Print this page Email this page
Users Online: 1459
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 20-24

Evaluation of the role of omental transposition in chronic limb ischemia: A prospective study


1 Department of Surgery, University College of Medical Sciences and GTB Hospital, New Delhi, India
2 Department of Nuclear Medicine, Institute of Nuclear Medicine and Allied Sciences, New Delhi, India

Date of Web Publication14-Jul-2014

Correspondence Address:
S Saha
Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi - 110 001
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.136705

Rights and Permissions
  Abstract 

Background: Surgical treatment options for thromboangitis obliterans (Burger's disease) and atherosclerosis where arterial reconstruction is not possible are limited. Omental transposition is one of the treatment modalities used in these patients. However, improvement in vascularity of the limb has been infrequently evaluated in previous studies. In this study, we evaluated the outcome of omental transposition in patients with chronic peripheral vascular disease in terms of clinical improvement and also objectively document the effect on limb vascularity using technetium 99 labeled methylene diphosphonate radionuclide scanning.
Materials and Methods: This prospective study was conducted in the Department of Surgery in a Tertiary Care Hospital in North India. A total of 22 patients suffering from chronic peripheral vascular disease unsuitable for corrective arterial surgery underwent omental transposition. Patients were evaluated 1 month after the operation for the change in the clinical parameters and vascularity of the limb using radionuclide scan.
Results: Five (22.7%) patients had complete relief, 12 (54.5%) patients had significant relief while 5 (22.7%) patients had no relief in the rest pain. Signs of healing of ulcer were present in 44.4% of patients having ulcers and coldness of the skin was decreased in 18 patients (81.8%). Radionuclide scan demonstrated increased vascularity in the thigh in 78.6% of patients, increased vascularity in calf in 86.4% and increased vascularity in the foot in 44.6%.
Conclusions: Omental transposition increases the blood supply in the transposed limb and may be considered as an effective modality for management of chronic limb ischemia in cases where definitive revascularization cannot be carried out.

Keywords: Chronic peripheral vascular disease, omental transposition, tromboangitis obliterans


How to cite this article:
Singh DP, Suhani, Saha S, Agrawal V, Kashyap R, Aggarwal N, Gupta S. Evaluation of the role of omental transposition in chronic limb ischemia: A prospective study. Arch Int Surg 2014;4:20-4

How to cite this URL:
Singh DP, Suhani, Saha S, Agrawal V, Kashyap R, Aggarwal N, Gupta S. Evaluation of the role of omental transposition in chronic limb ischemia: A prospective study. Arch Int Surg [serial online] 2014 [cited 2024 Mar 1];4:20-4. Available from: https://www.archintsurg.org/text.asp?2014/4/1/20/136705


  Introduction Top


Chronic peripheral disease is a significant problem in Indian population. The two main causes are thromboangiitis obliterans (TAO), (Buerger's disease) and atherosclerosis. Atherosclerosis is the most common cause of chronic arterial occlusive disease of the lower extremities, affecting mainly large and medium sized vessels in middle aged elderly males. [1] TAO is a segmental occlusive inflammatory condition of arteries and veins, characterized by thrombosis and recanalization of the affected vessels. It affects small and medium sized vessels of the upper and lower extremities and typically occurs in young male smokers. [2] In cases of TAO, treatment options include medical management, lumbar sympathectomy, arterial reconstruction, omental transposition and amputation. Cessation of smoking is the cornerstone in the treatment and favorably affects the prognosis at any stage of the disease. Medical treatment is of little benefit. [1] Arterial reconstruction is associated with poor results because of involvement of small and medium sized vessels. [3],[4] Lumbar sympathectomy has been widely employed for relief of vasospasm, but it only improves cutaneous circulation and has no effect on muscle blood flow. [5] In atherosclerotic disease, arterial reconstructive surgery or angioplasty is effective in case of large vessel disease with good distal run-off but there is no satisfactory treatment of the involvement of medium and small vessels.

