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Shahzad F, Ray E. Pelvic and Perineal Reconstruction. Plast Reconstr Surg 2024; 154:803e-816e. [PMID: 39314105 PMCID: PMC11424020 DOI: 10.1097/prs.0000000000011137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Classify types of bony pelvic resections. 2. Outline reconstructive options for pelvic and perineal defects. 3. Identify advantages and drawbacks of various reconstructive techniques. 4. Recognize the functional benefits of bony and soft-tissue reconstruction. SUMMARY Defects of the pelvis and perineum arise from tumors, trauma, infection, congenital differences, and gender incongruence. Pelvic resections can result in bony instability and soft-tissue deficiency. The goals of reconstruction are maintenance of spinopelvic continuity, elimination of dead space, resurfacing of cutaneous defects, and prevention of hernias. Perineal reconstruction has important functional considerations. Abdominoperineal resection and pelvic exenteration defects benefit from flap reconstruction to decrease pelvic wound complications. Vulvovaginal reconstruction is performed with flaps from the perineum, thigh, or abdomen. Scrotal and superficial penile defects are most commonly reconstructed with scrotal flaps and skin grafts. Total penile reconstruction most commonly uses a radial forearm free flap.
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Affiliation(s)
- Farooq Shahzad
- Plastic & Reconstructive Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Edward Ray
- Division of Plastic & Reconstructive Surgery, Cedars-Sinai Medical Center, Los Angeles, USA
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Kappos EA, Wendelspiess SR, Stoffel J, Djedovic G, Rieger UM, Bannasch H, Fritsche E, Constantinescu M, Andric M, Croner RS, Schmidt VJ, Plock J, Schaefer DJ, Horch RE. [Reconstruction of Oncological Defects in the Pelvic-perineal Region: Report on the Consensus Workshop at the 44th Annual Meeting of the DAM 2023 in Bern, CH]. HANDCHIR MIKROCHIR P 2024; 56:269-278. [PMID: 39137788 DOI: 10.1055/a-2358-1479] [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: 08/15/2024] Open
Abstract
The surgical-oncological treatment of pelvic and perineal malignancies is associated with a high complication rate and morbidity for patients. Modern multimodal treatment modalities, such as neoadjuvant radio-chemotherapy for anal or rectal cancer, increase the long-term survival rate while reducing the risk of local recurrence. Simultaneously, the increasing surgical radicality and higher oncological safety with wide resection margins is inevitably associated with larger and, due to radiation, more complex tissue defects in the perineal and sacral parts of the pelvic floor. Therefore, the plastic-surgical reconstruction of complex pelvic-perineal defects following oncological resection remains challenging. The reconstructive armamentarium, and thus the treatment of such defects, is broad and ranges from local, regional and muscle-based flaps to microvascular and perforator-based procedures. While the use of flaps is associated with a significant, well-documented reduction in postoperative complications compared to primary closure, there is still a lack of reliable data directly comparing the postoperative results of different reconstructive approaches. Additionaly, the current data shows that the quality of life of these patients is rarely recorded in a standardised manner. In a consensus workshop at the 44th annual meeting of the German-speaking Association for Microsurgery on the topic of "Reconstruction of oncological defects in the pelvic-perineal area", the current literature was discussed and recommendations for the reconstruction of complex defects in this area were developed. The aim of this workshop was to identify knowledge gaps and establish an expert consensus to ensure and continuously improve the quality of reconstruction in this challenging area. In addition, the importance of the "patient-reported outcome measures" in pelvic reconstruction was highlighted, and the commitment to its widespread use in the era of value-based healthcare was affirmed.
