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Arcieri M, Restaino S, Rosati A, Granese R, Martinelli C, Caretto AA, Cianci S, Driul L, Gentileschi S, Scambia G, Vizzielli G, Ercoli A. Primary flap closure of perineal defects to avoid empty pelvis syndrome after pelvic exenteration in gynecologic malignancies: An old question to explore a new answer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107278. [PMID: 38134482 DOI: 10.1016/j.ejso.2023.107278] [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] [Received: 06/19/2023] [Revised: 11/05/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023]
Abstract
Pelvic exenteration (PE) is a radical oncological surgical procedure proposed in patients with recurrent or persistent gynecological cancers. The radical alteration of pelvic anatomy and of pelvic floor integrity can cause major postoperative complications. Fortunately, PE can be combined with reconstructive procedures to decrease complications and functional and support problems of pelvic floor, reducing morbility and mortality and increasing quality of life. Many options for reconstructive surgery have been described, especially a wide spectrum of surgical flaps. Different selection criteria have been proposed to select patients for primary perineal defect flap closure without achieving any strict indication of the best option. The aim of this review is to focus on technical aspects and the advantages and disadvantages of each technique, providing an overview of those most frequently used for the treatment of pelvic floor defects after PE. Flaps based on the deep inferior epigastric artery, especially vertical rectus abdominis musculocutaneous (VRAM) flaps, and gracilis flaps, based on the gracilis muscle, are the most common reconstructive techniques used for pelvic floor and vaginal reconstruction. In our opinion, reconstructive surgery may be considered in case of total PE or type II/III PE and in patients submitted to prior pelvic irradiation. VRAM could be used to close extended defects at the time of PE, while gracilis flaps can be used in case of VRAM complications. Fortunately, numerous choices for reconstructive surgery have been devised. As these techniques continue to evolve, it is advisable to adopt an integrated, multi-disciplinary approach within a tertiary medical center.
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Affiliation(s)
- M Arcieri
- Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, Messina, Italy; Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy.
| | - S Restaino
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy
| | - A Rosati
- Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - R Granese
- Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, Messina, Italy
| | - C Martinelli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - A A Caretto
- Department of Plastic Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - S Cianci
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - L Driul
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy; Medical Area Department (DAME), University of Udine, Udine, Italy
| | - S Gentileschi
- Plastic Surgery, Lymphedema Center Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - G Scambia
- Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy; Department of Woman, Child and Public Health, Catholic University of Sacred Heart, Rome, Italy
| | - G Vizzielli
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy; Medical Area Department (DAME), University of Udine, Udine, Italy
| | - A Ercoli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
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Dzyubak O, Salman L, Covens A. Use of Rectus Flaps in Reconstructive Surgery for Gynecologic Cancer. Curr Oncol 2024; 31:394-402. [PMID: 38248111 PMCID: PMC10814897 DOI: 10.3390/curroncol31010026] [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] [Received: 11/30/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
The aim of this study was to explore the outcomes of pelvic reconstruction with a rectus abdominis myocutaneous (RAM) or rectus abdominis myoperitoneal (RAMP) flap following radical surgery for gynecologic malignancy. This is a retrospective case series of all pelvic reconstructions with RAM or RAMP flap performed in a gynecologic oncology service between 1998 and 2023. Reconstructions with other flaps were excluded. A total of 28 patients were included. Most patients had vulvar cancer (n = 15, 53.6%) and the majority had disease recurrence (n = 20, 71.4%). Exenteration was the most common procedure, being carried out in 20 (71.4%) patients. Pelvic reconstruction was carried out with a RAM flap in 24 (85.7%) cases and a RAMP flap in 4 (14.3%) cases. Flap-specific complications included cellulitis (14.3%), partial breakdown (17.9%), and necrosis (17.9%). Donor site complications included surgical site infection and necrosis occurring in seven (25.0%) and three (10.7%) patients, respectively. Neovaginal reconstruction was performed in 14 patients. Out of those, two (14.3%) had neovaginal stenosis and three (21.4%) had rectovaginal fistula. In total, 50% of patients were disease-free at the time of the last follow up. In conclusion, pelvic reconstruction with RAM/RAMP flaps, at the time of radical surgery for gynecologic cancer, is an uncommon procedure. In our case series, we had a significant complication rate with the most common being infection and necrosis. The development of a team approach, with input from services including Gynecologic Oncology and Plastic Surgery should be developed to decrease post-operative complications and improve patient outcomes.
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Affiliation(s)
- Oleksandra Dzyubak
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Lina Salman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
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Zhang W, Zeng A, Yang J, Cao D, Huang H, Wang X, You Y, Chen J, Lang J, Shen K. Outcome of vulvar reconstruction by anterolateral thigh flap in patients with advanced and recurrent vulvar malignancy. J Surg Oncol 2015; 111:985-91. [PMID: 25974742 DOI: 10.1002/jso.23908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 03/03/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Wei Zhang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Ang Zeng
- Department of Plastic Surgery; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Huifang Huang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Xiaojun Wang
- Department of Plastic Surgery; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Yan You
- Department of Pathology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Jie Chen
- Department of Pathology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Jinghe Lang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Keng Shen
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
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