Omental transposition has been used as a treatment option in chronic occlusive arterial diseases to improve the limb vascularity. The effectiveness of this procedure has been demonstrated in many studies; however, most of these studies have used clinical features to evaluate the outcome. [6] We conducted the present study to evaluate the change in limb vascularity following omental transposition in terms of improvement of clinical features and also objectively document the effect on limb vascularity using technetium 99 labeled methylene diphosphonate (MDP) radionuclide scanning.


  Materials and Methods Top


This study was conducted prospectively in the Department of Surgery in a Tertiary Care Hospital in North Delhi over a period of 2 years. An ethical clearance was obtained from the institutional ethical committee. Twenty two patients suffering from chronic peripheral vascular disease unsuitable for corrective arterial surgery (due to the absence of suitable distal vessel for revascularization) were included. After informed consent, all the patients fulfilling the inclusion criteria were clinically evaluated to identify the etiology of vascular disease, severity of disease and site of arterial blockage. The pain profile was documented using visual analogue scale (VAS) for subsequent comparison. [7] Presence of ulcer, gangrene and temperature of the skin were noted. Hemogram, renal function test, liver function test, lipid profile, blood sugar and electrocardiogram were done in all patients. Duplex scan of limb was done to assess the condition of vessels, base line flow rates and the site of block.

Evaluation of vascularity of the limb was done by radionuclide perfusion scanning. Technetium 99 labeled MDP was injected intravenously in the antecubital fossa. Dynamic and static images of the lower limb were acquired using large field of view gamma camera with parallel hole low energy high resolution collimator. All the patients underwent imaging in blood perfusion, blood pool and whole body dynamic phase. The scans were interpreted by visual evaluation and quantification. Quantification of radionuclide scan was done by calculating the region ratio. For calculating these ratios the regions of interest were drawn over the calf, thigh and foot of one limb and the same regions were taken on the opposite limb. The region-ratio was determined by calculating average counts per pixel in the above regions of interest in the diseased and the normal limbs. The normal calf to diseased calf (NC/DC), normal foot to diseased foot (NF/DF) and normal thigh to diseased thigh (NT/DT) ratios were calculated.

Operative technique

Surgical technique of the omental transfer was as described by Hoshino et al. All the patients were operated under general anesthesia. Through an upper midline incision omentum was delivered out and detached from the transverse colon. Based on vascular pattern, right or left gastroepiploic artery based omental pedicle was made. Lengthening of the omentum was carried out depending on the vascular anatomy. Subcutaneous tunnel was then made between the inguinal region on the side of the proposed transposition and the abdominal incision. The lengthened omentum was tunneled through this tunnel taking care not to kink or rotate the omentum. Further incisions were made distally and subcutaneous tunnels were connected to each other. Omentum was taken down through the tunnels up to the level of transposition taking the same precautions.

Post-operative follow-up was carried out at 1 month for the pain, ulcer healing and temperature of the limb. Technetium 99 labeled MDP radionuclide scan was done at 1 month and the region ratios were calculated to objectively evaluate the change in the vascularity of the limb. The NC-DC, NF-DF and NT-DT ratios were calculated.

For the purpose of this study, complete relief was defined as complete disappearance of symptoms after 1 month while significant relief was defined as more than 50% relief of symptoms.


  Results Top


A total of 22 patients with chronic obstructive arterial disease underwent omental transposition. Pre-operative features of patients are shown in [Table 1]. All patients were male with history of smoking. None of the patients were diabetic or hypertensive. All the patients had rest pain. On Doppler study, 7 (31.8%) patients had a block in the femoral artery, 8 (36.4%) in the popliteal artery and 7 (31.8%) patients had infrapopliteal block.
Table 1: Pre-operative features of patients

Click here to view


In 12 patients the omental pedicle was right gastroepiploic artery based while in 10 patients pedicle was left gastroepiploic artery based. The omental pedicle could be brought down to foot in 3 (13.6%), lower leg in 9 (40.9%), mid leg in 7 (31.8%), upper leg in 2 (9.1%) and thigh in 1 (4.5%) patient. At 1 month after the operation, 5 (22.7%) patients had complete relief, 12 (54.5%) had significant relief while 5 (22.7%) patients had no relief in the rest pain. Mean pre-operative pain score on VAS was 8.1, which improved to 3.7 at 1 month post-operative. Signs of healing of ulcer were present in 4 (44.4%) out of nine patients having ulcer. However, in 5 patients (55.6%) ulcer progressed with development of gangrene. Below knee amputation was done in these five patients. Coldness of the skin was decreased in 18 patients (81.8%). One patient developed incisional hernia from the site where the omentum was brought out from the abdomen.

