Reconstruction of large sacral defects following total sacrectomy

Sacrectomy and adjuvant radiotherapy for the treatment of sacral chordomas: a single-center experience over 27 years

STUDY DESIGN

Retrospective cohort (case only).

OBJECTIVE

To evaluate the results and survival determinants of 21 patients with sacral chordomas treated with en bloc resection and adjuvant radiotherapy.

SUMMARY OF BACKGROUND DATA

There are few long-term studies on treatment of sacral chordomas with more than 20 patients, and factors related to survival are not fully understood.

METHODS

Demographics, treatment, complications, and oncological outcomes were analyzed with summary statistics, hypothesis testing with Mantel-Haenszel-Cox analysis, log-rank test, Cox proportional hazard model, and Kaplan-Meier survival estimates as applicable.

RESULTS

There were 12 males and 9 females with mean age of 61 years (16-79) and mean follow-up of 5.8 years (2-19.2). Tumor stage was IB in 20 and IIIB in one; mean tumor size was 10.5 cm. Fourteen patients underwent combined anterior-posterior resection and 7 posterior resection alone; 18 received adjuvant radiotherapy. After treatment, bowel and bladder control were present in 4 and 5 patients, respectively. Complications included: wound infection (4), other wound complications (9), fistula (2), deep vein thrombosis (1), and pulmonary embolism (1). Median survival was 7.2 years. Eight (40%) had local recurrence and 4 (19%) metastatic disease. Mean disease-free interval before recurrence was 2.5 years (1-5). No patient (n = 8) treated in the past 9 years has had local or distant disease. Patients treated for recurrent tumor survived 5.7 years on average (range, 0.8-9) after the first recurrence. The only risk factor for tumor recurrence was proximal tumor extent (P = 0.05) There was a statistically significant association between recurrence and survival (RR = 3.8; 95% confidence interval, 1.0-15.3; P = 0.04).

CONCLUSION

Despite the complications, increased long-term survival can be achieved with treatment. Proximal tumor extent may be related to recurrence and survival. Recurrence rates have diminished over time, emphasizing the importance of an experienced multidisciplinary surgical team.

LEVEL OF EVIDENCE

N/A.

Immediate soft-tissue reconstruction using a rectus abdominis myocutaneous flap following wide resection of malignant bone tumours of the pelvis

Resection of malignant bony tumours of the pelvis creates large bone and soft-tissue defects, and is frequently associated with complications such as wound dehiscence and deep infection. We present the results of six patients in whom a rectus abdominis myocutaneous (RAM) flap was used following resection of a malignant tumour of the pelvis. Bony reconstruction was performed using a constrained hip tumour prosthesis in three patients, vascularised fibular graft in two and frozen autograft in one. At a mean follow-up of 63 months (16 to 115), no patients had a problem with the wound.

Immediate reconstruction using a RAM flap may be used after resection of a malignant tumour of the pelvis to provide an adequate volume of tissue to eliminate the dead space, cover the exposed bone or implants with well-vascularised soft tissue and to reduce the risk of complications.

Cite this article: Bone Joint J 2014;96-B:270–3.

Assessing the impact of a sacral resection on morbidity and survival after extended radical surgery for locally recurrent rectal cancer

OBJECTIVES

To describe the experience of sacrectomy with extended radical resection in the treatment of locally recurrent rectal cancer.

BACKGROUND

Resections of the bony pelvis, especially the sacrum, are becoming more common as part of extended radical exenterations for patients with recurrent rectal cancer. However, sacrectomy has been shown to carry a significant decrease in survival. Morbidity rates have been associated with the level of the sacrectomy (ie, >S3 junction).

METHODS

An analysis was conducted using prospective data from patients with recurrent rectal cancer who underwent pelvic exenteration involving sacrectomy from July 1998 until June 2011. The impact of the proximal level of sacrectomy [low (≤S3) vs high (≥S2-S3 disc)] was compared.

RESULTS

Of 240 exenteration patients, 79 underwent sacrectomy, with 49 for recurrent rectal cancer. An R0 margin was achieved in 36 (74%) patients. Achievement of clear operative margins (R0) conferred a large and significant benefit for disease-free survival compared with R1 and R2 resections (median 45 months vs 19 and 8 months, respectively; P = 0.045). Complications were reported in 40 (82%) patients, with major and minor complications in 19 (39%) and 38 (78%) patients, respectively. The proximal level of the sacrectomy (high vs low) did not significantly impair the ability to achieve a clear margin and was not associated with an increase in major or minor complications.

CONCLUSIONS

This large, single-center series has demonstrated that extended pelvic exenteration involving sacrectomy has excellent R0 margins and survival rates for recurrent rectal cancer. A high sacrectomy has comparable results with a more distal abdominosacral resection.

Current treatment of sacral giant cell tumour of bone: a review

Sacral giant cell tumour of bone has an insidious onset and slow growth rate, making early diagnosis difficult. The tumour has a high recurrence rate and is often fatal. Magnetic resonance imaging and computed tomography (CT), including CT-guided fine-needle biopsy, are useful for early diagnosis. Although therapy for sacral giant cell tumour often involves surgical resection and reconstruction challenges, improvements in various treatment modalities, including arterial embolization and radiotherapy, have widened the effective treatment options. The current surgical and adjuvant treatment modalities available for the management of sacral giant cell tumour are systematically reviewed and a suggested treatment algorithm is provided. En bloc excision remains the surgical procedure of choice, with functional reconstruction important in cases where the lesion is high in the sacrum. The use of adjuvant radiotherapy and chemotherapy remains controversial and should be studied further. Determination of the optimum treatment for sacral giant cell tumour will require randomized controlled trials. Early diagnosis, complete surgical resection with tumour-free margins and comprehensive treatment are important for local tumour control and improved outcome.

Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer

BACKGROUND

An alternative treatment for low rectal cancer is the cylindrical technique. We aim to compare the outcomes of patients undergoing conventional abdominoperineal resection (APR) versus cylindrical APR.

METHODS

A prospective, randomized, open-label, parallel controlled trial was conducted between January 2008 and December 2010. Sixty-seven patients with T3-T4 low rectal cancer were identified during the study period (conventional n = 32, cylindrical n = 35).

RESULTS

Patients who received cylindrical APR had less operative time for the perineal portion (P < .001), larger perineal defect (P < .001), less intraoperative blood loss (P = .001), larger total cross-sectional tissue area (P < .001), similar total operative time (P = .096), and more incidence of perineal pain (P < .001). The local recurrence of the cylindrical APR group was improved statistically (P = .048).

CONCLUSIONS

Cylindrical APR in the prone jackknife position has the potential to reduce the risk of local recurrence without increased complications when compared with conventional APR in the lithotomy position for the treatment of low rectal cancer.

A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database

AIM

The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration for primary advanced (PARC) or locally recurrent (LRRC) rectal cancer. We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long-term outcome.

METHOD

There were 90 consecutive patients (PARC/LRRC 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database.

RESULTS

The median age was 63 (32-75) years with a gender ratio of 7 women to 83 men. All patients were American Society of Anesthesiologists level I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC (P=0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC (P=0.007). Forty-four (49%) patients had no postoperative complications. Fifty-five major complications were registered. Two (2.2%) patients died within 30 days, and the total in-hospital mortality was 5.6%. The median follow-up was 12 (0.4-91) months. The 5-year survival was 46% for PARC and 17% for LRRC (P=0.16).

CONCLUSION

Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long-term survival, especially for patients with PARC. However, pelvic exenteration is also justified for patients with LRRC.

Utility of the omentum in sacral reconstruction following total sacrectomy due to recurrent and irradiated giant cell tumour of the spine

Reconstruction of the lumbosacral region after surgical excision of irradiated and recurrent spinal giant cell tumours remains a challenging problem. In this case report, we describe the use of the pedicled omentum flap in reconstruction of an irradiated and infected wide sacral defect of a 19-year-old male patient. The patient had radiotherapy and subsequent wide surgical resection after recurrence of the tumour. A myocutaneous flap from the gluteal area had failed previously. Local flap options could not be used because of the recent radiotherapy to the gluteal area. Since the patient had a laparotomy for tumour resection and a colostomy, abdominal muscles were not considered reliable for reconstructive procedures. A pedicled omentum flap was chosen as a reconstructive option because of its rich blood supply, large surface area, and angiogenic capacity. This report aims to describe the use of the pedicled omentum flap for reconstruction of the lumbosacral area following surgical resection of a spinal tumour, when gluteal and abdominal flap options for reconstruction are jeopardised.

Surgical treatment of sacral metastases: indications and results

OBJECT

Hematogenous metastases to the sacrum can produce significant pain and lead to spinal instability. The object of this study was to evaluate the palliative benefit of surgery in patients with these metastases.

METHODS

The authors retrospectively reviewed all cases involving patients undergoing surgery for metastatic disease to the sacrum at a single tertiary cancer center between 1993 and 2005.

RESULTS

Twenty-five patients (21 men, 4 women) were identified as having undergone sacral surgery for hematogenous metastatic disease during the study period. Their median age was 57 years (range 25-71 years). The indications for surgery included palliation of pain (in 24 cases), need for diagnosis (in 1 case), and spinal instability (in 3 cases). The most common primary disease was renal cell carcinoma. Complications occurred in 10 patients (40%). The median overall survival was 11 months (95% CI 5.4-16.6 months). The median time from the initial diagnosis to the diagnosis of metastatic disease in the sacrum was 14 months (95% CI 0.0-29.3 months). The numerical pain scores (scale 0-10) were improved from a median of 8 preoperatively to a median of 3 postoperatively at 90 days, 6 months, and 1 year (p < 0.01). Postoperative modified Frankel grades improved in 8 cases, worsened in 3 (due to disease progression), and remained unchanged in 14 (p = 0.19). Among patients with renal cell carcinoma, the median overall survival was better in those in whom the sacrum was the sole site of metastatic disease than in those with multiple sites of metastatic disease (16 vs 9 months, respectively; p = 0.053).

CONCLUSIONS

Surgery is effective to palliate pain with acceptable morbidity in patients with metastatic disease to the sacrum. In the subgroup of patients with renal cell carcinoma, those with the sacrum as their solitary site of metastatic disease demonstrated improved survival.

Posterior-Only Approach for En Bloc Sacrectomy

BACKGROUND:

En bloc resection of primary sacral tumors has a demonstrated survival benefit. Total and high sacral amputations are traditionally performed by using a staged anterior and subsequent posterior approach. However, we have found that en bloc resection and biomechanical reconstruction of the spinal column is possible from a posterior-only approach in many cases.

OBJECTIVE:

To assess our series of posterior-only sacrectomies, emphasizing postoperative complications and overall surgical and oncologic outcome.

METHODS:

Sixty-nine consecutive patients underwent sacral resections for tumor at our institution between 2004 and 2009. Medical records of all patients were reviewed, and patients were excluded if they had an intentional intralesional resection, hemipelvectomy, or a previous operation. The records of the resulting 36 consecutive patients who underwent primary posterior-only en bloc sacral resections were retrospectively reviewed.

