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Loverro M, Aloisi A, Tortorella L, Aletti GD, Kumar A. Trends and current aspects of reconstructive surgery for gynecological cancers. Int J Gynecol Cancer 2024; 34:426-435. [PMID: 38438169 DOI: 10.1136/ijgc-2023-004620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Gynecologic cancers can lead to gynecologic tract destruction with extension into both the gastrointestinal and urinary tracts. Recurrent disease can also affect the surrounding bony pelvis and pelvic musculature. As opposed to advanced ovarian cancer, where cytoreduction is the goal, in these scenarios, an oncologic approach to achieve negative margins is critical for benefit. Surgeries aimed at achieving a R0 resection in gynecologic oncology can have a significant impact on pelvic anatomy, and require reconstruction. Overall, it appears that these types of radical surgery are less frequently performed; however, when required, multidisciplinary teams at high-volume centers can potentially improve short-term morbidity. There are few data to examine the long-term, quality-of-life outcomes after reconstruction following oncologic resection in advanced and recurrent gynecologic cancers. In this review we outline considerations and approaches for reconstruction after surgery for gynecologic cancers. We also discuss areas of innovation, including minimally invasive surgery and the use of 3D surgical anatomy models for improved surgical planning.In the era of 'less is more', pelvic exenteration in gynecologic oncology is still indicated when there are no other curative-intent alternatives in persistent or recurrent gynecological malignancies confined to the pelvis or with otherwise unmanageable symptoms from fistula or radiation necrosis. Pelvic exenteration is one of the most destructive procedures performed on an elective basis, which inevitably carries a significant psychologic, sexual, physical, and emotional burden for the patient and caregivers. Such complex ultraradical surgery, which requires removal of the vagina, vulva, urinary tract, and/or gastrointestinal tract, subsequently needs creative and complex reconstructive procedures. The additional removal of sidewall or perineal structures, like pelvic floor muscles/vulva, or portions of the musculoskeletal pelvis, and the inclusion of intra-operative radiation further complicates reconstruction. This review paper will focus on the reconstruction aspects following pelvic exenteration, including options for urinary tract restoration, reconstruction of the vulva and vagina, as well as how to fill large empty spaces in the pelvis. While the predominant gastrointestinal outcome after exenteration in gynecologic oncology is an end colostomy, we also present some novel new options for gastrointestinal tract reconstruction at the end.
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Affiliation(s)
- Matteo Loverro
- Department of Gynecology and Obstetrics, Policlinico Universitario Agostino Gemelli, Roma, Italy
| | - Alessia Aloisi
- European Institute of Oncology IRCCS Library, Milan, Italy
| | - Lucia Tortorella
- Department of Women, Child and Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Damiano Aletti
- Department of Gynecology, European Institute of Oncology, Milano, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
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Rinkinen JR, Fruge S, Welten VM, Kinsley S, Bleday R, Irani J, Yoo J, Goldberg JE, Melnitchouk N, Talbot SG. Long-term outcomes analysis of flap-based perineal reconstruction. J Gastrointest Surg 2024; 28:57-63. [PMID: 38353075 DOI: 10.1016/j.gassur.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 10/17/2023] [Accepted: 11/03/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND High-risk patients undergoing abdominoperineal resection and pelvic exenteration may benefit from immediate flap reconstruction. However, there is currently no consensus on the ideal flap choice or patient for whom this is necessary. This study aimed to evaluate the long-term outcomes of using pedicled gracilis flaps for pelvic reconstruction and to analyze predictors of postoperative complications. METHODS This was a retrospective review of a single reconstructive surgeon's cases between January 2012 and June 2021 identifying patients who underwent perineal reconstruction secondary to oncologic resection. Preoperative and outcome variables were collected and analyzed to determine the risk of developing minor and major wound complications. RESULTS A total of 101 patients were included in the study with most patients (n = 88) undergoing unilateral gracilis flap reconstruction after oncologic resection. The mean follow-up period was 75 months. Of 101 patients, 8 (7.9%) developed early major complications, and an additional 13 (12.9%) developed late major complications. Minor complications developed in 33 patients (32.7%) with most cases being minor wound breakdown requiring local wound care. Most patients (n = 92, 91.1%) did not develop donor site complications. Anal cancer was significantly associated with early major complications, whereas younger age and elevated body mass index were significant predictors of developing minor wound complications. CONCLUSIONS This study builds on our previous work that demonstrated the long-term success rate of gracilis flap reconstruction after large pelvic oncologic resections. A few patients developed donor site complications, and perineal complications were usually easily managed with local wound care, thus making the gracilis flap an attractive alternative to abdominal-based flaps.
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Affiliation(s)
- Jacob R Rinkinen
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Seth Fruge
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Vanessa M Welten
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Sarah Kinsley
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Ronald Bleday
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Jennifer Irani
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - James Yoo
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Joel E Goldberg
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Nelya Melnitchouk
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Simon G Talbot
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States.