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Affiliation(s)
- Elisabeth A Kappos
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Basel, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Séverin R Wendelspiess
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Basel, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Julia Stoffel
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Basel, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Gabriel Djedovic
- Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Landeskrankenhaus Feldkirch, Feldkirch, Österreich
| | - Ulrich M Rieger
- Klinik für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | - Holger Bannasch
- Klinik für Plastische-, Hand- und Ästhetische Chirurgie, Schwarzwald-Baar Klinikum Donaueschingen, Donaueschingen, Deutschland
| | - Elmar Fritsche
- Abteilung für Hand- und Plastische Chirurgie, Luzerner Kantonsspital, Luzern, Schweiz
| | | | - Mihailo Andric
- Klinik für Allgemein-, Viszeral-, Gefäss- und Transplantationschirurgie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Roland S Croner
- Klinik für Allgemein-, Viszeral-, Gefäss- und Transplantationschirurgie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Volker J Schmidt
- Klinik für Plastische Chirurgie und Handchirurgie, Kantonsspital St. Gallen, Sankt Gallen, Schweiz
| | - JanA Plock
- Klinik für Plastische Chirurgie und Handchirurgie, Kantonsspital Aarau, Aarau, Schweiz
| | - Dirk J Schaefer
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Basel, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Raymund E Horch
- Plastische und Handchirurgische Klinik, Universitätsklinikum Erlangen, Erlangen, Deutschland
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Wendelspiess S, Kouba L, Stoffel J, Speck N, Appenzeller-Herzog C, Gahl B, Montavon C, Heinzelmann-Schwarz V, Lariu A, Schaefer DJ, Ismail T, Kappos EA. Perforator versus Non-Perforator Flap-Based Vulvoperineal Reconstruction-A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:2213. [PMID: 38927919 PMCID: PMC11202299 DOI: 10.3390/cancers16122213] [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: 05/08/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Patients with advanced vulvoperineal cancer require a multidisciplinary treatment approach to ensure oncological safety, timely recovery, and the highest possible quality of life (QoL). Reconstructions in this region often lead to complications, affecting approximately 30% of patients. Flap design has evolved towards perforator-based approaches to reduce functional deficits and (donor site) complications, since they allow for the preservation of relevant anatomical structures. Next to their greater surgical challenge in elevation, their superiority over non-perforator-based approaches is still debated. METHODS To compare outcomes between perforator and non-perforator flaps in female vulvoperineal reconstruction, we conducted a systematic review of English-language studies published after 1980, including randomized controlled trials, cohort studies, and case series. Data on demographics and surgical outcomes were extracted and classified using the Clavien-Dindo classification. We used a random-effects meta-analysis to derive a pooled estimate of complication frequency (%) in patients who received at least one perforator flap and in patients who received non-perforator flaps. RESULTS Among 2576 screened studies, 49 met our inclusion criteria, encompassing 1840 patients. The overall short-term surgical complication rate was comparable in patients receiving a perforator (n = 276) or a non-perforator flap (n = 1564) reconstruction (p* > 0.05). There was a tendency towards fewer complications when using perforator flaps. The assessment of patients' QoL was scarce. CONCLUSIONS Vulvoperineal reconstruction using perforator flaps shows promising results compared with non-perforator flaps. There is a need for the assessment of its long-term outcomes and for a systematic evaluation of patient QoL to further demonstrate its benefit for affected patients.
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Affiliation(s)
- Séverin Wendelspiess
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Loraine Kouba
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Julia Stoffel
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
| | - Nicole Speck
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Christian Appenzeller-Herzog
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- University Medical Library, University of Basel, 4051 Basel, Switzerland
| | - Brigitta Gahl
- Surgical Outcome Research Center, University Hospital Basel, 4031 Basel, Switzerland
| | - Céline Montavon
- Department of Gynecology and Gynecological Oncology, University Hospital Basel, 4031 Basel, Switzerland
| | - Viola Heinzelmann-Schwarz
- Department of Gynecology and Gynecological Oncology, University Hospital Basel, 4031 Basel, Switzerland
| | - Ana Lariu
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
- Faculty of General Medicine, University of Medicine and Pharmacy ‘Iuliu Hațieganu’, 400347 Cluj-Napoca, Romania
| | - Dirk J. Schaefer
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Tarek Ismail
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Elisabeth A. Kappos
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
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Moraru DC, Pertea M, Luca S, Bejan V, Panuta A, Tatar R, Enescu DM, Scripcariu DV, Scripcariu V. Personalized Decisional Algorithms for Soft Tissue Defect Reconstruction after Abdominoperineal Resection for Low-Lying Rectal Cancers. Curr Oncol 2024; 31:3253-3268. [PMID: 38920730 PMCID: PMC11202520 DOI: 10.3390/curroncol31060247] [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: 04/29/2024] [Revised: 05/25/2024] [Accepted: 06/03/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Abdominoperineal resection (APR)-the standard surgical procedure for low-lying rectal cancer (LRC)-leads to significant perineal defects, posing considerable reconstruction challenges that, in selected cases, necessitate the use of plastic surgery techniques (flaps). PURPOSE To develop valuable decision algorithms for choosing the appropriate surgical plan for the reconstruction of perineal defects. METHODS Our study included 245 LRC cases treated using APR. Guided by the few available publications in the field, we have designed several personalized decisional algorithms for managing perineal defects considering the following factors: preoperative radiotherapy, intraoperative position, surgical technique, perineal defect volume, and quality of tissues and perforators. The algorithms have been improved continuously during the entire period of our study based on the immediate and remote outcomes. RESULTS In 239 patients following APR, the direct closing procedure was performed versus 6 cases in which we used various types of flaps for perineal reconstruction. Perineal incisional hernia occurred in 12 patients (5.02%) with direct perineal wound closure versus in none of those reconstructed using flaps. CONCLUSION The reduced rate of postoperative complications suggests the efficiency of the proposed decisional algorithms; however, more extended studies are required to categorize them as evidence-based management guide tools.
