Reconstruction of large sacral defects following total sacrectomy

[Plastic reconstructive therapy for postoncologic defect wounds in the pelvis]

Surgical or multimodal therapy of tumors of the pelvis often results in complex defects leading to functional and structural deficits, with the inability to sit or even lie without pain. Multimodal therapy may cause induration of soft tissues and muscles, obstruction of the small bowel, fistulas, and infected cavities. Early soft tissue reconstruction, preferably with myocutaneous flaps, reduces postoperative problems in these patients by early coverage of defects, closure of cavities, and prevention of wound healing complications and therefore allows earlier rehabilitation.

The Gluteus Maximus Muscle Flap for Reconstruction of Sacral Chordoma Defects

Four patients diagnosed with sacral chordoma underwent reconstruction with the gluteus maximus flap using an approach based on available muscle remnants and their residual blood supply. The entire unilateral gluteus maximus muscle was turned over to fill the defect in 2 patients. The flap was based on 1 or 2 gluteal vessels, depending on vessel availability following tumor resection. When all 4 major pedicles had been ligated, bilateral advancement gluteal muscle flaps based on their distal blood supply were used (patient 3). A longitudinally split flap was used for secondary reconstruction of a partially obliterated defect (patient 4). Over a mean follow-up period of 8 months, there was no wound breakdown and all patients were ambulant.

Reconstruction after extirpation of sacral malignancies

Defects after extirpation of either sacral or rectal tumors often present a reconstructive challenge to plastics surgeons. Because of their relative infrequency, management guidelines, in the authors' opinion, have been overlooked. They think that successful, comprehensive treatment lends itself to an integrated team approach. They review their experience with immediate reconstruction after total sacrectomy for sacral malignancies performed between 1996 and 2001. Medical records were reviewed retrospectively for the surgical procedure, postoperative complications, and eventual outcome. A total of 9 patients underwent sacrectomy with a gluteus maximus flap for reconstruction. Six patients had a simultaneous omental flap for complete obliteration of the surgical defect. The authors' experience suggests that this combination of techniques is a reliable approach for reconstruction of these extensive surgical defects.

Current management of sacral chordoma

Sacral chordomas are relatively rare, locally invasive, malignant neoplasms. Although metastasis is infrequent at presentation, the prognosis for patients with chordoma of the sacrum is reported to be poor and attributable in most cases to intralesional resection. The value of adjuvant treatment is uncertain, and resection remains the primary mode of treatment. Chordomas are difficult to excise completely, but recent improvements in imaging and surgical techniques have allowed surgeons to perform more frequently en bloc sacral resections with wide surgical margins. The technical challenges of such operations, and the functional costs for the patient (with respect to anorectal and urogenital dysfunction) are significantly increased when the tumor involves high sacral levels. The authors review the clinical presentation and natural history of sacral chordoma and discuss the current treatment techniques and outcomes.

Management of locally advanced rectal cancer

The treatment of rectal cancer typically involves a multidisciplinary approach. A minority of patients will have tumors that are full thickness, involve adjacent structures, or have metastatic disease to regional lymph nodes. The combination of adjuvant therapy and surgical resection is the mainstay of treatment for locally advanced carcinoma of the rectum. This article will review the role of adjuvant chemotherapy and radiotherapy in patients with high risk tumors. The operative considerations in advanced rectal cancers will be reviewed. In particular, the role of mesorectal excision and exenterative surgery will be discussed.

Recent advances in reconstructive surgery for soft-tissue sarcomas

The size and complexity of wounds following soft-tissue sarcoma resection have increased over the years. Many advances have been made in reconstructive surgery during the past 30 years. These advances have occurred because of refined knowledge of muscle, skin, and fascial blood flow and through the development of free tissue transfer techniques. In this review, current methods of reconstruction following sarcoma resection are discussed, and advances are highlighted.