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Gao Z, Wang Y, Zeng Q, Rong W, Wang Z, Zhai Z, Ding C, An K, Gao Q, Niu P, Hong Y, He X, Huang W, Lei F, Wen B, Wang X, Gu J. Perineal defect reconstruction after surgery for advanced or locally recurrent rectal cancer involving organ resection: Multiple flaps combined with lining repair. Colorectal Dis 2023; 25:2087-2092. [PMID: 37612783 DOI: 10.1111/codi.16710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 08/25/2023]
Abstract
AIM The aim of this study was to investigate the efficacy of multiple perineal perforator flaps in repairing deep perineal defects after pelvic exenteration for locally advanced or recurrent rectal cancer. METHOD We investigated the outcomes of eight patients whose repairs involved a novel method of using an internal pudendal artery perforator (IPAP) flap combined with an inferior gluteal artery perforator (IGAP) flap. RESULTS There were four male and four female patients with a mean age of 56 years (36-72 years). Bilateral IPAP flaps combined with bilateral IGAP flaps were used in five patients, unilateral IPAP flaps combined with bilateral IGAP flaps were used in two patients and bilateral IPAP flaps were used in one patient. There were no functional limitations in daily activities during the 6-month follow-up period. CONCLUSION Our study showed that using multiple perineal perforator flaps combined with lining repair is feasible for repairing deep perineal defects in patients who have undergone rectal cancer surgery that includes pelvic exenteration.
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Affiliation(s)
- Zhaoya Gao
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Yanzhao Wang
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Qingmin Zeng
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Wanshui Rong
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Zilong Wang
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Zhichao Zhai
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Changmin Ding
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Ke An
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Qingkun Gao
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Pengfei Niu
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Yuming Hong
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Xiaomang He
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Wensheng Huang
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Fuming Lei
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Bing Wen
- Department of Plastic Surgery and Burn, Peking University First Hospital, Beijing, China
| | - Xin Wang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Jin Gu
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, China
- Peking University International Cancer Institute, Beijing, China
- Peking-Tsinghua Center for Life Science, Beijing, China
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Garcia MF, Tiwari KK, Gendreau JL, Burgess PL, Taupin P, Martin ED. Mesenchymal Stem Cells and Regenerative Therapy with Bilateral Gracilis Flaps for Perineal Reconstruction of a Wound Infection in the Setting of Anal Squamous Cell Carcinoma. Adv Skin Wound Care 2023; 36:1-7. [PMID: 37471451 DOI: 10.1097/asw.0000000000000009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
ABSTRACT Many patients are affected by HIV/AIDS, and these conditions are highly prevalent worldwide. Patients with HIV/AIDS can experience debilitating wound infections that often require flap reconstruction and become challenging for surgeons to treat. In the past 5 years, mesenchymal stem cells have been tested and used as regenerative therapy to promote the growth of tissues throughout the body because of their ability to successfully promote cellular mitogenesis. To the authors' knowledge, the use of mesenchymal stem cell grafting following necrosis of a myocutaneous gracilis flap (as part of perineal wound reconstruction) has never been reported in the literature.In addition, the use of mesenchymal stem cells and regenerative medicine combined in the setting of squamous cell carcinoma of the anus with prior radiation (along with comorbid AIDS) has not been previously documented.In this report, the authors outline the case of a 60-year-old patient who had a recipient bed (perineum) complication from prior radiation therapy. Complicating the clinical picture, the patient also developed a Pseudomonal organ space infection of the pelvis leading to the failure of a vertical rectus abdominis myocutaneous flap and myocutaneous gracilis flaps. As a result, the patient underwent serial operative debridements for source control, with the application of mesenchymal stem cells, fetal bovine dermis, porcine urinary bladder xenograft, and other regenerative medicine products, achieving a highly successful clinical outcome. A procedural description for future use and replication of this method is provided.
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Affiliation(s)
- Matthew F Garcia
- At Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, USA, Matthew F. Garcia, MD, is Transitional Year Resident; Kirti K. Tiwari, MS, is Chief, Research Operations; Julian L. Gendreau, MD, is Transitional Year Resident; and Pamela L. Burgess, MD, is Chief, General Surgery. Philippe Taupin, PhD, is Senior Manager, Medical Affairs, Integra LifeSciences, Princeton, New Jersey. Also at Dwight D. Eisenhower Army Medical Center, Eric D. Martin, DO, is Chief, Cardiovascular Surgery. Dr Taupin is an employee of Integra LifeSciences Corporation. The authors have disclosed no other financial relationships related to this article. Submitted March 5, 2022; accepted in revised form September 9, 2022
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Thomsen TV, Warming P, Hasanbegovic E, Rindom MB, Stolle LB. 30 days postoperative outcome associated with vertical rectus abdominis myocutaneous (VRAM) flap reconstruction after pelvic surgery. EUROPEAN JOURNAL OF PLASTIC SURGERY 2023. [DOI: 10.1007/s00238-022-02022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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DeLozier OM, Stiles ZE, Shibata D, Deneve JL, Monroe J, Dickson PV, Mathew A, Chandler RG, Behrman SW. Gracilis Flap Reconstruction After Proctocolectomy for Malignancy and Inflammatory Bowel Disease. Am Surg 2023; 89:247-254. [PMID: 33886373 DOI: 10.1177/00031348211011146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Gracilis flap reconstruction (GFR) following abdominoperineal resection (APR) or proctocolectomy (PC) can reduce pelvic wound complications but has not been adequately assessed in the setting of immunosuppression, fistulous disease, and neoadjuvant chemoradiation. METHODS Patients undergoing APR/PC with GFR were retrospectively analyzed with regard to perioperative characteristics, and morbidity was assessed. RESULTS Patients underwent GFR for rectal cancer (n = 28), anal cancer (n = 3), inflammatory bowel disease (n = 13), or benign fistulizing disease (n = 1). 22.2% were chronically immunosuppressed, and 66.7% underwent preoperative chemoradiation. Twenty (44.4%) patients had minor wound complications, all treated nonoperatively. Nine patients had major complications with 4 patients requiring reoperation. The 4 threatened flaps were unilateral, and all were salvaged. Donor site morbidity was minimal. Patients with major complications were older (56 vs. 71 years, P = .030), and less likely to have pelvic drains (P = .018). CONCLUSION In high-risk perineal wounds, GFR offers durable reconstruction with acceptably low morbidity.