Radionuclide scanning observations

On visual impression, in 16 patients (72.7%) the perfusion improved after omental transposition, while in three patients it decreased after omental transfer. All these three patients had foot ulcers which did not show signs of healing and required amputation later on. Three patients had no change in perfusion in the limb after operation. One of these three had symptomatic improvement but two patients (with ulcer) had no improvement of symptoms.

Region ratios

NC:DC perfusion ratio

The mean NC-DC perfusion ratio was 1.12 (standard deviation [SD]: 0.31) in the pre-operative period (n = 22), which decreased to 0.93 at 1 month. In 16 patients this ratio was more than one pre-operatively, indicating that perfusion was less in the DC, while in six patients the ratio was <1. In 19 (86.4%) patients this ratio decreased after omental transposition, which showed that perfusion increased in the DC. 15 of these 19 patients were also improved symptomatically but four patients had no improvement. All these four patients were having large foot ulcers, which later required amputation. In three patients the ratio increased after surgery. Two of these three patients were improved symptomatically. One patient did not improve. This patient was also having foot ulcer and required amputation later on. [Figure 1] shows the distribution of the patient according to the pre-operative and post-operative NC:DC perfusion ratio difference.
Figure 1: Distribution of the patients according to the pre-operative and post-operative Normal calf: Diseased calf perfusion ratio difference (series 1 — patients with clinical improvement in rest pain, series 2 — patients with no improvement in rest pain)

Click here to view


NF:DF perfusion ratio

This ratio was >1 in eight patients and <1 in 14 patients. In 10 patients it decreased after the operation, while 12 (55.4%) patients the ratio increased after the operation. On comparing the changes in perfusion in DF with NF, it was found that the mean perfusion ratio decreased from 0.92 (SD: 0.4) in the pre-operative period to 0.89 (SD: 0.42) in the follow-up [Figure 2].
Figure 2: Distribution of the patients according to the pre-operative and post-operative Normal foot: Diseased foot perfusion ratio difference (series 1 — patients with clinical improvement in rest pain, series 2 — patients with no improvement in rest pain)

Click here to view


NT:DT perfusion ratio

This ratio was calculated in 13 patients. In 11 (92.8%) patients the ratio decreased after omental transposition, which showed that perfusion increased in DT after surgery. In one patient the ratio increased. The mean perfusion ratio of NT to DT decreased from 1.1 (SD: 0.26) in the pre-operative period to 0.94 (SD: 0.19) in the post-operative period at 1 month [Figure 3].
Figure 3: Distribution of the patients according to the pre-operative and post-operative Normal thigh: Diseased thigh perfusion ratio difference (series 1 — patients with clinical improvement in rest pain, series 2 — patients with no improvement in rest pain)

Click here to view


Paired t-test showed that there was a significant difference in the pre-operative and post-operative scan ratios of NC and DC, NT and DT, NF and DF (P - 0.001, 0.001 and 0.008 respectively).


  Discussion Top


Chronic occlusive arterial diseases form a single largest entity amongst the peripheral vascular diseases. There is extremely high prevalence of TAO in India among people of low socio-economic class who smoke unfiltered cigarettes (bidis). [1] In patients with TAO, arterial revascularization is usually not possible due to the diffuse segmental involvement and involvement of distal vessels. Sympathectomy may provide short-term pain relief and promote ulcer healing in some patients with TAO, but no long-term benefit has been confirmed. [8] Similarly, in patients with atherosclerotic peripheral vascular disease where distal run-off is not good bypass surgery is not possible. Management of rest pain and severe ischemia in these patients is still problematic and many patients will eventually require a limb amputation.

