Keywords |
| Omentum, Omentoplasty, Omental transplant, Omental transposition, Peripheral Vascular
disease, Burgers disease, Thromoboangitis Obliterans |
Introduction |
| Daniel (1971) hoped omental transfer for
revascularization of extremities will postpone
amputation. Casten and Alday first studied
omental transplantation19. Alday and
Goldsmith gave an excellent description of
technique of omental lengthening. |
| Morrison described omentum as “Policeman
of the abdomen”. As it wraps around the
structures like gall bladder, appendix and
revascularises these structures when deprived
of their blood supply. |
| Hoshino 18classified the omentum as |
| Type I –Single layered omentum |
| Type II –Double layered omentum |
| Goldsmith discovered lipid fraction from the
omentum which exerts angiogenic properties.
Omentoplasty acts by increasing the collateral
circulation as it contains Angiogenic factor.20,
21 |
Mechanism of Action |
| When the procedure was introduced for
patients with atherosclerosis by Casten and
Aldy 19, it was thought that omental
transposition works by supplying extra blood
to the ischemic limb. However, this is difficult
to believe, as the diameter of omental vessels
is roughly one-tenth of the popliteal artery.
Later studies 6, 7, 8,9,10 have demonstrated that
the possible mechanism of action of omental
transfer is an increase in local collateral
circulation rather than any significant increase
in blood flow. Goldsmith et al. have
demonstrated that the omentum contains a
lipid fraction which promotes
neovascularisation. Thus a local action on
limb musculature with increased local
collateral circulation may be a possible mode
of action. 20, 21 |
| Omentum has been known to adhere to
surrounding structures and develop
connections with them, Hoshino et al. have
seen in limbs amputated after omental
transplantation that there were vascular
connections of omentum with limb
vasculature18. Babu et al have seen, in the
limbs amputated after omental transplantation,
revascularization of muscle from omental
vessels growing into it.15 |
| Aggarwal et al. performed postoperative
angiography in 50 patients who underwent
omental grafting and observed increase
number of collaterals at graft site with filling of vessels distal to the block in the limbs. In
an extension of the same study, 20 dogs
underwent allograft omental transfer in limbs
after ligation of the femoral artery in 10 of
these, at the end of three weeks exploration of
the graft site revealed increased number of
collaterals at the graft site with filling of
vessels distal to the site of the block. The
authors concluded that even a blood group and
human leukocyte antigen mismatched omental
graft is taken up and revascularises the
ischemic limb.14 |
| Subodh et al. performed post-operative
Doppler studies and selective celiac axis
angiography to study the circulation in the
omental graft. In 18 of their 20 cases, the
arterial pulsations were heard till the knee on
Doppler study. In 2 cases in which they were
not heard, there was no improvement in
symptoms. However on celiac-axis
angiography, the omental vessels were
visualized till the thigh in only six and upto
the knee in only four patients. The authors
concluded that omental transposition probably
works by promoting local collateralization.
Similar conclusions were drawn in another
study comparing free versus pedicled omental
graft.16 |
Materials and Methods |
| A total of 30 patients were part of this study.
The age group of the cases was between 23-
50 years. All the cases studied were male. The
patients were Beedi smokers (A beedi is a
rolled up tobacco without filter) and on an
average the patients smoked between 10- 30
beedis per day. The chosen cases did not have
posterior tibial, anterior tibial and
dorsalispedis artery pulsations. In 20 of our
cases, popliteal artery pulsation was absent.