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Affiliation(s)
- Olivia M DeLozier
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Zachary E Stiles
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Shibata
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Justin Monroe
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paxton V Dickson
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alex Mathew
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert G Chandler
- Department of Plastic Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Stephen W Behrman
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
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7
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Prasath V, Naides AI, Weisberger JS, Quinn PL, Ayyala HS, Lee ES, Girard AO, Chokshi RJ. Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis. Surgery 2023; 173:521-528. [PMID: 36418205 DOI: 10.1016/j.surg.2022.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/25/2022] [Accepted: 09/11/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. METHODS A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. RESULTS Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. CONCLUSION Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.
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Affiliation(s)
| | | | - Joseph S Weisberger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Patrick L Quinn
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Haripriya S Ayyala
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Division of Plastic & Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Edward S Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Alisa O Girard
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.
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Wang A, Yang J, Bian C, Liu A, Zhou H. Laparoscopic abdominoperineal excision and partial vaginectomy with unilateral transverse gracilis flap vaginal reconstruction for locally advanced rectal cancer - a video vignette. Colorectal Dis 2022; 24:1627-1628. [PMID: 35776857 DOI: 10.1111/codi.16244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/07/2022] [Accepted: 06/26/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Anqi Wang
- Department of Colorectal Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Jize Yang
- Department of Plastic Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China.,Department of Plastic and Reconstructive Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Ce Bian
- Department of Colorectal Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Antang Liu
- Department of Plastic Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China.,Department of Plastic and Reconstructive Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Haiyang Zhou
- Department of Colorectal Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China
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Surgical Outcomes of VRAM vs. Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection: A Proportional Meta-Analysis. Cancers (Basel) 2022; 14:cancers14174300. [PMID: 36077834 PMCID: PMC9454697 DOI: 10.3390/cancers14174300] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary The rate of perineal complications after abdominoperineal reconstruction for the treatment of cancers ranges from 25% to 60% in the literature. It is well-established in current literature that direct closure has a higher complication rate than closure with a flap. Several reconstructive options have been proposed to fill the dead space with well-vascularized tissue. Every surgeon would like to be comfortable in selecting which flap has superiority in terms of surgical outcome. In the absence of a meta-analysis on the subject due to the scarcity of RCT and comparative studies, we used a proportional meta-analysis to analyze the surgical outcomes after reconstruction with either VRAM flap or gracilis flap following oncologic resection of the vulvo-perineal region. Abstract Pelvic exenteration and abdominoperineal resection are radical techniques commonly used for locally advanced or recurrent pelvic malignancy with high morbidity due to large pelvic defects. Flaps can help provide healthy, well-vascularized, non-irradiated tissues to fill pelvic dead space. We conducted a proportional meta-analysis to compare surgical outcomes of vertical rectus abdominus myocutaneous flap (VRAM) vs. gracilis flap for vulvo-perineal reconstruction following oncologic resection. A comprehensive literature search was conducted in the MEDLINE, PubMed, Embase, Google Scholar, and Cochrane Library databases. Proportional meta-analysis was performed to compare the surgical outcomes of using VRAM or gracilis flaps. Our review yielded 16 eligible studies. The pooled resolution rate of overall donor site complications for VRAM flap (pooled proportion = 0.576 [95% CI 0.387, 0.754]) was significantly higher than the pooled rate of overall donor site complications of gracilis flap (pooled proportion = 0.160 [95% CI 0.058, 0.295]). Partial and total flap necrosis were similar in both groups. There was no statistically significant difference between minor and major complications for both flaps. Both flaps can be used safely for vulvo-perineal reconstruction following oncologic resection with similar recipient site outcomes, although the VRAM flap will have more donor site complications than the gracilis flap.
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Zhang C, Yang X, Bi H. Application of depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. BMC Surg 2022; 22:304. [PMID: 35933336 PMCID: PMC9357311 DOI: 10.1186/s12893-022-01755-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. Methods A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months. Results The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications. Conclusions A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.
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Affiliation(s)
- Chen Zhang
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Xin Yang
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Hongsen Bi
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China.
