i have no relevant financial conflicts or disclosures...omentum –good cop or bad cop? good bad...
TRANSCRIPT
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I have no relevant financial
conflicts or disclosures
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Omentum:
Good Cop or Bad Cop?
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Omentum – Purpose?
• Hippocrates: formation and absorption of fluid
• Aristotle: protects the intestine against cold
• Vesalius: fixation ligament for the transverse
colon
• Ross (1890’s): protects the intestine against
injury “It is like a man-of-war ready to
sail to any port in which there is impending
trouble”
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Sir Rutherford Morison
British Medical Journal 1906
• “A special protective agency…the
abdominal policeman. It travels
around the abdomen with
considerable activity, and is attracted
by some sort of information to
neighborhoods in which mischief is
brewing”
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OmentumThe Policemen of the Abdomen
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Omentum:
Good Cop or Bad Cop?
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Omentum
• What is it and why does it exist?
• How does it work:
How does it move ?
How does it adhere ?
What is its role in malignancies ?
What is its role in bowel obstruction?
• What good is it?
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Omentum
• How can we use it:
• Should we remove it?
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Omentum - Structure
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J. Pathology 1926 Florey, Walker and
Carleton
“The question of omental reaction resolves
itself into two questions: (1) through what
agency does the omentum get into contact
with an injured area or foreign body, and (2)
how does it attach itself thereto?”
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How Does It Move?
• Intrinsic omental movement
o “chemiotaxis”
o Morison – moves like a jelly fish
o Cantacuzene – differences in electric potential
o Hertzler – leukocyte dependent “an individual’s
omentum is as smart as their leukocytes”
• Passive movement
– Diaphragmatic motion
– Peristalsis
– Gravity
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Omentum - movement
Movements of the omentum were randomAllen MS, Surgery 1954
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Omentum - Attachment
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Omentum - Attachment
?
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Omentum – What is its
function?Activated by:
– Infection
– Trauma
– Ischemia
– Foreign bodies
– Obesity
– Tumor metastases
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Activation of the Omentum
One week after activation with foreign body:
• Milky spots expand 15 to 20-fold
• Blood vessel density increases 3-fold
• Increased production of:VEGF P-/ E- selectin bFGF
• Increased progenitor cells, marked by: – SDF-1α
– CXCR-4
– WT-1
Litbarg et al. Cell Tissue Res 2007
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Boston: Officer O’mently
To The RescueSurgical Utility of Omentum
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Plastic Surgical Applications
“The omental free flap is a valuable option
for reconstructive efforts in nearly all
anatomic regions. This is a result of its
inherent anatomy and vascularity, and its
angiogenic, immunogenic, and lymphatic
properties” Mazzaferro et al., J Reconstr
Microsurg 2018
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Wound Bed Preparation
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Omentum as Healer
• Vascularized Omental Lymphatic Transfer
(VOLT)
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Omentum as Healer
• Anastomotic augmentation
– Duodenum
– Colon
– Esophagus
– Bronchus
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Graham Patch
for perforated ulcer
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Anastomotic Augmentation
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Does Omentum Improve
Anastomotic Healing?• Dai et al. Surgery 2011 Prospective
randomized study esophageal cancer resections
(n=255)
– Anastomotic leaks:
• 1% with omentum wrap
• 6% w/o omentum wrap p< 0.05
– Strictures:
• 6% with omentum wrap
• 16% w/o omentum wrap p< 0.05
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Does Omentum Improve
Anastomotic Healing?• Wiggins et al. Surgical Oncology 2015
Meta-analysis of esophageal and
colorectal anastomoses ( 9 studies, n= 2296)
– Esophageal leaks:
• 2.9% with omentum wrap
• 10.5% w/o omentum wrap p< 0.0001
– Colorectal leaks:
• 5.0% with omentum wrap
• 8.4% w/o omentum wrap NS
No difference in stricture or mortality
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Anastomotic Healing
Bronchus in lung transplantation or lung
resection?
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How Does Omentum Augment
Anastomotic Healing?• Neovascularity
– VEGF?
• Improved control of infection/ inflammation
– Milky spots
• Structural integrity
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Omentum
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Anastomotic Healing
Bronchus in lung transplantation or lung
resection?
Dog studies: omentum increases
capillary ingrowth to bronchus after auto-
transplantation
Early years of lung transplantation;
routinely used omental wraps -> now rarely
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Anastomotic Healing
Bronchus in lung transplantation or lung
resection?
Pancreatic fistula prevention?