11 cases had non-healing ulcers and 20 had dry gangrene of toe/toes or forefoot, with rest
pain. (Table 2) |
| Obese and diabetic patients have not been
selected since, the delineation of omental
vascular pattern is difficult in obese patients
and diabetic would usually have associated
coronary disease and are more prone for
infection. (Figures 1, 2, 3) |
| In the post operative period, patient were
given parenteral nutrition for 48 hours and
switched on to oral feeds once the peristalsis
returns. Routine antibiotics and analgesics
were given. Patient was advised to keep the
limb in extension for 2-3 days and allowed to
bear weight on 4th or 5th day onwards. On 10th
day, sutures were removed and patient is made
to walk. |
| All patients underwent a Doppler scan of the
lower limb prior to Surgery. The Doppler
study was done to mainly demonstrate the
block and the flow in the distal vessels |
Assessment of the Effect of
Omentoplasty |
| The criteria used to assess
Subjective: Symptomatic improvement. |
Objective: |
| 1) Improvement in the local skin temperature |
| 2) Healing of ulcers and amputation site. |
| 3) Measurement of oxygen saturation by
pulseoximetry |
| The patients were assessed after 7 days, 1
month and 3 months after undergoing the
procedure. |
| In all patients pulseoximetry was used to
measure pre and post-operative O2 saturation. |
Results |
Observations |
| The youngest patient in the study was 23yrs
old and the oldest 50yrs old. All of the studied
patients were male. All of the patients were
from low socio-economic status. Most of them
were manual labourers. |
Clinical Presentation |
| None of the patients were on any medications
except oral analgesics before admission.
All the patients in the study were non-diabetic
and normotensive at the time of admission. |
Habituations |
| All the patients in our study were beedi
smokers (100%) (Beedis are rolled up tobacco
without a filter) .15 (50%) of them were also
occasional alcoholics. 5 (17%) of them also
used smokeless tobacco in pan chewing. |
Duration of smoking |
| Around 54% of patients smoked beedis for 10-
20 years |
Amount of smoking |
| 77% of patients smoked 10-30 beedis/day |
Peripheral arterial pulsations |
| The pulses were assessed both by clinical
examination and a hand held Doppler probe. |
Correlation of symptoms with signs |
| All the patients in the study presented with
symptoms involving only one lower limb. But
during clinical examination, 50% of patients,
also had involvement of opposite lower limb
also 3% of them had clinical involvement of
upper limb also. |
Level of omental transplantation |
| See Table 8. |
Complications |
| In post operative period, 10 patients had post
operative infection of wounds. All of these
patients were treated with regular dressing and
antibiotic according to culture and sensitivity
reports. 70% of these patients responded with
this treatment. In 30% of these patients
infection was associated with necrosis of
omentum. |
Duration of Hospital Stay |
| Duration of hospital stay varied from 18-90
days. Most of the patients stayed for 20-35
days. The length of post operative stay was
increased in the patients due to wound
infections and due to no improvement
following the procedure in 3 patients. |
| During follow-up the patients were assessed at
7th day, 1 month and 3 months following
intervention. |
| O2 Saturation by pulseoximetry was also
measured in toes during follow-up
examination in 10 patients. |
Analysis |
| All the 30 patients in this study were males in
the age group of 23-50 yrs. Mean age of the
patient being 36.5 yrs (Table 1). History of
smoking was present in all the cases. Around
70% of patients smoked for more than 10 yrs
(Table 4). About 77% of patients smoked 10-
30 beedis/day (Table 5). Chief symptoms
were intermittent claudication, rest pain,
gangrene of toes and ulceration at tip of toes
or foot (Table 2). |
| No patient underwent lumbar sympathectomy
prior to omental transplantation. Clinical
manifestations of the affected limb revealed
absence of dorsalis pedis and anterior tibial in
all the 30 patients, absence of posterior tibial in 28 patients and popliteal in 20 patients.