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Objective Perfusion Assessment in Gracilis Muscle Interposition—A Novel Software-Based Approach to Indocyanine Green Derived Near-Infrared Fluorescence in Reconstructive Surgery. Life (Basel) 2022; 12:life12020278. [PMID: 35207565 PMCID: PMC8874768 DOI: 10.3390/life12020278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Gracilis muscle interposition (GMI) is an established treatment option for complex perineal fistulas and reconstruction. The outcome is limited by complications such as necrosis, impaired wound healing and fistula persistence or recurrence. Quantifiable methods of assessing muscle flap perfusion intraoperatively are lacking. This study evaluates a novel and objective software-based assessment of indocyanine green near-infrared fluorescence (ICG-NIRF) in GMI. Methods: Intraoperative ICG-NIRF visualization data of five patients with inflammatory bowel disease (IBD) undergoing GMI for perineal fistula and reconstruction were analyzed retrospectively. A new software was utilized to generate perfusion curves for the specific regions of interest (ROIs) of each GMI by depicting the fluorescence intensity over time. Additionally, a pixel-to-pixel and perfusion zone analysis were performed. The findings were correlated with the clinical outcome. Results: Four patients underwent GMI without postoperative complications within 3 months. The novel perfusion indicators identified here (shape of the perfusion curve, maximum slope value, distribution and range) indicated adequate perfusion. In one patient, GMI failed. In this case, the perfusion indicators suggested impaired perfusion. Conclusions: We present a novel, software-based approach for ICG-NIRF perfusion assessment, identifying previously unknown objective indicators of muscle flap perfusion. Ready for intraoperative real-time use, this method has considerable potential to optimize GMI surgery in the future.
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12
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Assi H, Persson A, Palmquist I, Öberg M, Buchwald P, Lydrup ML. Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study. Eur J Surg Oncol 2021; 48:1161-1166. [PMID: 34794841 DOI: 10.1016/j.ejso.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/15/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Beyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction. METHOD This retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients' data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification. RESULTS One hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients. CONCLUSION bTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.
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Affiliation(s)
- Hanin Assi
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden.
| | - Anna Persson
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Ingrid Palmquist
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Martin Öberg
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
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Ward J, Little M, Ayres B, Soldin M. Perineal reconstruction supplemented by abdominal advancement following recurrent penile cancer: Two cases. JPRAS Open 2021; 30:47-52. [PMID: 34458541 PMCID: PMC8377526 DOI: 10.1016/j.jpra.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 07/11/2021] [Indexed: 11/21/2022] Open
Abstract
Reconstruction after excision of locoregionally recurrent penile cancer can be a surgical challenge. In this short study, we present two cases of perineal reconstruction using bilateral gracilis flaps supplemented by abdominal advancement for salvage of recurrent penile cancer, reviewing relevant literature and outlining our local approach to the perineum.
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Affiliation(s)
- J Ward
- Department of Plastic and Reconstructive Surgery, St George's Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
| | - M Little
- Department of Plastic and Reconstructive Surgery, St George's Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
| | - B Ayres
- Department of Urology, St George's Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
| | - M Soldin
- Department of Plastic and Reconstructive Surgery, St George's Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
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Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods. Plast Reconstr Surg 2021; 147:1420-1435. [PMID: 33973948 DOI: 10.1097/prs.0000000000007976] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. METHODS A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. RESULTS The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. CONCLUSIONS Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.
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Chavan RN, Saklani AP, Desouza AL, Rohila J, Kazi M, Sukumar V, Jajoo B. V-Y Gluteal Advancement Fasciocutaneous Flap for Reconstruction of Perineal Defects After Surgery for Anorectal Cancers- A Single-Center Experience. Indian J Surg Oncol 2021; 12:241-245. [PMID: 34295065 DOI: 10.1007/s13193-021-01311-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022] Open
Abstract
An ideal method of perineal closure after resection for low rectal cancer surgery is a topic of debate. Morbidity associated with primary perineal closure due to wound break down delays recovery from surgery and adjuvant treatment with poor oncological outcome at the end. Herewith, we present our experience with V-Y gluteal advancement fasciocutaneous flap done for 131 patients for reconstruction of perineal and pelvic defect. With our experience, this is a safe and simple method with an acceptable complication rate that can be practiced by colorectal surgeons, even in the absence of a dedicated plastic surgery team.
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Affiliation(s)
- Rahulkumar N Chavan
- Department of Surgical Oncology, Colorectal Surgery Unit, Tata Memorial Hospital, Mumbai, 400012 India
| | - Avanish P Saklani
- Department of Surgical Oncology ,Colorectal Surgery Unit, Tata Memorial Hospital, Mumbai, 400012 India
| | - Ashwin L Desouza
- Department of Surgical Oncology ,Colorectal Surgery Unit, Tata Memorial Hospital, Mumbai, 400012 India
| | - Jitender Rohila
- Department of Surgical Oncology ,Colorectal Surgery Unit, Tata Memorial Hospital, Mumbai, 400012 India
| | - Mufaddal Kazi
- Department of Surgical Oncology ,Colorectal Surgery Unit, Tata Memorial Hospital, Mumbai, 400012 India
| | - Vivek Sukumar
- Department of Surgical Oncology ,Colorectal Surgery Unit, Tata Memorial Hospital, Mumbai, 400012 India
| | - Bhushan Jajoo
- Department of Surgical Oncology ,Colorectal Surgery Unit, Tata Memorial Hospital, Mumbai, 400012 India
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16
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Elia J, Do NTK, Chang TNJ, Lai CH, Chou HH, Chang FCS, Huang JJ. Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps. J Reconstr Microsurg 2021; 38:10-26. [PMID: 33853124 DOI: 10.1055/s-0041-1727199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications. METHODS A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed. RESULTS Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm2. The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications. CONCLUSION In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.
