Radical surgery with omental flap for uncontrolled locally recurrent breast cancer

What are the short- and long-term abdominal consequences of an omentectomy? A systematic review

This review provides an overview regarding the abdominal effects of an omentectomy, with or without extra-peritoneal reconstructions. In general, reported complication rates were low. Short-term complications involved ileus, bowel stenosis, abdominal abscess and sepsis (range 0.0%-23%). Donor-site hernia was mainly reported as long-term complication (up to 32%) and negligible gastrointestinal complications were observed. However, the level of evidence and methodological quality are quite low with a maximum of 8.5 years follow-up.

Robotic omental flap harvest for near-total anterior chest wall coverage: a potential application of robotic techniques in plastic and reconstructive surgery

We present the robotic harvest of a pedicled omentum flap for reconstruction of a near-total anterior chest wall defect. The patient was a 68-year-old woman with recurrent secondary chest wall angiosarcoma after previous mastectomy and radiation therapy. She underwent neoadjuvant chemotherapy and radiation, followed by wide radical chest wall resection with a final defect size of 15×35 cm. A one-stage reconstruction was performed with an omentum flap harvested by robotic technique and split-thickness skin grafts from thigh donor sites. The patient healed with minimal complications. Our case supports more widespread application of robotics in plastic and reconstructive surgery.

Omentum a powerful biological source in regenerative surgery

The Omentum is a large flat adipose tissue layer nestling on the surface of the intra-peritoneal organs. Besides fat storage, omentum has key biological functions in immune-regulation and tissue regeneration.

Omentum biological properties include neovascularization, haemostasis, tissue healing and regeneration and as an in vivo incubator for cells and tissue cultivation. Some of these properties have long been noted in surgical practice and used empirically in several procedures.

In this review article, the author tries to highlight the omentum biological properties and their application in regenerative surgery procedures. Further, he has started a process of standardisation of basic biological principles to pave the way for future surgical practice.

Chest Wall Resection for Recurrent Breast Cancer in the Modern Era: A Systematic Review and Meta-analysis

OBJECTIVE

To review the literature on chest wall resection for recurrent breast cancer and evaluate overall survival (OS) and quality-of-life (QOL) outcomes.

BACKGROUND

Full-thickness chest wall resection for recurrent breast cancer is controversial, as historically these recurrences have been thought of as a harbinger of systemic disease.

METHODS

A systematic search in MEDLINE, EMBASE, and Cochrane CENTRAL identified 48 eligible studies, all retrospective, accounting for 1305 patients. The review is reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary end points were patient-centered QOL outcomes and OS; secondary outcomes included disease-free survival (DFS) and 30-day morbidity. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies instrument and the Oxford Centre for Evidence-Based Medicine's levels of evidence tool. Random-effects meta-analysis was used to create pooled estimates. Meta-regressions and sensitivity analyses were used to explore study heterogeneity by age, year of publication, risk of bias, and surgical intent (curative vs palliative).

RESULTS

Studies consistently reported excellent OS and DFS in properly selected patients. Pooled estimates for 5-year OS in all studies and those from the past 15 years were 40.8% [95% confidence interval (CI) 35.2-46.7) and 43.1% (95% CI 35.8-50.7), whereas pooled 5-year DFS was 27.1% (95% CI 16.6-41.0). Eight studies reported excellent outcomes related to QOL. Mortality was consistently low (<1%) and 30-day pooled morbidity was 20.2% (95% CI 15.3%-26.3%). Study quality varied, and risk of selection bias in included studies was high.

CONCLUSIONS

Full-thickness chest wall resection can be performed with excellent survival and low morbidity. Few studies report on QOL; prospective studies should focus on patient-centered outcomes in this population.

[Greater omentum flap: Treatment of chronic wounds and seroma: About a case]

INTRODUCTION

Cicatricial complications after abdominal or pelvic surgery are more frequent in obese patients. In this case, infection, seroma and delays in scarring can be extremely difficult to treat. The objective of this technical note is to present an original case of an obese patient operated nine years ago of a hysterectomy by laparotomy and chronically presenting a non-resolving septic seroma despite multiple surgical procedures whose healing could be obtained by a flap of greater omentum.

