo
bage using chest wall muscles.
- additional plom-

In patients with successful results, pulmonary symp-

Fig 1 . Method of transposing the omentum in a patient whose empy-
emu space is located in the upper thorax and whose residual lung has
tight adhesions to the thoracic wall. The omentum is brought up
through a subcutaneous tunnel.
toms resolved completely and there has been no recur-
rence during follow-up. Patients 9 and 10 had recurrence
of symptoms about 1 month after omental plombage.
Both of them were malnourished elderly patients with
large empyemas and persistent infection of the lung
parenchyma in whom pleuropneumonectomy was impos-
sible because of their poor general condition and reduced
lung function. In patient 9, after an open-window thora-
costomy, the omentum and chest wall muscles were used
to cover many fistulas of various sizes. Postoperative
bronchography showed, however, that obliteration of the
fistulas was only partially successful. In patient 10 a
recurrent free space developed 1 month after operation
and repeat cavernostomy showed partial recurrence of the
fistulas even though the omentum was viable and tightly
adherent to the top of the empyema space. Patients 11
and 12 are alive and well 6 months after operation, but it
is too early to assess the long-term results in these
patients.
In all patients with postoperative acute empyema
(group l), we successfully achieved closure of the bron-
chial fistula by using the omental covering (Table 1). Four
of the 5 patients in this group had stage I11 lung carci-
Ann Thorac Surg SHIRAKUSA ET AL 423
1990;50:42&4 OMENTAL USE FOR SURGERY OF THORACIC EMPYEMA

previously performed open-window thoracostomy fol-

Fig 3 . A celiac angiogram performed 3 weeks after omental transposi-
tion in patient 4 shows thin ornental vessels farrows) covering the
surface of the bed of a large empyema space.
lowed by myoplasty in select patients, using methods
reported previously [ 1-3, 5, 81. For empyema with fistula,
pleuropneumonectomy is a potentially curative opera-
tion, but it may be too invasive for patients at risk.
Bronchial fistulas generally heal poorly owing to an inad-
equate blood supply and persistent infection [7]. The
omentum has a rich blood supply and tends to adhere
well to inflammatory tissue [7, 151. In 21 empyemic
patients, Hankins and colleagues [6] reported six recur-
rences and unsuccessful treatment in 4 patients; in 2
others, treatment was partially successful but myoplasty
had to be repeated. Myoplasty is a safer procedure than
pleuropneumonectomy or extended thoracoplasty, but
myoplasty does not always provide satisfactory results in
elderly or thin, malnourished patients.
The remarkable power of the omentum to aid tissue
repair may result from its encouragement of cellular
proliferation and fibrous tissue formation, as well as its
adhesion to surrounding organs [10,16, 181. Furthermore,
both the rich omental lymphatic system and the revascu-
larization promoted by the omentum permit rapid reab-
sorption of inflammatory exudates, with little local infec-
tion [3, 151. Miller and co-workers [20] reported good
results in 2 patients who underwent closure of a post-
pneumonectomy empyema space with use of both ex-
trathoracic muscle flaps and omental grafts. In this series,
we also added plombage with chest wall muscles in a few
patients in whom the thin omental tissue was not suffi-

noma, and 1 had a stage I tumor. Patient 1 died of

recurrence of carcinoma in the early postoperative period.