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Affiliation(s)
- Jhonatan Elia
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Nicholas T K Do
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tommy N-J Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chyong-Huey Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Hung-Hsueh Chou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Frank C-S Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Jung-Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
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17
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Sharp O, Kapur S, Shaikh I, Rosich-Medina A, Haywood R. The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction: A cohort study. J Plast Reconstr Aesthet Surg 2021; 74:2654-2663. [PMID: 33952435 DOI: 10.1016/j.bjps.2021.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/27/2021] [Accepted: 03/11/2021] [Indexed: 11/16/2022]
Abstract
The result of an extra-levator abdominoperineal excision of the rectum (ELAPE) is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator (PAP) and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective case note review of patients undergoing pelvo-perineal reconstruction with combined gracilis and PAP flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, while two patients underwent total pelvic exenteration. The median age was 57 (range 47-74) years, inpatient stay was 22 (11-47) days and the follow-up was 10 (5-21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm PAP flap loss. All other flaps survived completely. Median time to heal was 4 (1-6) months. This is the first series reporting combined bilateral gracilis and PAP flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity.
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Affiliation(s)
- Olivia Sharp
- Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
| | - Sandeep Kapur
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Irshad Shaikh
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Anais Rosich-Medina
- Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Richard Haywood
- Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK; Department of Anatomy, Norwich Medical School, University of East Anglia, Norwich, UK
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18
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Chi D, Chen AD, Bucknor A, Seyidova N, Bletsis P, Chattha A, Egeler S, Del Valle D, Lin SJ. Hospital volume is associated with cost and outcomes variation in 2,942 pelvic reconstructions. J Plast Reconstr Aesthet Surg 2021; 74:2645-2653. [PMID: 33888434 DOI: 10.1016/j.bjps.2021.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 12/14/2020] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Complex pelvic reconstruction is challenging for plastic and reconstructive surgeons following surgical resection of the lower gastrointestinal or genitourinary tract. Complication rates and hospital costs are variable and may be linked to the hospital case volume of pelvic reconstructions performed. A comprehensive examination of these factors has yet to be performed. METHODS Data were retrieved for patients undergoing pedicled flap reconstruction after pelvic resections in the American National Inpatient Sample database between 2010 and 2014. Patients were then separated into three groups based on hospital case volume for pelvic reconstruction. Multivariate logistic regression and gamma regression with log-link function were used to analyze associations between hospital case volume, surgical outcomes, and cost. RESULTS In total, 2,942 patients underwent pelvic flap reconstruction with surgical complications occurring in 1,466 patients (49.8%). Total median cost was $38,469.40. Pelvic reconstructions performed at high-volume hospitals were significantly associated with fewer surgical complications (low: 51.4%, medium: 52.8%, high: 34.8%; p < 0.001) and increased costs (low: $35,645.14, medium: $38,714.92, high: $44,967.29; p < 0.001). After regression adjustment, high hospital volume was the strongest independently associated factor for decreased surgical complications (Exp[β], 0.454; 95% Confidence Interval, 0.346-0.596; p < 0.001) and increased hospital cost (Exp[β], 1.351; 95% Confidence Interval, 1.285-1.421; p < 0.001). CONCLUSIONS Patients undergoing pelvic flap reconstruction after oncologic resections experience high complication rates. High case volume hospitals were independently associated with significantly fewer surgical complications but increased hospital costs. Reconstructive surgeons may approach these challenging patients with greater awareness of these associations to improve outcomes and address cost drivers.
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Affiliation(s)
- David Chi
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO, USA
| | - Austin D Chen
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexandra Bucknor
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Nargiz Seyidova
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Patrick Bletsis
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Anmol Chattha
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sabine Egeler
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Diana Del Valle
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Dee EC, Byrne JD, Wo JY. Evolution of the Role of Radiotherapy for Anal Cancer. Cancers (Basel) 2021; 13:1208. [PMID: 33801992 PMCID: PMC8001637 DOI: 10.3390/cancers13061208] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 12/11/2022] Open
Abstract
Prior to the 1980s, the primary management of localized anal cancer was surgical resection. Dr. Norman Nigro and colleagues introduced neoadjuvant chemoradiotherapy prior to abdominoperineal resection. Chemoradiotherapy 5-fluorouracil and mitomycin C afforded patients complete pathologic response and obviated the need for upfront surgery. More recent studies have attempted to alter or exclude chemotherapy used in the Nigro regimen to mitigate toxicity, often with worse outcomes. Reductions in acute adverse effects have been associated with marked advancements in radiotherapy delivery using intensity-modulated radiation therapy (IMRT) and image-guidance radiation delivery, resulting in increased tolerance to greater radiation doses. Ongoing trials are attempting to improve IMRT-based treatment of locally advanced disease with efforts to increase personalized treatment. Studies are also examining the role of newer treatment modalities such as proton therapy in treating anal cancer. Here we review the evolution of radiotherapy for anal cancer and describe recent advances. We also elaborate on radiotherapy's role in locally persistent or recurrent anal cancer.