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Affiliation(s)
- Dan Cristian Moraru
- Department of Plastic Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (D.C.M.); (S.L.)
- Plastic, Reconstructive Surgery and Burns Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania;
| | - Mihaela Pertea
- Department of Plastic Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (D.C.M.); (S.L.)
- Plastic, Reconstructive Surgery and Burns Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania;
| | - Stefana Luca
- Department of Plastic Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (D.C.M.); (S.L.)
- Plastic, Reconstructive Surgery and Burns Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania;
| | - Valentin Bejan
- Department of Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (V.B.); (V.S.)
- First Surgery Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania
| | - Andrian Panuta
- Plastic, Reconstructive Surgery and Burns Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania;
- Department of Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (V.B.); (V.S.)
| | - Raluca Tatar
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.T.); (D.M.E.)
- Department of Plastic, Reconstructive Surgery and Burns, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
| | - Dan Mircea Enescu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.T.); (D.M.E.)
- Department of Plastic, Reconstructive Surgery and Burns, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
| | - Dragos Viorel Scripcariu
- Department of Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (V.B.); (V.S.)
- First Oncological Surgery Clinic, Regional Institute of Oncology (IRO), 700483 Iași, Romania
| | - Viorel Scripcariu
- Department of Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (V.B.); (V.S.)
- First Oncological Surgery Clinic, Regional Institute of Oncology (IRO), 700483 Iași, Romania
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Mirnezami AH, Drami I, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Denys A, Pape E, van Ramshorst GH, Baker D, Bignall E, Blair I, Davis P, Edwards T, Jackson K, Leendertse PG, Love-Mott E, MacKenzie L, Martens F, Meredith D, Nettleton SE, Trotman MP, van Hecke JJM, Weemaes AMJ, Abecasis N, Angenete E, Aziz O, Bacalbasa N, Barton D, Baseckas G, Beggs A, Brown K, Buchwald P, Burling D, Burns E, Caycedo-Marulanda A, Chang GJ, Coyne PE, Croner RS, Daniels IR, Denost QD, Drozdov E, Eglinton T, Espín-Basany E, Evans MD, Flatmark K, Folkesson J, Frizelle FA, Gallego MA, Gil-Moreno A, Goffredo P, Griffiths B, Gwenaël F, Harris DA, Iversen LH, Kandaswamy GV, Kazi M, Kelly ME, Kokelaar R, Kusters M, Langheinrich MC, Larach T, Lydrup ML, Lyons A, Mann C, McDermott FD, Monson JRT, Neeff H, Negoi I, Ng JL, Nicolaou M, Palmer G, Parnaby C, Pellino G, Peterson AC, Quyn A, Rogers A, Rothbarth J, Abu Saadeh F, Saklani A, Sammour T, Sayyed R, Smart NJ, Smith T, Sorrentino L, Steele SR, Stitzenberg K, Taylor C, Teras J, Thanapal MR, Thorgersen E, Vasquez-Jimenez W, Waller J, Weber K, Wolthuis A, Winter DC, Brangan G, Vimalachandran D, Aalbers AGJ, Abdul Aziz N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Baker RP, Bali M, Baransi S, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Bui A, Burgess A, Burger JWA, Campain N, Carvalhal S, Castro L, Ceelen W, Chan KKL, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Damjanovic L, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Egger E, Enrique-Navascues JM, Espín-Basany E, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Fleming F, Flor B, Foskett K, Funder J, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Giner F, Ginther N, Glover T, Golda T, Gomez CM, Harris C, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Jenkins JT, Jourand K, Kaffenberger S, Kapur S, Kanemitsu Y, Kaufman M, Kelley SR, Keller DS, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Lago V, Lakkis Z, Lampe B, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lynch AC, Mackintosh M, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Morton JR, Mullaney TG, Navarro AS, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Pappou E, Park J, Patsouras D, Peacock O, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steffens D, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor D, Tejedor P, Tekin A, Tekkis PP, Thaysen HV, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Yano H, Yip B, Yip J, Yoo RN, Zappa MA. The empty pelvis syndrome: a core data set from the PelvEx collaborative. Br J Surg 2024; 111:znae042. [PMID: 38456677 PMCID: PMC10921833 DOI: 10.1093/bjs/znae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored. METHOD Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition. RESULTS One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed. CONCLUSIONS EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.