Omental transposition has been used in these patients as a treatment option. Intact pedicled omentum can introduce a new source of blood into ischemic limb by a relatively simple procedure. Casten and Alday first used this technique and reported good clinical results in terms of relief of symptoms and complete healing of ulceration and gangrenous areas of toes and feet. [6] Thereafter, many studies have demonstrated the usefulness of omental transposition in salvaging limbs unsuitable for conventional revascularization procedures. [9],[10] The mechanism by which omental transposition relieves pain in patients with chronic limb ischemia is not very clear. It probably acts by increasing the local collateral circulation. [9],[10] The analysis of the implanted omentum and the ischemic muscle of the implanted limb has shown that the vessels of the omentum invade the ischemic muscular tissue and supply blood to the muscle. [11] It has also been demonstrated that the omentum contains a lipid fraction, which promotes neovascularization. [12],[13] Post-operative angiography had shown that there is an increased number of collaterals at the graft site with filling of vessels distal to the block after omental transposition. [14] Improved vascularity in the limb has also been demonstrated on serial post-operative Doppler studies. [15]

Most of the studies evaluating omental transposition have used clinical features as the outcome measure and only few studies have objectively evaluated the effect of omental transposition on vascularity of the limb. The present study was carried out to evaluate the outcome of omental transposition using both subjective and objective parameters. Radioisotope scanning has been used in the past in patients with occlusive arterial diseases to evaluate the limb perfusion and the healing potential of ischemic ulcer. [16],[17],[18] Previous studies have shown improvement in the rest pain in 72-94%, healing of ulcers in 73-83% and improvement of skin temperature in 83-100% of patients after omental transposition. [9],[11],[19],[20],[21] Present study showed improvement in the rest pain in 77.3%, healing of foot ulcer in 44.4% and improvement in limb temperature in 83% of patients. However, in 5 out of 9 patients with leg ulcer there was progression with development of gangrene and below knee amputation had to be done. Most of these patients showed no significant changes in perfusion on radio nuclide scanning.

In this study, the improvement in the vascularity of the limb has been demonstrated objectively by radionuclide scan. The comparison of the pre-operative and the post-operative scan by visual impression showed increased vascularity in 72.7% patients after omental transposition. The absolute radioactivity over the limb was not used for measuring the perfusion as the amount of radioactivity varied from patient to patient due to a different rate of radioactive decay. Hence, the ratios of perfusion between various areas of diseased limbs and normal limb were used to document the perfusion. After the omental transposition 55.4% of patients showed increased perfusion in foot, 86.4% had increased calf perfusion and 78.6% had increased perfusion in the thigh. The mean perfusion ratios significantly improved in the post-operative period. This clearly showed that the omental transposition improved the vascular supply of the limb.


  Conclusion Top


Omental transposition increases the blood supply in the transposed limb and leads to improvement in rest pain, intermittent claudication and non-healing ulcer. Hence, it may be considered an effective modality for management of chronic limb ischemia when definitive revascularization cannot be done.

 
  References Top

1.Weitz JI, Byrne J, Clagett GP, Farkouh ME, Porter JM, Sackett DL, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: A critical review. Circulation 1996;94:3026-49.  Back to cited text no. 1
    
2.Olin JW. Thromboangiitis obliterans (Buerger's disease). N Engl J Med 2000;343:864-9.  Back to cited text no. 2
    
3.Nishikimi N. Fate of limbs with failed vascular reconstruction in Buerger's disease patients. Int J Cardiol 2000;75 Suppl 1:S183-5.  Back to cited text no. 3
    
4.Shionoya S, Ban I, Nakata Y, Matsubara J, Hirai M. Vascular reconstruction in Buerger's disease. Br J Surg 1976;63:841-6.  Back to cited text no. 4
    
5.Shionoya S, Ban I, Nakata Y, Matsubara J, Shinjo K. Diagnosis, pathology, and treatment of Buerger's disease. Surgery 1974;75:695-700.  Back to cited text no. 5
    