RESULTS:

Of the posterior-only patients, all underwent midline posterior approaches for en bloc sacral resection. Sacral amputation was defined by the by sacral root preservation: total (2 cases), high (8 cases), middle (9 cases), low (12 cases), and distal (5 cases). Chordoma was the most common tumor type (30 cases), and surgical margins were marginal in 34 cases and contaminated in 2. Overall, there were 13 complications, including 9 wound infections/revisions. The extent of sacrectomy, and thus the extent of roots sacrificed, correlated with functional outcome.

CONCLUSION:

It may be possible to perform a posterior-only approach to en bloc sacral resections/reconstructions in patients with tumors that do not extend beyond the lumbosacral junction or invade the bowel requiring bowel resection and diversion.

Infections in surgery of primary tumors of the sacrum

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To evaluate the risk of infection, related treatment, and outcome after surgery of the 2 most common primary sacral tumors.

SUMMARY OF BACKGROUND DATA

Rarity of sacral tumors has limited the number of population-based studies. Treatment depends on malignancy or local aggressiveness: wide resection is indicated for malignant lesions, intralesional surgery for benign.

METHODS

We studied 82 patients with sacral chordomas (55 cases) or giant cell tumor (GCT) (27 cases) treated between 1976 and 2005. All patients had IV antibiotic therapy with amikacin and teicoplanin. Surgery of chordoma was resection; surgery of GCT was intralesional excision. Infections were classified as immediate postoperative, early (within 6 months), and late (more than 6 months from surgery). Mean follow-up was 9.5 years (range: 3-27 years). Some factors possibly influencing the risk of infection were statistically analyzed by Kaplan Meier curves and log-rank test.

RESULTS

No deep infections were observed in the GCT series. Three patients with sacral chordoma died for postoperative complications and were excluded from this analysis. Of the remaining 52 patients with chordoma, 23/52 had deep wound infection (44%) that required 1 or more surgical debridements combined with antibiotics, according to cultures. In 16 patients (70%), infection occurred within 4 weeks postoperatively, and in 7 within 6 months. Most frequent bacteria were Enterococcus (23%), Escherichia coli (20%), and Pseudomonas aeruginosa (18%). In 74% of cases, infection was multimicrobial. Level of resection, previous intralesional treatment elsewhere, tumor volume, and age did not statistically influence risk of infection.

CONCLUSION

Type of surgery was the prominent factor related to a major risk of infection. Operating procedure time correlated as well. Resections of sacral chordoma imply a high risk of deep infection, while intralesional excision of GCT does not. All infections healed with surgical debridements and antibiotic therapy.

Pelvic resections

The complexity of pelvic anatomy and the extent of tumor growth makes treatment of patients with primary bone sarcomas in the pelvis difficult in terms of local control. Before the 1970s, most tumors in the bony pelvis were surgically treated with hindquarter amputation. Currently, improved techniques for clinical staging, adjuvant treatments, evolutions in metallurgy, and development of new surgical techniques make limb-salvage surgery and reconstruction possible alternatives to hemipelvectomy and resection-arthrodesis. The advantages of amputation over resections at the pelvis are a lower incidence of complications, a limited area at risk for recurrence, and a faster recovery time compared with all but the most limited pelvic resections. The disadvantages, especially after periacetabular resections, are leg-length discrepancy and impaired hip and gait function. The indication for limb salvage is the ability to obtain wide margins without compromising survival and function. Although having to resect the sciatic nerve to obtain adequate margins does not always mean that an amputation should be performed, the combination of a major pelvic resection and the functional consequences of sciatic nerve resection results in an extremity usually not worth saving; loss of femoral nerve function does not result in a significant gait disturbance, especially if the hemipelvis is stable. Reconstruction options after major pelvic resections have also evolved, but they remain difficult, especially when the acetabulum is involved.

Anterior thigh flap extended hemipelvectomy and spinoiliac arthrodesis

We present the technique of anterior thigh flap extended external hemipelvectomy with spinoiliac arthrodesis in treatment of the patient with recurrent low-grade pelvic chondrosarcoma extending to the lower lumbar spine. Extended hemipelvectomy involves skeletal resection beyond the standard hemipelvectomy that is the SI joint by removal of contiguous musculoskeletal structures, such as elements of the sacral and lumbar spine or contralateral pelvic bone, in addition to the affected innominate bone. Spinoiliac arthrodesis reestablishes spinopelvic stability; the anterior thigh musculocutaneous flap provides reliable well-vascularized soft tissue coverage. This technique may serve an important role in the surgical management of patients with low-grade pelvic malignancies.

The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients

PURPOSE

The vertical rectus abdominis muscle (VRAM) flap is considered a safe and simple option to cover defects of the trunk and proximal thigh. Detailed long-time follow-up studies in oncologic patients including complications and donor site morbidity are rare. In this study, complications and donor site morbidity were analysed.

METHODS

Data of 78 consecutive patients with oncologic disease, having received VRAM flaps, were analysed retrospectively. Patients with soft tissue sarcomas (n = 38), radiation ulcers (n = 18), carcinoma (n = 10), wound-healing difficulties after tumour resection (n = 8), breast reconstruction after ablation (n = 3) and malignant melanoma (n = 1) were included. Statistics concerning patients' satisfaction, the occurrence of wound-healing difficulties, incisional herniation, loss of abdominal wall strength in correlation to operative and (neo)adjuvant treatment and patients' history were performed. The mean follow-up time was 5.5 years.