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Giannas E, Kavallieros K, Nanidis T, Giannas J, Tekkis P, Kontovounisios C. Re-Do Plastic Reconstruction for Locally Advanced and Recurrent Colorectal Cancer Following a beyond Total Mesorectal Excision (TME) Operation-Key Considerations. J Clin Med 2024; 13:1228. [PMID: 38592018 PMCID: PMC10932044 DOI: 10.3390/jcm13051228] [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: 12/13/2023] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
Innovation in surgery and pelvic oncology have redefined the boundaries of pelvic exenteration for CRC. However, surgical approaches and outcomes following repeat exenteration and reconstruction are not well described. The resulting defect from a second beyond Total Mesorectal Excision (TME) presents a challenge to the reconstructive surgeon. The aim of this study was to explore reconstructive options for patients undergoing repeat beyond TME for recurrent CRC following previous beyond TME and regional reconstruction. MEDLINE and Embase were searched for relevant articles, yielding 2353 studies. However, following full text review and the application of the inclusion criteria, all the studies were excluded. This study demonstrated the lack of reporting on re-do reconstruction techniques following repeat exenteration for recurrent CRC. Based on this finding, we conducted a point-by-point discussion of certain key aspects that should be taken into consideration when approaching this patient cohort.
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Affiliation(s)
- Emmanuel Giannas
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Konstantinos Kavallieros
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Theodoros Nanidis
- Department of Plastic Surgery, The Royal Marsden Hospital, London SW3 6JJ, UK;
| | - John Giannas
- Department of Plastic and Reconstructive Surgery, Euroclinic, 115 21 Athens, Greece;
- Department of Plastic and Reconstructive Surgery, The London Welbeck Hospital, London W1G 83N, UK
| | - Paris Tekkis
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
- Department of Surgery, The Royal Marsden Hospital, London SE3 6JJ, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
- Department of Surgery, The Royal Marsden Hospital, London SE3 6JJ, UK
- 2nd Surgical Department Evaggelismos, Athens General Hospital, 115 21 Athens, Greece
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7
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Platteau E, Denys A, Buncamper M, van Ramshorst GH. A systematic review of female sexual function after surgery for locally advanced or recurrent colorectal cancer - first step to filling the knowledge gap. Colorectal Dis 2023; 25:2294-2305. [PMID: 37872739 DOI: 10.1111/codi.16767] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/25/2023]
Abstract
AIM Locally advanced and recurrent colorectal cancer can require extended surgery, including reconstruction of the vagina. This complex surgery carries high morbidity. The aim of this study was to analyse the impact on female sexual functioning of pelvic exenteration (PE), with or without vaginal flap reconstruction, for locally advanced or recurrent colorectal cancer. METHOD The protocol with search strategies for PubMed (Medline), EMBASE and the Cochrane Library was registered in PROSPERO. Studies published from 2000 onwards meeting the inclusion criteria were considered. Study selection (Rayyan), data extraction, rating of evidence (GRADE) and risk of bias (ROBINS-I) were conducted independently by two reviewers. RESULTS Six of 2479 identified records were included: four retrospective and two cross-sectional studies. Of all 860 patients included, PE was performed in 314 patients. Seven hundred and thirty-two had rectal cancer (85.1%), 80 nonadvanced rectal cancer (10.9%), 393 locally advanced rectal cancer (53.7%) and 217 locally recurrent rectal cancer (29.6%); for 45 patients the type of rectal cancer remained unspecified (6.1%). Three studies reported on both preoperative and postoperative female sexual activity. Of the 153 women who were sexually active preoperatively, 64 (41.8%) reported postoperative sexual activity. The VRAM flap was used the most frequently and resulted in a sexual activity ratio of 18% postoperatively. Four studies, using six different validated questionnaires, reported mostly lowered sexual functioning postoperatively. CONCLUSION Most studies showed that PE can result in severe sexual dysfunction despite reconstruction. Future prospective studies can fill the current knowledge gap by assessing long-term sexual outcomes in women.