Femoral pulsations were present in all
patients. The disease was restricted to one
lower limb only in 50%. In 47% it involved
bilateral lower limbs and only in 3% bilateral
lower limbs with upper limb (Table 6). |
| Omental transplantation along with lumbar
sympathectomy was done as a single stage
procedure in 66% of patients. In 33% of
patients only omental transplantation was
done. The procedure was well tolerated by all
the patients and there was no intra and post
operative mortality. Omental transfer was
possible up to below the knee in 71% of
patients. However, in 23% of patients,
omentum could be lengthened only up to
above knee level. The time taken for surgery
ranges between 2-3hrs (Tables 7-8). |
| Amputation of toes was done simultaneously
in all the 20 patients who presented with
gangrene of toes. |
| The patients were assessed post operatively in
form of; |
| Subjective – Improvement in intermittent
claudication and rest pain. |
| • Improvement |
| i. Objective - Increase in skin temperature |
| • Increase oxygen saturation as
measured by pulseoximetry |
| During follow up, the patients were assessed
at post operative day 7, at 1 month and 3
months after the procedure. Intermittent
claudication was relieved in 25 patients
(83%). Rest pain which was present in 15
patients (50%) before the procedure was
relieved in all the patients at the end of 3
months (100%). Healing of ulcer occurred in 10 out of 11 patients (91%). The healing of
amputated toe site occurred in 15 out of 20
patients during 3 months follow-up (75%).
The O2 saturation measured by pulseoximetry
measured in all patients increased from 72%
on an average to 94% after 3 months of
follow-up (Tables 10 – 11). |
| In 10 patients in our study, a postoperative
complication in form of wound infection was
noticed. In 7 of these patients (70%) the
wound infection was minor and responded to
the treatment given. In rest 3 of these patient
(30%), necrosis of the omentum occurred
which was associated with wound infection. In
these patients the symptoms did not subside.
All of 3 patients eventually required major
amputations. No other complication was
encountered in this study (Table 9). |
Discussion |
| Burger’s disease (Thromboangitis Obliterans)
continues to be a major surgical problem. Its
treatment has remained an enigma and
multiple strategies have been employed. Drug
therapy is of benefit only in early stages.
Surgical treatment options have consisted of
sympathectomy, direct arterial surgery,
adrenalectomy and amputation as a last resort.
With the exception of smoking, none of these
measures is curative and conflicting results
have been obtained. |
| However, in patients with critical limb
ischemia, surgery is required to salvage the
limb. Traditionally, patients who have
ischemic signs and symptoms have been
offered sympathectomy despite the fact that
relapses are frequent due to normalization of
vasomotor tone within 2 weeks to 6 months
after operation. Arterial reconstruction is
usually impossible due to distal nature of the
disease and carries a high failure rate. In
patients who are in imminent danger of requiring major amputation, omental pedicled
transplantation is a viable alternative for limb
salvage and also significantly improves signs
and symptoms. |
| Greater omentum is a primitive part of
gastrointestinal system containing a vast
network of blood supply and lymphatics, even
if deprived of its own blood supply it might
survive by attacking arteries in the vicinity.
Goldsmith et al. 20,21discovered a lipid fraction
from the omentum with angiogenic influences.
This property of omental pedicle graft to
induce neo angiogenesis and thereby
improving circulation of surrounding tissues
has been well established. Hence omentum
has been used to revascularise the ischemic
limb7, 8, 9, 10, 11. Nishimura et al. showed an
increase in muscle blood flow during exercise
and reactive hyperemia by using xenon (Xe
133) clearance study 2. |
| Babu, Menon, Vaidyanathan (in 1990)
obtained relief in intermittent claudication in
92% patients with TAO, relief in intermittent
claudication in 92% patients with TAO, relief
from rest pain in 86% , healing of ulcers in
100% of their patients. 14% of their patients
required major amputation 15 |
| Ranwaka, Sharma (in 1999) obtained relief in
intermittent claudication in 86.6%, relief from
rest pain in 66.6% and healing of ulcers in
80% in their patients.17 |
| The results in our study are consistent with
these results of some previous studies as
shown in Table 12. |
| The mechanism by which omentopexy
increases vascularity of the ischemic limb is
not exactly known. Probably omental
transposition works by promoting local
collateralization, since omentum is known to
possess angiogenic factor, which stimulates
the formation of capillary channels making available collateral channels in the existing
circulation. |
| Subodh et al. (1994)13 tried to find out the
mechanism by which the omental graft
increases the blood supply to the limbs. They
performed Doppler ultrasound studies and
celiac digital subtraction angiography to study
the circulation though the omental graft. Only
in 6 out of 12 patients could they visualize
omental vessels till mid-thigh and only in four
up to the knee joint. They concluded that
omental transposition acts not by significantly
supplying extra blood to the limbs but by
acting locally on the limb musculature and
probably causing increased collateral
circulation. |
| Although in the absence of such investigating
facilities and financial constraints, we were
not able to visualize omental vessels but we
could certainly appreciate an excellent
symptomatic relief obtained in these patients.
