Use of an omental pedicle graft to repair a large oesophageal defect.

A 41 year old man presented with a three month history of chest pain, decreased effort tolerance, and haemoptysis. A chest radiograph suggested a large cavitating neoplasm replacing the entire left upper lobe and diffuse opacification of the remaining lung on that side. Other investigations were non-contributory. Rigid bronchoscopy identified the presence of blood within the orifice of the left upper lobe bronchus but no endobronchial lesion was identified. At thoracotomy a large lung abscess was found to be replacing the entire left upper lobe. A considerable amount ofthe lower lobe was necrotic. Lobar dissection was impossible. The inflammatory reaction was so intense that intrapericardial division of the hilar structures was necessary to perform a pneumonectomy safely. There was no free pus within the thoracic cavity. The patient's initial postoperative recovery was uneventful and he was discharged on the eighth day, well and having no medication. He presented 17 days later with back pain, vomiting, and abdominal distension. An emergency endoscopic examination showed a substantial full thickness defect of the oesophagus at 30 cm. The patient was referred to the regional thoracic service, where an Omnipaque examination confirmed the presence of an oesophagopleural fistula. Emergency thoracotomy was performed. A 5 x 3 cm defect was identified in the oesophagus adjacent to the inferior pulmonary vein. The diaphragm was incised anteriorly at the junction of the tendonous and muscular areas, with a sufficiently long incision (2 5 cm) to deliver a long pedicle of omentum into the thorax. Subperiosteal excision of the seventh rib was performed to prepare an intercostal muscle pedicle flap. No attempt was made to approximate the edges of the oesophagus. The fistula was closed by creating a two layer patch with both pedicles (figure). A central venous line was inserted to give total parenteral nutrition for six days. The patient recovered and was swallowing normally on discharge 31 days after the repair. A