RESULTS

No complete flap loss was observed. A body mass index over 30 was positively correlated with wound-healing difficulties; radiation had no negative effect. A contralateral cutaneous pedicle could reduce the risk of lymphoedema in groin defect patients. Incisional hernia was present in 13%. Strength endurance of the abdominal wall was reduced compared to an age-matched control. Most patients were satisfied with the postoperative result.

CONCLUSIONS

VRAM flaps are reliable tools for defect coverage in the oncologic patient to prevent chronic ulceration, lymphangitis or more severe complications like septic rupture of femoral vessels and hip disarticulation. Donor site morbidity is tolerable, and patients' satisfaction is high.

Clinical algorithms for the surgical management of locally recurrent rectal cancer

PURPOSE

Advances in surgical practice have helped expand the options for patients with locally recurrent rectal cancer through improvements in reconstructive options, management of operative complications, addition of intraoperative adjuvant therapies, and postoperative care. This review outlines the presentation and management of patients with locally recurrent rectal cancer, and it describes easy-to-apply clinical algorithms to aid management.

METHODS

The electronic literature was searched for studies reporting outcomes for locally recurrent rectal cancer limited to the English language.

RESULTS

Prospective and retrospective case series and single-center experiences were identified. A total of 106 articles were selected for full-text review of which 82 fulfilled the inclusion criteria. No randomized studies were identified. We found that multimodality treatment of locally recurrent rectal cancer can improve 5-year survival from 0% to over 40%, and selected patients may survive up to 10 years. A mixture of imaging modalities is used in patient selection for surgery. An R0 resection is consistently a favorable prognostic factor. R1 resection and surgery in the setting of oligometastases compare favorably with nonoperative palliation. Although mortality figures remain low, morbidity is significant and mostly wound related.

CONCLUSIONS

Improvements in radiological imaging modalities and technical improvements in surgical and reconstructive options have facilitated more accurate staging, better selection of patients for surgery, reduced morbidity and mortality, and higher R0 resections. Optimal management is in specialist units with a multidisciplinary approach with the use of multimodal therapy.

Surgery for recurrent rectal cancer: technical notes and management of complications

Local recurrence following surgery for rectal cancer remains a significant clinical problem and poses major therapeutic challenges. Radical surgical salvage is the only option with potential for curative treatment and is indicated in carefully selected patients. Surgery also provides acceptable palliation in certain cases. Nevertheless, such surgery is challenging, not commonly used, and historically associated with considerable morbidity and mortality. In more recent times, improvements in surgical techniques, reconstruction methods and management of perioperative complications have helped expand the options available for patients with recurrent rectal cancer. This review article highlights the techniques employed at our institution for the management of locally recurrent rectal cancer with particular emphasis on the surgical approaches, the methods used for reconstruction and the avoidance of complications.

Pelvic floor reconstruction using human acellular dermal matrix after cylindrical abdominoperineal resection

PURPOSE

Patients who undergo cylindrical abdominoperineal resection can have significant complications, especially those who require pelvic reconstruction using myocutaneous flaps. Reconstruction using a biomaterial may be a novel alternative. The purpose of this study is to report the initial results of pelvic reconstruction using human acellular dermal matrix after cylindrical abdominoperineal resection.

METHODS

Between January 2008 and February 2009, pelvic floor reconstruction was performed in 12 consecutive patients who underwent cylindrical abdominoperineal resection for advanced ultralow rectal cancer.

RESULTS

Two weeks after the operation, primary complete healing of the perineal wound was seen in 11 patients. At a median follow-up of 8 months, there was no perineal wound breakdown, bulge, or herniation. One patient had an asymptomatic seroma, one patient had a perineal wound infection, and 4 patients had perineal pain that resolved.

CONCLUSIONS

Human acellular dermal matrix provided a safe alternative for the reconstruction of large pelvic defect in the patients after cylindrical abdominoperineal resection.

Adjuvant radiation therapy and chondroid chordoma subtype are associated with a lower tumor recurrence rate of cranial chordoma

Cranial chordomas are rare tumors that have been difficult to study given their low prevalence. Individual case series with decades of data collection provide some insight into the pathobiology of this tumor and its responses to treatment. This meta-analysis is an attempt to aggregate the sum experiences and present a comprehensive review of their findings. We performed a comprehensive review of studies published in English language literature and found a total of over 2,000 patients treated for cranial chordoma. Patient information was then extracted from each paper and aggregated into a comprehensive database. The tumor recurrences in these patients were then stratified according to age (<21 vs. >21 years), histological findings (chondroid vs. typical) and treatment (surgery and radiation vs. surgery only). Data was analyzed via Pearson chi-square and t-test. A total of 464 non-duplicated patients from 121 articles treated for cranial chordoma met the inclusion criteria. The recurrence rate among all patients was 68% (314 patients) with an average disease-free interval of 45 months (median, 23 months). The mean follow-up time was 39 months (median, 27 months). The patients in younger group, patients with chordoma with chondroid histologic type, and patients who received surgery and adjuvant radiotherapy had significantly lower recurrence rate than their respective counterparts. The results of our systematic analysis provide useful data for practitioners in objectively summarizing the tumor recurrence in patients with cranial chordomas. Our data suggests that younger patients with chondroid type cranial chordoma treated with both surgery and radiation may have improved rates of tumor recurrence in the treatment of these tumors.