SURGICAL TECHNIQUE

The ideal is to carry out this intervention in a double team with a digestive surgeon in case of intra-abdominal visceral or vascular wound during dissection. The greater omentum flap was raised in a conventional manner over the gastroepiploic artery. A sufficiently wide orifice should be left at the level of the abdominal aponeurosis in order to avoid any compression of the pedicle. Finally, the flap must be spread over the whole surface of the detachment and fixed to the anterior aponeurosis.

CONCLUSION

Reliability and vascular and lymphatic richness make the greater omentum flap a very effective method in chronic wound cases associated with important seroma. The scarring obtained in the clinical case presented thus highlights the specific qualities of this flap.

Omentum for Mammary Disorders: A 30-Year Systematic Review

PURPOSE

Although the safety of applying omentum to the female breast for total breast reconstruction is controversial, it has recently been used to treat certain mammary disorders as well. A systematic review was therefore conducted to analyze and establish the suitability and safety of applying omentum to the breast.

METHODS

Covereing the interval from January 1984 to December 2013, we performed searches in MEDLINE, Embase, SciELO, and Google-Scholar for original articles describing the applicability of greater omentum to the breast and its clinical complications.

RESULTS

Sixty observational articles with 985 women were chosen. The main clinical indications were total breast reconstruction after mastectomy due to breast cancer (45 studies), radiation damage (23 studies), and congenital Poland syndrome (4 studies). Altogether, 273 complications were identified among the 985 women treated. The most frequent was flap necrosis (26.74 %). The most serious was injury to the digestive system (1.10 %). There was a 35.48 % incidence of local breast cancer recurrence in eight observational studies on oncological risk. Seven of the eight included only women with advanced cancer. One of these studies reported the incidence and relapse time predominantly according to the primary tumor size.

CONCLUSIONS

Although the oncological risk remains unclear, there was a high volume of complications that affected the digestive system. These findings suggest that omentum has well established applicability, but only for total breast reconstruction of huge defects, where muscular/myocutaneous or perforator flaps may be unsuitable.

Outcome of full-thickness chest wall resection for isolated breast cancer recurrence

OBJECTIVES

Local breast cancer recurrence is often viewed as an early sign of rapidly progressive metastatic disease for which chest wall resection (CWR) can provide no benefits. We retrospectively reviewed our experience with full-thickness CWR to determine whether long-term outcomes warranted this aggressive procedure.

METHODS

Between 2001 and 2012, 33 women (mean age, 50.7 years; range, 33-72 years) underwent en-bloc CWR with curative intent. Mean disease-free interval from initial tumour resection was 90.5 months (range, 2-252 months). Resection included skin, muscle and an average of 2.7 ribs (range, 1-8 ribs) and was extended to the sternum (n = 21), subclavian vessels (n = 9), lung (n = 8), pericardium (n = 8), phrenic nerve (n = 2) or T1 nerve root (n = 1). Complete R0 resection was achieved in 31 (94%) patients. Chest wall reconstruction was performed in 28 patients, with polytetrafluoroethylene mesh (n = 17) or titanium ribs (n = 11). A musculocutaneous flap was used in 17 (52%) patients.

RESULTS

Postoperative morbidity was 36%, with no deaths. Median follow-up was 33 months (range, 3-96 months). Median survival was 69 months and 1-, 3- and 5-year survival rates were 100, 81 and 63%, respectively. Recurrence developed in 13 patients, including 12 with distant metastases. Disease-free survival rates were 77, 57 and 50% after 1, 3 and 5 years, respectively. By univariate analysis, only resection extended to intrathoracic structures was associated with better survival (P = 0.033).

CONCLUSIONS

En-bloc full-thickness CWR eventually extended to adjacent structures provides acceptable morbidity and excellent long-term survival and should be considered the treatment of choice in locally recurrent breast cancer.

Microsurgical chest wall reconstruction after oncologic resections

Defect reconstruction after radical oncologic resection of malignant chest wall tumors requires adequate soft tissue reconstruction with function, stability, integrity, and an aesthetically acceptable result of the chest wall. The purpose of this article is to describe possible reconstructive microsurgical pathways after full-thickness oncologic resections of the chest wall. Several reliable free flaps are described, and morbidity and mortality rates of patients are discussed.