6.Casten DF, Alday ES. Omental transfer for revascularization of the extremities. Surg Gynecol Obstet 1971;132:301-4.  Back to cited text no. 6
    
7.Syrjala KL, Chapman CR. Measurement of pain. In: Loeser JD, Butler SH, Chapman CR, Turk DC, editors. Bonica's Management of Pain. 3 rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 311-2.  Back to cited text no. 7
    
8.Holiday FA, Barendregt WB, Slappendel R, Crul BJ, Buskens FG, van der Vliet JA. Lumbar sympathectomy in critical limb ischaemia: Surgical, chemical or not at all? Cardiovasc Surg 1999;7:200-2.  Back to cited text no. 8
    
9.Talwar S, Jain S, Porwal R, Laddha BL, Prasad P. Free versus pedicled omental grafts for limb salvage in Buerger's disease. Aust N Z J Surg 1998;68:38-40.  Back to cited text no. 9
    
10.Subodh S, Mohan JC, Malik VK. Omentopexy in limb revascularisation in Buerger's disease. Indian Heart J 1994;46:355-7.  Back to cited text no. 10
    
11.Hoshino S, Hamada O, Iwaya F, Takahira H, Honda K. Omental transplantation for chronic occlusive arterial diseases. Int Surg 1979;64:21-9.  Back to cited text no. 11
    
12.Goldsmith HS, Griffith AL, Catsimpoolas N. Increased vascular perfusion after administration of an omental lipid fraction. Surg Gynecol Obstet 1986;162:579-83.  Back to cited text no. 12
    
13.Goldsmith HS, Griffith AL, Kupferman A, Catsimpoolas N. Lipid angiogenic factor from omentum. JAMA 1984;252:2034-6.  Back to cited text no. 13
    
14.Agarwal VK, Bajaj S. Salvage of end stage extremity by omentopexy in Buerger's disease. Indian J Thorac Cardiovasc Surg 1987;5:12-17.  Back to cited text no. 14
    
15.Khazanchi RK, Nanda V, Kumar R, Garg P, Guleria S, Bal S. Omentum autotransplantation in thromboangiitis obliterans: Report of three cases. Surg Today 1999;29:86-90.  Back to cited text no. 15
    
16.Dibos PE, Muhletaler CA, Natarajan TK, Wagner HN Jr. Intravenous radionuclide arteriography in peripheral occlusive arterial disease. Radiology 1972;102:181-3.  Back to cited text no. 16
    
17.Siegel ME, Williams GM, Giargiana FA, Wagner HN. A useful, objective criterion for determining the healing potential of an ischemic ulcer. J Nucl Med 1975;16:993-5.  Back to cited text no. 17
    
18.Johnson WC, Patten DH. Predictability of healing of ischemic leg ulcers by radioisotopic and Doppler ultrasonic examination. Am J Surg 1977;133:485-9.  Back to cited text no. 18
    
19.Nishimura A, Sano F, Nakanishi Y, Koshino I, Kasai Y. Omental transplantation for relief of limb ischemia. Surg Forum 1977;28:213-5.  Back to cited text no. 19
    
20.Maurya SD, Singhal S, Gupta HC, Elhence IP, Sharma BD. Pedicled omental grafts in the revascularization of ischemic lower limbs in Buerger's disease. Int Surg 1985;70:253-5.  Back to cited text no. 20
    
21.Singh I, Ramteke VK. The role of omental transfer in Buerger's disease: New Delhi's experience. Aust N Z J Surg 1996;66:372-6.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


This article has been cited by
1 An Observational Study to Analyze Outcome of Omentopexy in Buerger’s Disease in Tertiary Care Center
Kaichun Thiumai,Shalu Gupta,Somendra Bansal,Bhanwar Lal Yadav,Pradeep Verma
Indian Journal of Surgery. 2021;
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed4235    
    Printed201    
    Emailed0    
    PDF Downloaded332    
    Comments [Add]    
    Cited by others 1    

Recommend this journal