Staged sacrectomy--an adaptive approach

Object Sacral tumors are commonly diagnosed late and therefore present at an advanced stage. The late presentation makes curative surgery technically demanding. Sacrectomy is fraught with a high local recurrence rate and potential complications: deep infection; substantial blood loss; large-bone and soft-tissue defects; bladder, bowel, and sexual dysfunction; spinopelvic nonunion; and gait disturbance. The aim of this study was to analyze the complications and morbidity of sacrectomy and the modifications meant to reduce the morbidity. Methods This is a retrospective study of the patients who underwent sacrectomy between February 1997 and September 2008 in the Department of Surgical Oncology, Government Royapettah Hospital, Kilpauk Medical College, in Chennai, Tamilnadu, India. Sacrectomy was performed using 1 of the following approaches: posterior approach, abdominolateral approach, or abdominosacral approach, either as sequential or staged operations. The morbidity rate after the sequential and staged abdominosacral approaches was analyzed. Functional assessment was made based on the Enneking functional scoring system. The results were analyzed and survival analysis was done using the Kaplan-Meier method (with SPSS software). Results Nineteen patients underwent sacrectomy, of which 12 operations were partial, 3 were subtotal, and 4 were total sacrectomy. Histological diagnosis included giant cell tumor, chordoma, chondroblastoma, adenocarcinoma of rectum, and retroperitoneal sarcoma. The giant cell tumor was the most common tumor in this series, followed by chordoma. The patients' mean age at diagnosis was 32 years. There were 10 male and 9 female patients. Fortyseven percent of patients had bowel and bladder disturbances postoperatively, and 57.89% of patients had wound complications. The median follow-up duration was 24 months (range 2-140 months). The 5-year overall survival rate was 70.4%, and the 5-year disease-free survival rate was 65% (based on the Kaplan-Meier method). The local recurrence rate (5 cases) was 26.32%. The median duration for first recurrence was 12 months (range 3-17 months). Distant metastasis occurred in 1 patient (5.26%), and 4 patients died, 1 of them due to pulmonary thromboembolism, in the postoperative period. Based on the Enneking system of functional evaluation, 5 patients (26.32%) had excellent outcome, 6 (31.57%) had good outcome, 5 (26.32%) had fair outcome, and 3 (15.78%) had poor outcome. Spinopelvic reconstruction was not performed in any of the patients, and all were ambulatory postoperatively. The staged abdominosacral approach has markedly reduced patient morbidity in terms of reduction of operating time, blood loss, anesthesia complications, and wound complications. Conclusions Sacrectomy, a dreaded operation that often results in morbidity, is now feasible with modifications and improvement in surgical technique. The staged abdominosacral approach reduces the immediate postoperative morbidity. Use of a gluteal advancement flap reduces the incidence of wound complications. With modern surgical facilities and postoperative care, sacrectomy is feasible via the staged abdominosacral approach.

“Reversed turnover” latissimus dorsi muscle flap for reconstruction of a deep sacral defect after a severe pelvic fracture

A 17-year-old man was severely injured including a fractured pelvis and a degloving injury to the lumbar, sacral, and gluteal regions. After multiple revisions, a 6 x 7 cm wide x 10 cm deep defect in the sacral area was successfully treated by transfer of a reversed turnover latissimus dorsi muscle flap. He is now fully mobilised three years later.

Sacrectomy for primary sacral tumors

PURPOSE

En bloc resection with adequate margins has provided a chance for cure of primary sacral tumors. However, high sacral lesions are challenging because of the complexity of the surgical approach. The aims of this study were to describe a modification in technique and to evaluate the outcomes.

METHODS

This is a study of eight sacrectomies performed at King Chulalongkorn Memorial Hospital between February 2000 and July 2007. Cadaveric dissections were carried out prior to surgery. We have modified the technique by ligation of the branches of the external iliac veins, resulting in "isolation" of the external iliac veins. Spinopelvic reconstruction was performed for total and extended total sacrectomy. Closure of the sacral defect was done with use of the Hartmann stump and the gluteus maximus flaps.

RESULTS

Two total sacrectomies, one extended total sacrectomy, and five subtotal S1 sacrectomies were performed. En bloc resection with adequate margins was achieved in all patients. The patient who underwent extended total sacrectomy and one patient who underwent total sacrectomy had nonunion requiring removal of the spinopelvic instrumentation. Five patients who underwent subtotal sacrectomy were ambulating well postoperatively, except for one who had an S1 fracture after falling. No sacral hernias were observed. None of the patients developed recurrence of the primary tumor. Mean follow-up time was four years.

CONCLUSIONS

Sacrectomy for primary sacral tumors can be safely conducted, achieving tumor-free margins and acceptable functional and long-term outcomes.

Reconstruction of the pelvic floor with a biological mesh after abdominoperineal excision for rectal cancer

AIM

The aim of the study is to describe the results of reconstruction of the pelvic floor by using an absorbable biological mesh after having performed an abdomino-perineal resection with excision of whole of the pelvic floor for rectal cancer

MATERIAL AND METHODS

Eleven consecutive patients had reconstruction of the pelvic floor after abdominoperineal excision (APR) with a biological mesh. The peri- and postoperative courses were registered in a prospective database. Six patients received preoperative radiochemotherapy.

RESULTS

One patient had the mesh removed due to infection and later developed local recurrence. The rest had an uneventful postoperative course despite more pain than is usually experienced in the perineal wound after traditional APR.

CONCLUSION

The use of a biological mesh for pelvic floor reconstruction is feasible with satisfactory results. A randomised trial is warranted in order to evaluate this technique properly.

Reconstruction of large sacral defects following tumour resection: a report of two cases

Sacral tumours often present surgical resection and reconstruction challenges. Wide resections result in large sacral defects and neoadjuvant radiotherapy impairs wound healing. The wounds need to be covered with bulky, well-vascularised, healthy tissues. We present 2 cases where large sacral defects were reconstructed following tumour resection. Both defects were reconstructed with inferiorly based, transpelvic, pedicled vertical rectus abdominis myocutaneous flaps. This is a robust flap and carries a well-vascularised muscle bulk and skin paddle. The donor site is distant from the lesion site and is thus unaffected by both the resection and radiotherapy. This is a useful flap for reconstructing large sacral defects.