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Affiliation(s)
| | - James D. Byrne
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA 02115, USA;
| | - Jennifer Y. Wo
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA;
- Department of Radiation Oncology, Massachusetts General Hospital, 100 Blossom St., Boston, MA 02114, USA
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20
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Agarwal H, Katiyar A, Priyadarshani P, Kumar S, Gupta A, Sagar S. Magnitude and outcomes of complex perineal injury - A retrospective analysis of five years' data from a Level 1 trauma centre. Trop Doct 2021; 51:344-349. [PMID: 33683163 DOI: 10.1177/0049475521998185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Complex perineal injuries pose a major diagnostic and therapeutic challenge to trauma surgeons. A retrospective review of the hospital records of 29 patients with complex perineal injury following blunt trauma was done. Demographic profile, management and outcomes were collected. Quality of life analysis was conducted for patients with complex perineal injuries who were discharged. The most predominant mode of injury was a road crash: being a pedestrian run over by a heavy motor vehicle. Pelvic fracture was seen in 20, anorectal involvement in 22 and urogenital injuries in 14. Urgent surgical debridement was done in all patients, faecal diversion in 27 and urinary diversion in 14. There were nine deaths, three from haemorrhage, and the remainder from sepsis and multi-organ dysfunction. Complex perineal injury remains a major cause of morbidity and mortality in trauma patients. There is a need to ensure adequate rehabilitation services for such patients.
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Affiliation(s)
- Harshit Agarwal
- Senior Resident, Division of Trauma Surgery & Critical Care, JPNATC, AIIMS, New Delhi, India
| | - Anand Katiyar
- Senior Resident, Division of Trauma Surgery & Critical Care, JPNATC, AIIMS, New Delhi, India
| | - Pratyusha Priyadarshani
- Assistant Professor, Division of Trauma Surgery & Critical Care, JPNATC, AIIMS, New Delhi, India
| | - Subodh Kumar
- Professor, Division of Trauma Surgery & Critical Care, JPNATC, AIIMS, New Delhi, India
| | - Amit Gupta
- Professor, Division of Trauma Surgery & Critical Care, JPNATC, AIIMS, New Delhi, India
| | - Sushma Sagar
- Professor, Division of Trauma Surgery & Critical Care, JPNATC, AIIMS, New Delhi, India
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21
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A 20-year tertiary cancer center’s experience utilizing the pedicled gracilis myocutaneous flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01692-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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LaBove GA, Evans GR, Biggerstaff B, Richland BK, Lee SA, Banyard DA, Khoshab N. Ten-Year experience with vertical rectus abdominis myocutaneous flap for reconstruction of abdominoperineal resection defects. JPRAS Open 2020; 27:90-98. [PMID: 33376767 PMCID: PMC7758273 DOI: 10.1016/j.jpra.2020.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/17/2020] [Accepted: 11/21/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose We evaluate outcomes of our single center using vertical rectus abdominis myocutaneous (VRAM) flaps for reconstruction after abdominoperineal resection (APR). Our goal was to analyze factors that may affect perineal wound healing, a problematic complication with APR reconstructions due to location and high frequency of neoadjuvant chemoradiation. Methods This single-center, retrospective study analyzed all VRAM flap perineal reconstruction patients after APR defect over a 10-year period (from July 2008 to June 2018). Outcome measures focused on factors that may affect perineal wound healing complication rates: cancer stage (I/II vs III/IV), neoadjuvant chemoradiation, surgeon's years in practice (<5 years vs >5 years), and pelvic closed suction drain use. Results Twenty-eight patients met inclusion criteria. The overall major perineal wound complication rate was 14.3% (4 patients). Lack of perioperative closed suction pelvic drain use was associated with a significantly higher rate of major perineal wound complications (28.6% vs 0% and p = 0.031). All four major wound complications occurred in patients who did not have a pelvic drain. The major perineal wound complication rate for patients who underwent neoadjuvant chemoradiation was 22% vs 0% with no neoadjuvant chemoradiation (p = 0.107). Conclusion While our cohort represents a relatively small single-center study, our 14.3% rate of major perineal wound complications is consistent with previous studies in the literature. Our findings show that perioperative pelvic closed suction drain use is associated with a lower rate of perineal wound complications. While neoadjuvant chemoradiation trended toward a higher incidence of perineal wound complications, it did not reach statistical significance.