Comment
In empyema without fistula, decortication or extrapericos-
tal air plombage usually is used; the former procedure is
performed for a localized and the latter for an extensive
empyema. However, the treatment of empyema with
fistula is more varied because it often is difficult. The
mortality in patients with a bronchial stump fistula after
pneumonectomy is considerable. In the treatment of acute
empyema resulting from bronchial fistula, we have per-
formed an open-window thoracostomy as an emergency
procedure. After daily irrigation with antibiotics, we then
performed repeat closure of the bronchial stump and
muscle plombage. The results, however, were sometimes
not favorable. In elderly patients with bronchial carci-
noma, the bronchial stump may be at risk of ischemia
because of the dissection of surrounding tissues. Accord-
ingly, in the case of a large bronchial stump with dehis-
cence due to ischemia, covering the fistula with a muscle
flap alone will be inadequate because muscle lacks the
ability of fat to promote angiogenesis [19]. For this reason,
we used the omentum for closing bronchial stump fistulas
in this series and obtained good results. Fig 4. A chest roentgenogram performed 6 months after operation in
Several surgical techniques have been introduced for patient 4 S ~ O Z U Sthe rtiarked decrease in the right apical dead space (ar-
the treatment of chronic empyema with fistula. We have rows).
424 SHIRAKUSA ET AL
OMENTAL USE FOR SURGERY OF THORACIC EMPYEMA
cient to cover t h e empyema surface. W e do not believe
that complete closure of an empyema space is always
needed, however, provided that the residual space is kept
clean by daily gauze dressings a n d provided that omental
coverage of the fistula openings is sufficient. The residual
space decreases considerably i n such cases with time,
even though it does n o t become completely obliterated. In
3 patients with chronic empyema, additional muscle
plombage w a s not performed. All are now alive and well
despite having a residual pleural space.
Based on their experience i n chest wall reconstruction
with omentum, Jurkiewicz a n d Arnold [ l l ] stressed that
the right gastroepiploic artery is usually lager than the left
and that omental flaps accordingly should be based on the
right gastroepiploic vessels. W e believe that either artery
m a y be used, although in all our patients the right
gastroepiploic vessels were used for the blood supply of
the flap. Use of t h e o m e n t u m should be avoided in
patients who have had a n y previous operation on the
gastrointestinal tract o r who have any kind of active
abdominal disease.
Regarding postoperative complications, subacute ileus
with brief postoperative abdominal distention developed
in only 1 patient. Although there is a theoretical risk of
herniation of t h e abdominal organs, this complication did
not occur i n o u r series. W h e n using a n omental flap, one
m u s t be careful to avoid a n y kinking, compression, or
rotation of the vascular pedicle [15]. Formation of larger
hematomas i n t h e o m e n t u m should also be avoided [12].
Infection may spread to t h e abdominal cavity because a
passage is created surgically between t h e empyemic space
a n d t h e abdomen, particularly i n cases of pulmonary
tuberculosis o r aspergillosis. Therefore, to achieve steril-
ization of the empyema space, we recommend a n open-
w i n d o w thoracostomy followed by daily gauze dressings
for several m o n t h s before its closure is attempted.
T w o patients in our series h a d unsuccessful results. The
cause of failure w a s considered to be that both patients
were malnourished a n d h a d severe chronic infection of
t h e airways a n d l u n g parenchyma. Thus, it appears that if
t h e l u n g has foci of persistent infection with fistulas
connecting to t h e empyema space, omental plombage
may not be successful.
References
1. Cicero R, Vecchyo C, Porter JK, Carreno J. Open window
thoracostomy and plastic surgery with muscle flaps in the
treatment of chronic empyema. Chest 1986;89:36&74.
2. Shaji FM, Ginsberg RJ, Cooper JD, Pearson FG. Open win-
Ann Thorac Surg
1990;50:42&4
dow thoracostomy in the management of postpneumonec-
tomy empyema with or without bronchopleural fistula. J
Thorac Cardiovasc Surg 1983;86:81&22.
3. Eerola S, Virkulla L, Vastela E. Treatment of postpneumonec-
tomy empyema and associated bronchopleural fistula. Scand
J Thorac Cardiovasc Surg 1988;22:235-9.
4. Chicarilli ZN, Ariyan S, Glenn WL, Seashore JH. Manage-
ment of recalcitrant bronchopleural fistulas with muscle flap
obliteration. Plast Reconstr Surg 1985;75:882-7.
5. Hankins JR, Miller JE, McLaughlin JS. The use of chest wall
muscle flaps to close bronchopleural fistulas: experience with
21 patients. Ann Thorac Surg 1978;25:491-9.
6. Virkkula L, Eerola S. Use of omental pedicle for treatment of
bronchial fistula after lower lobectomy. Scand J Thorac Car-
diovasc Surg 1975;9:287-90.
7. Rocha AG, Robertson GA. Sealing the postpneumonectomy
space: use of a pectoralis major myodermal flap. Ann Thorac
Surg 1984;38:221-6.
8. Casten DF, Alday ES. Omental transfer for revascularization
of the extremities. Surg Gynecol Obstet 1971;132:3014.
9. Dupont C, Menard Y. Transposition of the greater omentum
for reconstruction of the chest wall. Plast Reconstr Surg
1972;49:263-7.
10. Goldsmith HS, Beattie EJ. Carotid artery protection by pedi-
cled omental wrapping. Surg Gynecol Obstet 1970;130:57-60.
11. Jurkiewicz MJ, Arnold PG. The omentum: an account of its
use in the reconstruction of the chest wall. Ann Surg 1977;
185:548-54.
12. Lima 0, Goldberg M, Peters WJ, et al. Bronchial omentopexy
in canine lung transplantation. J Thorac Cardiovasc Surg
1982;83:41%21.
13. Morgan E, Lima 0, Goldberg M, et al. Successful revascular-
ization of totally ischemic bronchial autografts with omental
pedicle flaps in dogs. J Thorac Cardiovasc Surg 1982; 84:
204-10.
14. Segulin JR, Loisance DY. Omental transposition for closure
of median sternotomy following severe mediastinal and
vascular infection. Chest 1985;88:684-6.
15. lverson LIG, Young JN, Ecker RR, et al. Closure of bron-
chopleural fistulas by an omental flap. Am J Surg 1986;:152:
40-1.
16. Dubois P, Choiniere L, Cooper JD. Bronchial omentopexy in
canine lung allotransplantation. Ann Thorac Surg 1984;38:
211-3.
17. Heath BJ, Bagnato VJ. Postpneumonectomy mediastinitis
treated by omental transfer without postoperative irrigation
or drainage. J Thorac Cardiovasc Surg 1987;94:355-60.
18. Mathiesen DJ, Grillo HC, Vlahakes GJ, Daggett WM. The
omentum in the management of complicated cardiothoracic
problems. J Thorac Cardiovasc Surg 1988;95:677-84.
19. Miller J1, Mansour KA, Nahai F, et al. Single-stage complete
muscle flap closure of the postpneumonectomy empyema
space: a new method and possible solution to a disturbing
complication. Ann Thorac Surg 1984;38:227-31.