A difficult case: omental transposition flap reconstruction of a large radionecrotic axillary ulcer in a patient with extensive previous abdominal surgery

Radionecrotic ulcers due to breast cancer treatment is a highly morbid and disabling condition, causing pain, malodour, need for frequent dressings, reduced range of shoulder movements and an unacceptable cosmetic appearance. In patients with radiotherapy to the chest and/or axilla and general poor health the usual reconstructive options may not be suitable due to regional tissue damage and inappropriate long anaesthetic time, respectively. Described procedures include the pedicled latisimus dorsi flap, transverse rectus abdominal flap (TRAM) and omental transposition flap, as well as free tissue transfer (e.g. free TRAM, DIEP). We report a case of a morbidly obese female patient presenting with a large radionecrotic ulcer in her left axilla, following mastectomy, axillary clearance and local radiotherapy to left chest and axilla for breast cancer. She underwent reconstruction using an omental transposition flap, despite previous abdominal surgery.

Full-thickness resection with myocutaneous flap reconstruction for locally recurrent breast cancer

BACKGROUND

Despite available recommendations, therapeutic procedures of locally recurrent breast cancer are very different. This retrospective study presents the possibilities and results of complete, full-thickness chest wall resection.

METHODS

Between 1985 and 2006, 63 women (mean age, 58 years) with local recurrence of breast cancer invading the chest wall underwent chest wall resection with myocutaneous flap coverage and are included in this study. Adequate lung, cardiovascular, renal, and hepatic functions were additional eligibility requirements for inclusion. Preoperative known extrapulmonary metastases, pleural dissemination, and Eastern Cooperative Oncology Group (ECOG) status 3 or 4 were exclusion criteria. Survival rates were calculated by the Kaplan-Meier method. Univariable and multivariable Cox regression analysis was used for relative risk factors.

RESULTS

The median interval between operation for the primary tumor and of the local recurrence was 89 months, with median follow-up at 28 months. In the total collective, cumulative 5-, 10- and 15-year survival rates were 46%, 29%, and 22%, respectively, with a median survival of 56 months. R0 resection was associated with a 5-year survival of 50.4%. Prognostic factors were patient age at the time of the primary operation and tumor invasion of bony structures. Mortality was 1.6% and morbidity was 25%.

CONCLUSIONS

Full-thickness chest wall resection of locally recurrent breast cancer performed by a team of thoracic and plastic surgeons provides the best survival rates, with low mortality and morbidity. An earlier application of this method may lead to further improvement of these results.

Results of chest wall resection for recurrent or locally advanced breast malignancies

Between 1998 and 2003 we observed 15 women who underwent full thickness chest wall resection (FTCWR) followed by plastic reconstruction for locally recurrent or primary breast cancer. Preoperative symptoms were: pain (5 patients), malodorous ulceration (3 patients), presence of tumour mass (4 patients) and thoracic deformity (2 patients). One patient was asymptomatic. Surgery was partial sternectomy with rib resection in 9 patients, rib resection alone in 5, and total sternectomy in one. No perioperative mortality or major morbidity occurred; minor complications occurred in 3 patients (20%). Five of the six surviving patients reported a positive overall outcome in a telephonic interview. Median overall and disease-free survival were 23.4 and 17.5 months, respectively. In conclusion, FTCWR is a safe procedure with low morbidity and mortality that can provide good symptoms palliation in patients with locally advanced breast malignancies, so it should be considered more often by interdisciplinary care providers in those patients who fail to respond to classic multimodality treatment.

Full-Thickness Chest Wall Resection for Recurrent Breast Carcinoma: An Institutional Review and Meta-analysis

Locoregional recurrence of breast cancer can occur in up to 30 per cent of patients and has often been considered to indicate a poor prognosis. We reviewed our experience with full-thickness chest wall resection for recurrent breast cancer and conducted a meta-analysis of the English literature to determine patient characteristics and outcomes. Twenty-two women with isolated chest wall recurrence of breast cancer were treated between 1970 and 2000 at our institution. We reviewed their preoperative demographics, operative management and outcome, and combined our results with seven other English language studies. A majority of women (90%) underwent a mastectomy as initial management of their breast cancer. Only 18 per cent of patients had meta-static disease at the time of chest wall resection, and 71 per cent of patients had an R0 resection. The 5-year disease-free survival at City of Hope National Medical Center (COH) was 67 per cent and was 45 per cent for the entire group of 400 patients. The 5-year overall survival was 71 per cent for the COH group and 45 per cent for the entire group. Several studies reported prognostic factors, the most common being a better prognosis in patients with a disease-free interval greater than 24 months. Full-thickness chest wall resection for patients with isolated local recurrence of breast cancer can provide long-term palliation and even cure in some patients.