En Bloc Total Sacrectomy Performed in a Single Stage through a Posterior Approach

Objective:

Total sacrectomies are performed for extensive en bloctumor resections. Exposure traditionally combines a posterior approach with a laparotomy to facilitate vascular control. We present a case of a total en bloc sacrectomy performed entirely through the posterior approach, thereby avoiding the need for a laparotomy.

Clinical Presentation:

A 57-year-old man presented with sacral pain and loss of bowel and bladder function. A large sacral mass was identified and submitted to biopsy. Results were consistent with an osteoblastoma, although osteosarcoma could not be excluded on pathological examination. The patient was taken to the operating room for a total sacrectomy and en bloc resection of the mass.

Technique:

Lateral iliac osteotomies were performed, followed by an L5–S1 discectomy and resection of the annulus, thus mobilizing the sacrum. Gradual distraction of the interspace coupled with upward traction of the sacrum provided an anterior exposure through which the internal iliac vessels were controlled, dissected, and divided. A combined transperineal approach completed the posterior dissection and the tumor was delivered en bloc. Lumbopelvic reconstruction was performed simultaneously.

Conclusion:

With the use of interspace distraction and sacral elevation to facilitate vascular control, a total sacrectomy was performed without the need for the anterior exposure of a laparotomy.

Surgisis Mesh Repair of a Postsacrectomy Perineal Hernia along with Posterior Proctosigmoidectomy for Concomitant Stricture

Postsacrectomy hernias are uncommon and can present with different signs and symptoms, including constipation, fecal incontinence, bowel obstruction, pain, and posterior bulging. We report a 50-year-old man who underwent sacrectomy for malignant fibrosarcoma complicated with sacral hernia. He presented with obstructive symptoms resulting from a strictured segment of herniated sigmoid colon and underwent bowel resection along with repair of his hernia. We additionally present a review of the literature and treatment of this rare disease.

Successful management of recurrent coccygeal hernia with the de-epithelialised rectus abdominis musculocutaneous flap

OBJECTIVE

Little data exist about the optimal management of the rare coccygeal hernia. A novel method of repair is reported.

METHODS

A 46-year-old woman presented with a symptomatic coccygeal hernia after resection of the coccyx for a tumour. She had previously been reconstructed with an on-lay polytetrafluorethylene (PTFE) mesh but subsequently developed a hernia. A de-epithelialised vertical rectus abdominis musculocutaneous flap was elevated and passed through the hernia defect. The de-epithelialised dermis was secured to the levator ani and to the periosteum of the sacrum via access through a posterior approach. The gluteal skin was closed primarily over the inset flap.

RESULTS

The de-epithelialised rectus abdominis musculocutaneous flap is a viable option for the treatment of coccygeal hernia.

RELEVANCE

The de-epithelialised rectus abdominis flap has several advantages over other techniques including mesh repair and anterior or posterior flap repairs of the coccygeal hernia. The transposed muscle blocks herniation through the pelvic floor and does not create the dead space that is associated with posterior flap repairs such as the bilateral gluteal advancements. It also has the advantages of the posterior approach mesh repair, as the de-epithelialised dermis provides significant strength when secured like mesh to healthy local tissue.

Reconstructive strategies in soft tissue reconstruction after resection of spinal neoplasms

STUDY DESIGN

A retrospective study of 134 consecutive cases in 92 patients who underwent soft tissue reconstruction of the spinal region following tumor removal.

OBJECTIVE

To better understand how to optimize outcomes in soft tissue reconstruction of the spine region.

SUMMARY OF BACKGROUND DATA

With the increasing use of instrumentation and the fact that many patients with spinal neoplasms have debilitated wound-healing capacity, most of these patients are at high risk for postsurgical wound complications. Unfortunately, the optimal strategy to prevent and to manage complex wound complications involving the spinal region remains unclear.

METHODS

Factors potentially associated with the outcome of the reconstruction, including previous radiation therapy, chemotherapy, or surgery; medical comorbidities; timing of the reconstructive surgery; location of the defect; reconstructive approach; and presence of instrumentation, were evaluated and compared.

RESULTS

Of 92 patients, 29 patients (32%) developed postoperative wound complications. Among 32 patients with instrumentation of the spine, the 10 patients who had prophylactic soft tissue reconstruction had a significantly lower incidence of complications than did the 22 patients who had not (20% vs. 45%, P = 0.018). Furthermore, those who had previous surgery to the spine had a significantly higher risk of developing exposed instrumentation than did those who did not (21% vs. 0%, P = 0.002). Of 9 patients with exposed instrumentation, all but 1 patient had successful coverage of the instrumentation. Ninety (98%) of 92 patients had successful closure of the wound at the time of their last follow-up.

CONCLUSIONS

In the presence of instrumentation, providing preemptive soft tissue reconstruction at the time of the initial spinal surgery can help minimize potentially serious wound complications. For management of wound complications that have developed, an aggressive debridement and coverage with well-vascularized tissue can allow for expedient wound healing while maintaining stabilized instrumentation.

A New Technique of ???Double-A??? Bilateral Flaps Based on Perforators for the Treatment of Sacral Defects

BACKGROUND

Myocutaneous and fasciocutaneous flaps can provide stable coverage of sacral defects. For neurologically intact patients, sensate innervated gluteal artery perforator flaps are the ideal solution. For patients with spinal cord injury, soft-tissue coverage can be performed with a variety of noninnervated flaps.