There was immediate relief of pain; the
progression of gangrene stopped, and ulcers
healed, a major amputation was avoided in
90% of patients. |
| Another interesting finding in the present
series was that most of the patients
experienced pain relief, immediately
following surgery. Possible causes may be (i)
Psychological relief that operation has been
performed (ii) Bed rest (hospital admission)
(iii) Supervision and almost complete
stoppage of smoking leading to remission of
the disease (iv) lumbar sympathectomy
performed simultaneously in 2/3rd of the
patients. |
| In the present study, objective tests were
carried out to see improvement in circulation.
Skin temperature increased in 90% of patients.
Pulseoximetry, an excellent method of
assessing limb perfusion revealed a clear
benefit in tissue oxygenation after pedicled
omental transplantation. |
Conclusion |
| • Patients presenting with critical limb
ischemia due to thromboangitis obliterans
often have no hope for limb salvage, for
such cases, omental transplantation offers
a procedure which can result in improved
limb circulation and limb salvage. |
| • The level of omental transplantation had
no bearing on the improvement in
symptoms thereby supporting the potency
of omental pedicle graft to induce
neoangiogenesis and thereby improving
circulation of surrounding tissues. |
| • This is a fairly simple operation, which
can be performed by general surgeons.
This operation does not need special
instruments and can be done in all general
hospitals. The postoperative care is also
simple; post operatively Ryle’s tube
aspirations are done periodically due to
presence of Gastric ileus. Secondly,
wound inspection should be done to look
for any infection/ discharge from the
wounds. |
| • Single stage lumbar sympathectomy and
omental transplantation is a better
procedure in end state Thromboangitis
obliterans with the advantages of a single
stage operation and low cost. |
| • Immediate improvement in symptoms
cannot just be explained in psychological
basis as was demonstrated by increase in
skin temperature and improved tissue
oxygenation by pulseoximetry. |
| • The present study has short comings in
form of (i) short duration of follow up (ii)
no Doppler or angiographic evidence
during follow up (iii). No histological proof of neovascularization of muscles.
The present study, however, proved
beyond doubt, the role of omental
transplantation in clinical improvement
and as a limb salvage procedure in
Burger’s disease. |
| • By this surgery the pathological progress
of the disease cannot be stopped but it
can be delayed significantly. |
| However much work needs to be done in this
field. The question regarding the mechanism
of action of omentum needs to be answered.
Long term prospective randomized and
controlled trials with longer follow up are
required to establish this procedure as the first
line of management in patients with Burger’s
disease. |
Conflict of Interest |
| None |
| Table 1: Age groups of patients studied |
 |
| Table 2: Clinical Presentations of various cases |
 |
| Table 3: Habituations of the patients |
 |
| Table 4: Duration of Smoking |
 |
| Table 5: Duration and amount of smoking |
 |
| Table 6: Peripheral arterial Pulses |
 |
| Table 7: Extent of the disease |
 |
| Table 8: Level of omental transplantation |
 |
| Table 9: Duration of Hospital stay |
 |
| Table 10: Follow up Results |
 |
| Table 11: Oxygen Saturation of the limb during follow up |
 |
| Table 12: Comparison of Our Study with previous results |
 |
| Figure 1: Omentum being mobilized |
 |
| Figure 2: Omentum mobilized to reach till below knee |
 |
| Figure 3: Skin incisions made on the limb for subcutaneous tunneling of the
Omentum |
 |
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