Meta analysis w/ 2971 patientsTian Y et al. Hepatogastroenterology 2015
No reduction
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Omentum as Healer
Subtotal nephrectomy model
Rat model of 5/6 nephrectomy
Control animals had omentectomy
Experimental animals polydextran gel
particles injected to activate omentum
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Omentum as Healer
• After 12 weeks:
– Experimental rats had lower creat, BUN, less
glomerulosclerosis, thinner basement
membrane
– Stem cell Antigen-1, WT-1, and CD34
expression at the renal-omentum interface
Omentum slowed the progression of CKD, and
the repair of the injured kidney was associated
with stem cell activity derived from the omentum
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Omentum as Healer
Subtotal nephrectomy model
Activated omentum preserves renal function
Intra-abdominal fistula management
Reduction of femoral artery aneurysm after
axillary- bifemoral by-pass
Myocardial perfusion
Neural injury/ scarring/ ischemia
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©2005American Society of Plastic Surgeons. Published by Lippincott Williams & Wilkins, Inc. 2
Fig. 3
s of the Wrist: A Long-Term Follow-Up.Gbert; Steichen, James
Plastic & Reconstructive Surgery. 115(1):163-171, January 2005.DOI: 10.1097/01.PRS.0000138808.77038.D7
Fig. 3 . Omentum placed around the median nerve and microvascular anastomosis performed in the distal forearm.
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Omentum as Healer- Infection
• Omental flaps for:
– Mediastinitis
– Vascular graft infections
65 patients 93% survival
Frautschi RS et al. Ann Plast Surg 2017
– Infected AAA
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Infected Abdominal Aortic
Aneurysm
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Omentum as Healer
• Treatment for CNS disease:
– Spinal cord injury
– TIA
– Stroke
– Alzheimer’s Disease?
Neurotrophic factors
Improved neovascularization – esp. MMD
Konieczny MJ et al. World Neurosurgery 2016
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Omental Transposition for
Alzheimer’s Diseaes• Hypothesis: Decreased cerebral blood
flow is a cause of AD, not a consequence
of AD
• 9 of 25 patients treated with OT had
reversal of symptoms
• Theory: improved blood flow & VEGF,
stem cells, nerve growth factors
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Omentum as Safe Harbor
• Tissue engineering “incubator”
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Porcine Engineered Intestine
Grikscheit, CHLA
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Engineered Intestine
Courtesy of T.
Grikscheit, CHLA
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Omentum as Source of
Problems• Cysts
• Torsion
• Site of metastases
• Adhesive bowel obstruction
• Spontaneous bleeding
• “Engine of obesity”
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Omentum - Obesity
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Omentum: Role in Obesity
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Omentum in Obesity
• Produces adipokines:
Resistin Adiponectin
MIP MCP-1
IL-6 TNFα
GRO TIMP-1
• Omental fat effects myometrial artery
contraction
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Omentectomy as Rx for Obesity
• 2002 – 50 patients randomized to
omentectomy vs. no omentectomy with
adjustable gastric banding.
– Omentectomy associated with significantly
improved insulin sensitivity and glucose
tolerance at 2 years
• 2017 – 49 patients randomized to gastric
by-pass with and w/o omentectomy
– No significant improvement on weight, insulin
sensitivity, or hemodynamic profile
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Omentum - metastases
• Intra-abdominal malignancies
Ovarian, gastric, colon
• Adipocytes: micro-environment favorable
to metastases
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Omentum - metastases
• Intra-abdominal malignancies
Ovarian, gastric, colon
• Adipocytes: micro-environment favorable
to metastases
Chemokines Adhesion molecules
Growth factors
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Omentum – To keep or
remove?• David Tapper – “get rid of that (damn)
omentum. If you don’t, it will always
(mess) you up.”
• “The greater omentum, a useless and
hazardous organ for the patient and
surgeon. Advantages of omentectomy in
all abdominal operations” Yodice in El Dia
Medico, 1963
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Omentum – Role in Adhesions
Injury
Inflammation -> Fibrinous exudate
Decrease of t-PA
Overaccumulation of fibrin exudates
Increase of PAI-1
and PAI-2
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Omentum – To keep or remove?
Peritoneal dialysis
Retention of omentum:
? Increased filtration
? Improved immunologic protection
? Increased obstruction
Phan et al.
J Ped Surg 2013: Lack of omentectomy associated
with 2-fold increased risk of infection and malfunction, and
higher mortality
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Omentum – To keep or
remove?Ariake et al. Int. J. Surg 2015
Case:control study of 113 patients w/ ASBO
18 developed recurrence
95 no recurrence
Multivariate analysis: Omentectomy was
associated with 3-fold risk of recurrent
ASBO
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Omentum – Good Cop or Bad
Cop?
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Omentum
• Simple structure -> complex physiology
• Provides protection
• Versatile applications
• Central role in obesity
Must be treated with respect!
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Omentum – Good Cop or Bad
Cop?
Good
Bad