METHODS

Between 1997 and 2004, the authors operated on 30 patients, 21 men and nine women, using bilateral gluteal distal fasciocutaneous and proximal musculocutaneous vertical vector rotation-advancement flaps, based on perforators with V-Y closures. The ages of the patients ranged from 32 to 74 years. Twenty-five patients had spinal cord injuries and all had sacral pressure sores extending to the bone. Three patients had low-grade malignant tumors (sacral chordomas); one had a sacral radiation-induced necrosis and two senile patients with large sacral defects had chronic renal failure and multiple sclerosis. No comorbidities were found in the sample.

RESULTS

All the lesions were closed successfully. After follow-up of 1 to 8 years, 27 patients never required repeated surgery after wound complications. Three patients had infection and partial dehiscence of the flaps that healed after reoperation with V-Y readvancement; three died as a result of their primary diseases.

CONCLUSIONS

This flap design has been used only in selected cases because, after its elevation, use of other gluteal-based flaps for future sacral reconstructions may not be possible. Five neurologically intact patients were found to have good sensitive protection of the flaps and adequate cushion contour after surgery because the authors conserved the gluteal arteries, perforators, and their corresponding sensory nerves.

Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer

BACKGROUND

Intraoperative tumour perforation, positive tumour margins, wound complications and local recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer. An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor. The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients.

METHODS

The principles of operation are that the mesorectum is not dissected off the levator muscles, the perineal dissection is done in the prone position and the levator muscles are resected en bloc with the anus and lower rectum. The perineal defect is reconstructed with a gluteus maximus flap. Between 2001 and 2005, 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital.

RESULTS

Two patients had ypT0 tumours, 20 ypT3 and six ypT4 tumours. Bowel perforation occurred in one, the circumferential resection margin (CRM) was positive in two, and four patients had local perineal wound complications. Two patients developed local recurrence after a median follow-up of 16 months.

CONCLUSION

The extended posterior perineal approach with gluteus maximus flap reconstruction in APR has a low risk of bowel perforation, CRM involvement and local perineal wound complications. The rate of local recurrence may be lower than with conventional APR.

Transsciatic foramen pedicle VRAM coverage of gluteal defects

Tumors of the gluteal region are rare. Defects from resection often can be closed primarily. Some patients require local flaps such as a gluteus maximus V-Y advancement flap. Such flaps typically result in some muscle dysfunction. In addition, the use of local irradiated tissue may lead to wound complications and prolonged hospitalization. Avoiding local radiated tissue, such as the gluteal muscles, can be beneficial. We report our experience using a novel route by passage through the transsciatic foramen to transpose a pedicle vertical rectus abdominis myocutaneous flap. This regional option avoids gluteal muscle dysfunction and potential wound complication from irradiated tissue.

A novel "four-rod technique" for lumbo-pelvic reconstruction: theory and technical considerations

STUDY DESIGN

Surgical technique with case example.

OBJECTIVE

To report on a novel technique that allows for the placement of 4 separate longitudinal rods across the lumbo-pelvic junction.

SUMMARY OF BACKGROUND DATA

Despite advances in surgical techniques and instrumentation, lumbo-pelvic fixation remains a significant challenge. Fusions to the pelvis create long lever arms and generate high forces across the lumbosacral junction, resulting in high rates of screw pullout and implant fracture. In the attempt to achieve better bony fixation, techniques described include the use of bone cement, hydroxyapatite, and expandable screws. Although this process has decreased the incidence of screw pullout, it has not addressed the problem of rod fracture at the lumbo-pelvic junction.

METHOD

There are 4 separate longitudinal rods placed across the lumbo-pelvic junction that couples proximal lumbar screw anchors to 4 separate pelvic fixation points. Proximal lumbar fixation anchors are based on alternating Roy-Camille "straight ahead" screws and Magerl "lateral to medial converging" pedicle screws. There are 4 distal pelvic fixation anchors used based on 1 pair of Galveston-like screws and 1 pair of proximal iliac wing screws.

RESULTS

Early results of both ex vivo and in vivo reconstruction show that careful insertion of the lumbar and pelvic screws allows for divergent placement of the pedicle screw heads in a manner that 2 longitudinal rods can be placed per side, resulting in a total of 4 longitudinal rods across the lumbo-pelvic junction. Selection of cross-links in various combinations allows for additional axial and torsional stability, depending on the desired reconstruction.

CONCLUSION

Longer follow-up is necessary, and biomechanical and finite element studies are needed to show long-term efficacy of this technique, however, early results indicate that such a construct is feasible. Furthermore, depending on the general medical condition of the patient, immediate postoperative weight bearing is possible and reasonable.

Reconstruction of parasacral hernia with acellular human dermis graft

Parasacral hernias are defects through the pelvic floor which occur as the result of sacral resection. These defects are often large, and are frequently the result of treatment for sacral malignancies. This report documents the case of a 71-year-old woman who underwent radical coccygectomy and partial sacrectomy for a chordoma and subsequently presented 1 year later with a large parasacral hernia. The defect was repaired using an acellular human dermis graft with a gluteus maximus muscle-advancement flap overlay. This article summarizes the current literature of this challenging clinical problem, and examines the use of acellular human dermis in the repair of complex hernias.