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Affiliation(s)
- Elke Platteau
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Andreas Denys
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Marlon Buncamper
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Plastic Surgery, Ghent University Hospital, Ghent, Belgium
| | - Gabrielle H van Ramshorst
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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8
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Brown KGM, Solomon MJ, Steffens D, Ng KS, Byrne CM, Austin KKS, Lee PJ. Pelvic Exenteration for Squamous Cell Carcinoma of the Anus: Oncological, Morbidity, and Quality-of-Life Outcomes. Dis Colon Rectum 2023; 66:1427-1434. [PMID: 37493254 DOI: 10.1097/dcr.0000000000002919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Salvage surgery is the only potentially curative treatment option for recurrent squamous cell carcinoma of the anus. Where adjacent pelvic viscera, soft tissues, and bone are involved, pelvic exenteration with a wide perineal excision may be required to ensure clear surgical margins and increase the likelihood of long-term survival. OBJECTIVE To report oncological, morbidity, and quality-of-life outcomes of pelvic exenteration for anal squamous cell carcinoma. DESIGN Cohort study with retrospective analysis of prospectively collected data. SETTINGS This study was conducted at a high-volume pelvic exenteration center. PATIENTS Those who underwent pelvic exenteration for anal squamous cell carcinoma between 1994 and 2022. MAIN OUTCOME MEASURES Local recurrence-free and overall survival, intraoperative and postoperative complication rates, R0 resection rate, and long-term quality-of-life outcomes. RESULTS Of 958 patients who underwent pelvic exenteration, 66 (6.9%) had anal squamous cell carcinoma. Thirty-two patients (48.5%) were male and the median age was 57 years (range, 31-79). Ten patients (15%) had primary anal squamous cell carcinoma, 49 (74%) had a recurrent tumor, and 7 (11%) had a re-recurrent tumor. Twenty-two patients (33%) and 16 patients (24%) had a major complication and unplanned return to the operating theater, respectively. Of the 62 patients who underwent pelvic exenteration with curative intent, 50 (81%) had R0 resection, and the 5-year overall and local recurrence-free survival rates were 41% and 37%, respectively. R0 resection was associated with a higher 5-year overall survival (50% vs 8%, p < 0.001). The mental health component scores and several individual quality-of-life domains presented improved trajectories postoperatively (all p values <0.05). LIMITATIONS The generalizability of the findings outside specialist pelvic exenteration centers may be limited. CONCLUSIONS Morbidity, long-term survival, and quality-of-life outcomes after pelvic exenteration for anal squamous cell carcinoma are comparable to published outcomes of pelvic exenteration for other tumor types. EXENTERACIN PLVICA POR CARCINOMA EPIDERMOIDE DE ANO RESULTADOS ONCOLGICOS, DE MORBILIDAD Y DE CALIDAD DE VIDA ANTECEDENTES:La cirugía de rescate es la única opción de tratamiento potencialmente curativa para el carcinoma de células escamosas del ano recurrente. Cuando están involucradas vísceras pélvicas, tejidos blandos y huesos adyacentes, puede ser necesaria una exenteración pélvica con una escisión perineal amplia para asegurar márgenes quirúrgicos claros y aumentar la probabilidad de supervivencia a largo plazo.OBJETIVO:Informar sobre los resultados oncológicos, de morbilidad y de calidad de vida de la exenteración pélvica por carcinoma anal de células escamosas.DISEÑO:Estudio de cohortes con análisis retrospectivo de datos recogidos prospectivamente.ENTORNO CLINICO:Este estudio se realizó en un centro de exenteración pélvica de alto volumen.PACIENTES:Aquellos que se sometieron a exenteración pélvica por carcinoma anal de células escamosas entre 1994 y 2022.PRINCIPALES MEDIDAS DE VALORACIÓN:Supervivencia global y libre de recidiva local, tasas de complicaciones intraoperatorias y posoperatorias, tasa de resección R0 y resultados de calidad de vida a largo plazo.RESULTADOS:De 958 pacientes que se sometieron a exenteración pélvica, 66 (6,9%) tenían carcinoma anal de células escamosas. 32 pacientes (48,5%) eran varones y la mediana de edad fue de 57 años (rango 31-79). 10 pacientes (15%) tenían carcinoma anal primario de células escamosas, 49 (74%) tenían un tumor recurrente y 7 (11%) tenían una segunda recurrencia. 