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Affiliation(s)
- Gabrielle A LaBove
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Gregory Rd Evans
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Brian Biggerstaff
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Brandon K Richland
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Seung Ah Lee
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Derek A Banyard
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Nima Khoshab
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
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Options and outcomes of soft tissue reconstruction in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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24
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Thiele JR, Weber J, Neeff HP, Manegold P, Fichtner-Feigl S, Stark GB, Eisenhardt SU. Reconstruction of Perineal Defects: A Comparison of the Myocutaneous Gracilis and the Gluteal Fold Flap in Interdisciplinary Anorectal Tumor Resection. Front Oncol 2020; 10:668. [PMID: 32435617 PMCID: PMC7218107 DOI: 10.3389/fonc.2020.00668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 04/09/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction: Resection of anorectal malignancies may result in extensive perineal/pelvic defects that require an interdisciplinary surgical approach involving reconstructive surgery. The myocutaneous gracilis flap (MGF) and the gluteal fold flap (GFF) are common options for defect coverage in this area. Here we report our experience with the MGF/GFF and compare the outcome regarding clinical key parameters. Methods: In a retrospective chart review, we collected data from the Department of Plastic Surgery of the University of Freiburg from December 2008–18 focusing on epidemiological, oncological, and therapy-related data including comorbidities (ASA Classification) and peri-/postoperative complications (Clavien-Dindo-System). Results: Twenty-nine patients were included with a mean follow-up of 17 months. Of the cases, 19 (65.5%) presented with recurrent disease, 21 (72.4%) received radiochemotherapy preoperatively, 2 (6.9%) received chemotherapy alone. Microscopic tumor free margins were achieved in 25 cases (86.2%). 17 patients (7 men, 10 women, rectal adenocarcinoma n = 11; anal squamous cell carcinoma n = 6; mean age 58.5 ± 10.68, mean BMI 23.1, mean ASA score 2.8) received a MGF (unilateral n = 10; bilateral n = 7). Twelve patients (7 men, 5 women, rectal adenocarcinoma n = 7; anal squamous cell carcinoma n = 4, proctodeal gland carcinoma n = 1, mean age 66.2 ± 9.2, mean BMI 23.6, mean ASA score 2.6) received coverage with a GFF (unilateral n = 4; bilateral n = 8). Mean operation time of coverage was 105 ± 9 min for unilateral and 163 ± 11 for bilateral MGFs, 70 ± 13 min for unilateral and 107 ± 14 for bilateral GFFs. Complications affected 62%. There was no significant difference in the complication rate between the MGF- and GFF-group. Complications were mainly wound healing disorders that did not extend the hospital stay. No flap loss and no complication that lead to long-lasting disability was documented (both groups). Pain-free sitting took more time in the GFF-group due to the location of the donor site. Conclusion: MG-flaps and GF-flaps prove to be reliable and robust techniques for perineal/pelvic reconstruction. Though flap elevation is significantly faster for GF-flaps, preoperative planning and intraoperative Doppler confirmation are advisable. With comparable complication rates, we suggest a decision-making based on distribution of adipose tissue for dead space obliteration, intraoperative patient positioning, and perforator vessel quality/distribution.
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Affiliation(s)
- Jan R Thiele
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Janick Weber
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Hannes P Neeff
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Philipp Manegold
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - G B Stark
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
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25
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Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2733. [PMID: 32440406 PMCID: PMC7209827 DOI: 10.1097/gox.0000000000002733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
Background: Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author’s (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration. Methods: Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate. Results: A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49–71 years) and 24.9 kg/m2 (IQR: 24.2–26.7 kg/m2) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn’s disease, and 1 (4.3%) with Paget’s disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient. Conclusions: The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.
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Immediate Reconstruction After Colorectal Cancer Resection: A Cohort Analysis Through the National Surgical Quality Improvement Program and Outcomes Review. Ann Plast Surg 2020; 84:196-200. [PMID: 31904642 DOI: 10.1097/sap.0000000000002103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Colorectal cancer is one of the most common and fatal malignancies in the United States. When localized to the distal gastrointestinal tract, surgical therapy includes abdominoperineal resection (APR) or pelvic exenteration (PEX). Subsequent ablative defects are considerable, impart concerning morbidity, and often necessitate autologous reconstruction. The aim of this study was to assess postoperative outcomes after reconstruction of APR and PEX defects. METHODS The American College of Surgeons National Surgical Quality Improvement Program (2005-2017) was queried for patients undergoing APR for lower gastrointestinal malignancies with concurrent autologous reconstructions. Cases of disseminated cancer were excluded. Postoperative adverse event profiles, including rates of wound and systemic complications, were evaluated. Multivariate regression analysis controlling for age, sex, body mass index, and operative time was performed to calculate adjusted odds ratios (ORs). RESULTS A total of 1309 patients were identified as undergoing APR/PEX with concomitant reconstruction. The majority (96.9%) of reconstructions consisted of muscle, myocutaneous, fasciocutaneous, or omental pedicled flaps. Of the cohort, 45.7% experienced at least 1 all-cause complication within 30-days of the procedure. Having a limited or moderate frailty (frailty index of "1" or "2") was identified as a predictor of all-cause complications [OR, 1.556; 95% confidence interval (CI), 1.187-2.040, P = 0.001; and OR, 1.741; 95% CI, 1.193-2.541, P = 0.004, respectively], whereas smoking was a predictor of wound complications (OR, 1.462; 95% CI, 1.070-1.996, P = 0.017) and steroid use was a predictor of mild systemic complications (OR, 2.006; 95% CI, 1.058-3.805, P = 0.033). CONCLUSION Anorectal cancer resection often necessitates reconstruction secondary to postexenteration perineal defects. The incidence of postoperative complications is relatively high, and several risk factors are identified to help refine patient optimization.
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An Algorithmic Approach to Perineal Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2572. [PMID: 32537311 PMCID: PMC7288874 DOI: 10.1097/gox.0000000000002572] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/18/2019] [Indexed: 01/11/2023]
Abstract
Perineal wounds are one of the more challenging plastic surgical defects to reconstruct. Resections in the perineum vary in size and are frequently complicated by radiation, chemotherapy, and contamination. Furthermore, the awkward location and potential need to maintain function of the anus, urethra, and vagina and to allow comfortable sitting all contribute to the complexity of these reconstructions. In light of this complex nature, many options are available for flap coverage. In this paper, we discuss the properties of perineal defects that make each option appropriate.