Reconstruction of Extensive Partial or Total Sacrectomy Defects With a Transabdominal Vertical Rectus Abdominis Myocutaneous Flap

Following partial or total sacrectomy, extensive soft tissue defects are frequently created. These ablations typically involve an anterior and a posterior approach, creating a large communication between the abdominal cavity and the central gluteal region. Local flap options are usually not sufficient for definitive closure of these large defects. We have found that the most useful option for reconstruction in these cases is a vertical rectus abdominis myocutaneous (VRAM) flap, passed transabdominally through the peritoneal cavity into the sacral defect during the initial anterior-approach portion of the procedure and then inset following completion of the posterior-approach final resection. Advantages of the VRAM flap are that it can supply ample skin, as well as soft tissue bulk, is easy to perform, and does not require microvascular techniques. Utilizing a prospectively maintained database, all patients over the last 14 years who underwent reconstruction utilizing a transabdominal VRAM flap following extensive partial or total sacrectomy with intraabdominal communication were identified. A retrospective chart review was then performed. Our study population consisted of 12 patients with a mean age of 58.5 years. Following sacrectomy, all patients underwent reconstruction with a VRAM flap. Flap sizes averaged 9.1 x 27 cm. Early flap complications included 3 small areas of flap necrosis at the distal, superior portion of the flap, 2 of which required minimal operative intervention of debridement and reclosure. No late flap complications have occurred, and all 12 patients completely healed, with a mean follow-up time of 29.1 months. Following sacrectomy, extensive soft tissue defects are created in the sacral area and communicate with the abdominal cavity. In these situations, we have found the inferiorly-based pedicled VRAM, passed transabdominally, to be the most reliable and useful choice of flap reconstruction. It has a low incidence of complications, low morbidity, and is easy to perform with a high success rate.

En bloc resection of primary sacral tumors: classification of surgical approaches and outcome

OBJECT

En bloc resection with adequate margins is associated with the highest probability of long-term tumor control or cure in most cases of primary sacral malignancies. The authors present their experience with a systematic approach to these lesions. They provide a novel classification of surgical techniques based on the level of nerve root sacrifice and evaluate the functional and oncological outcomes.

METHODS

Seventy-eight consecutive patients underwent 94 resections of sacral neoplasms at The University of Texas M. D. Anderson Cancer Center in Houston between August 1993 and June 2002. The records of 29 consecutive patients who underwent en bloc resection of primary sacral tumors were retrospectively reviewed. The median follow-up period was 55 months (range 1-103 months). Chordoma was the most frequent tumor type (16 cases). Midline sacral amputation was performed in 25 patients (eight low, four middle, seven high, and five total sacrectomies; one hemicorporectomy). Lateral sacrectomy was undertaken in four patients (two unilateral excisions of the sacroiliac joint and two hemisacrectomies). The surgical margins were wide in 19 cases, marginal in nine, and contaminated in one. The type of sacrectomy correlated with characteristic outcomes with respect to bladder, bowel, and ambulatory functions. Duration of hospital stay was related to the extent of sacrectomy (p = 0.003, Wilcoxon signed-rank test). The median Kaplan-Meier disease-free survival for patients with chordoma was 68 months (95% confidence interval 46-90 months).

CONCLUSIONS

Classification of en bloc sacral resection techniques by the level of nerve root transection is useful in predicting postoperative function and the potential for morbidity. Adequate surgical margins should not be compromised to preserve function when they are necessary to affect tumor control.

Tumors of the retrorectal space

PURPOSE

Retrorectal tumors are a diverse group of masses derived from a variety of embryologic origins. Because of this, some confusion is associated with their diagnosis and management. Although rare, a basic understanding of the etiology, presentation, work-up, and treatment of retrorectal masses is essential.

METHODS

The incidence, classification, diagnosis, treatment, and prognosis of these masses are presented. A comprehensive review of the literature is included in our analysis.

RESULTS

Retrorectal lesions can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. Benign and malignant lesions behave similarly. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history. Biopsy of these lesions should be avoided to prevent tumor seeding, fecal fistula, meningitis, and abscess formation. Complete surgical resection, usually after appropriate specialized imaging, remains the cornerstone of their treatment. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primarily to local control, which often is difficult to achieve for malignant lesions.

CONCLUSIONS

Retrorectal masses present a challenging surgical problem from diagnosis to treatment. A high index of suspicion and resultant early diagnosis, followed by thorough preoperative planning, is required for optimal management and outcome.

Reconstruction after total sacrectomy: early experience with a new surgical technique

Nine patients had sacrectomy with ilio-lumbar arthrodesis for treatment of sacral malignancies at our institution between 2000 and 2004. Five patients had total sacrectomy, three had a sagittal hemisacrectomy, and one had an extended internal hemipelvectomy Type I-S. The average patient age was 39 years. Tumors were Stage IIB in seven patients and Stage IB in two patients. A combined anteroposterior approach was used and a wide surgical margin was attained in all seven patients. A new form of reconstruction using structural fibular grafts and pedicle screw-rod instrumentation was used to create a triangular construct along the anatomic force transmission vectors from the femoral heads to the lumbar spine. The average followup was 18 months. At latest followup, seven patients were alive with no evidence of disease, and two had died from disease. One patient suffered postoperative infection. Independent ambulation was noted in seven patients at last followup. Eight patients had stable reconstructions at latest followup (one patient, who died in December 2004, had a stable reconstruction and was walking with braces and a walker before her death). One patient had instrumentation failure twice and had additional revision instrumentation and bone grafting procedures. She eventually obtained a solid lumbopelvic fusion and walks with Canadian crutches and ankle-foot orthoses. The technique of reconstruction reported here offers promise in dealing with the challenges of reestablishing spinopelvic stability in this difficult anatomic location.

LEVEL OF EVIDENCE

Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.