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Local Therapy Options for Recurrent Rectal and Anal Cancer: Current Strategies and New Directions. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00445-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Urinary tract fistulas represent a complex group of pathologies that present significant management challenges. While most such fistulas ultimately require definitive surgical management, compromised local tissue quality or other factors often render straightforward simple one layered closure challenging with a substantial risk of failure. Interpositional tissue flaps have become a mainstay of treatment in these circumstances, enabling the delivery of healthy tissue from other locations to the site of pathology. Herein, we present an overview of the assessment and management of complex urinary tract fistulas involving the reproductive and gastrointestinal organs, and the decision to utilize flaps. We review the underlying principles of tissue flaps and classify different types of flaps. We conclude with a discussion of the indications, advantages, disadvantages, and harvesting techniques for the most commonly utilized flaps in urinary tract fistula repair.
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Affiliation(s)
- Andrew C Margules
- Department of Urology, Medical University of South Carolina, 96 Jonathan Lucas St., CSB 620, Charleston, SC, 29425, USA.
| | - Eric S Rovner
- Department of Urology, Medical University of South Carolina, 96 Jonathan Lucas St., CSB 620, Charleston, SC, 29425, USA
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Stein MJ, Karir A, Ramji M, Allen M, Bain JR, Avram R, Boushey R, Auer R, Jarmuske M. Surgical outcomes of VRAM versus gracilis flaps for the reconstruction of pelvic defects following oncologic resection✰. J Plast Reconstr Aesthet Surg 2019; 72:565-571. [DOI: 10.1016/j.bjps.2018.12.044] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 12/14/2018] [Accepted: 12/21/2018] [Indexed: 11/15/2022]
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The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects. Int J Colorectal Dis 2019; 34:501-511. [PMID: 30610436 DOI: 10.1007/s00384-018-03222-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2018] [Indexed: 02/04/2023]
Abstract
AIM Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. METHODS We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. RESULTS Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. CONCLUSIONS The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.
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Reappraisal of Perforasomes of the Superficial Femoral, Descending Genicular, and Saphenous Arteries and Clinical Applications to Locoregional Reconstruction. Plast Reconstr Surg 2019; 143:613e-627e. [DOI: 10.1097/prs.0000000000005395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Modified V-Y Fasciocutaneous Flap Reconstruction After Abdominoperineal Resection in Irradiated Patients Prevents Wound Dehiscence and Associated Complications. Ann Plast Surg 2019; 82:218-223. [DOI: 10.1097/sap.0000000000001672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ciudad P, Huang TC, Manrique OJ, Agko M, Sapountzis S, Nicoli F, Diya Sabbagh M, Pont LP, Moran SL, Chen H. Expanding the applications of the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for extensive defects. Microsurgery 2018; 39:316-325. [DOI: 10.1002/micr.30413] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 11/18/2018] [Accepted: 11/27/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic SurgeryNational Cancer Institute of Peru (INEN) Lima Peru
- Department of Plastic and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | | | - Oscar J. Manrique
- Division of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of GeorgiaAugusta University Augusta Georgia
| | - Stamatis Sapountzis
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Fabio Nicoli
- University of Tor VergataPlastic and Reconstructive Surgery Rome Italy
| | - M. Diya Sabbagh
- Division of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Luis Parra Pont
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Steven L. Moran
- Division of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Hung‐Chi Chen
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
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Morton M, Melnitchouk N, Bleday R. Squamous cell carcinoma of the anal canal. Curr Probl Cancer 2018; 42:486-492. [PMID: 30497849 DOI: 10.1016/j.currproblcancer.2018.11.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/20/2018] [Indexed: 02/06/2023]
Abstract
Anal squamous cell carcinoma (SCC) is a rare cancer and accounts for approximately 4% of all cancers of the lower alimentary tract. The dominant etiology is infection with human papilloma virus (HPV), which is the most common sexually transmitted disease in the United States. Integration of HPV DNA into the host genome seems to be the driving mechanism behind carcinogenesis. Vaccines directed against oncogenic HPV serotypes exist, and their utility for preventing anal neoplasia is under investigation. Additional risk factors for developing SCC include HIV infection, anal receptive intercourse, smoking, and immunosuppression. Patients with known anal intraepithelial neoplasia (AIN) must be carefully screened with periodic digital rectal exam and anoscopy. The most common presenting symptom is bleeding, with up to one third of patients presenting asymptomatic. Once tissue diagnosis is made, staging of primary tumor is accomplished with either MRI or transanal ultrasound. Distant disease is evaluated with CT of chest abdomen and pelvis vs whole body PET/CT. The gold standard treatment for stage I-III disease remains the Nigro protocol, first described in 1974. Stage I disease not involving sphincter may be treated with local excision. Distant disease is treated with systemic chemotherapy with radiation reserved for locoregional symptoms. Careful surveillance is mandatory after completion of chemoradiation. Salvage abdominoperineal resection can achieve locoregional control in up to 77% of patients with persistent or recurrent disease. Morbidity is high, mostly owing to wound complications, and as such a flap reconstruction of the perineum is warranted.
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