22 (33%) y 16 pacientes (24%) tuvieron una complicación mayor y regreso no planificado al quirófano, respectivamente. De los 62 pacientes que se sometieron a una exenteración pélvica con intención curativa, 50 (81%) tuvieron una resección R0, las tasas de supervivencia global y libre de recidiva local a los 5 años fueron del 41% y el 37%, respectivamente. La resección R0 se asoció con una mayor supervivencia general a los 5 años (50% frente a 8%, p < 0,001). Las puntuaciones del componente de salud mental y varios dominios de calidad de vida individuales presentaron trayectorias mejoradas después de la operación (todos los valores de p < 0,05).LIMITACIONES:La generalización de los hallazgos fuera de los centros especializados en exenteración pélvica puede ser limitada.CONCLUSIONES:Los resultados de morbilidad, supervivencia a largo plazo y calidad de vida después de la EP para el carcinoma anal de células escamosas son comparables a los resultados publicados de la exenteración pélvica para otros tipos de tumores. (Traducción-Dr. Ingrid Melo ).
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Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, Australia
| | - Christopher M Byrne
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
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Assi H, Guné H, Buchwald P, Lagergren J, Lydrup ML, Öberg M. A New Technique for Pelvic and Vaginal Reconstruction in Abdominoperineal Rectal Excision: Combination of Gluteus Maximus Flap and Fasciocutaneous Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5317. [PMID: 37817923 PMCID: PMC10561799 DOI: 10.1097/gox.0000000000005317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/24/2023] [Indexed: 10/12/2023]
Abstract
Resection of advanced rectal cancer might result in significant tissue loss, including pelvic floor and parts of the vaginal wall. Pelvic floor reconstruction using a musculocutaneous flap offers optimized healing abilities and the possibility of vaginal reconstruction. In Skåne University Hospital, two different flap techniques are used to reconstruct the perineum: the vertical rectus abdominis musculocutaneous flap and the gluteus maximus (GM) flap. A combination of a GM flap and a fasciocutanous flap, referred to locally as a GM special (GMS) flap, is used for posterior vaginal wall reconstruction in women undergoing abdominoperineal resections including parts of or the total posterior vaginal wall. The GMS flap was introduced through a national collaboration in Sweden in 2013. The aim of this article is to offer a detailed description and illustrations of the surgical technique used to construct the GMS flap, focusing on the posterior vaginal wall reconstruction. In our experience, the GMS flap is a resilient and cosmetically appealing choice that is technically easily harvested. The flap has acceptable morbidity and long-term results with adequate neovaginal measurements. Collaborative work is further encouraged.
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Affiliation(s)
- Hanin Assi
- From the Department of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Henrik Guné
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Pamela Buchwald
- From the Department of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Jakob Lagergren
- Department of Surgery, Capio S:t Göran Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Marie-Louise Lydrup
- From the Department of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Martin Öberg
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
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Pividori M, Gangloff D, Ferron G, Meresse T, Delay E, Rivoire M, Perez S, Vaucher R, Frobert P. Outcomes of DIEP flap reconstruction after pelvic cancer surgery: A retrospective multicenter case series. J Plast Reconstr Aesthet Surg 2023; 85:242-251. [PMID: 37531805 DOI: 10.1016/j.bjps.2023.07.005] [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: 08/23/2022] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Flap reconstruction is often required after pelvic tumor resection to reduce wound complications. The use of perforator flaps has been shown to reduce donor site morbidity. The purpose of this study was to evaluate the outcomes of pedicled deep inferior epigastric perforator (pDIEP) flap reconstruction. METHODS This was a retrospective multicenter study of patients who underwent immediate pDIEP flap reconstruction for a pelvic or perineal defect after tumor resection between November 2012 and June 2022. The primary outcome was abdominal donor site morbidity, and the secondary outcome was perineal morbidity. RESULTS Thirty-four patients (median age, 57.5 years) who underwent pelvic exenteration (n = 31), extralevator abdominoperineal excision (n = 2), or extended vaginal hysterectomy (n = 1) were included. The most common indications were recurrent cervical (n = 19) and anal (n = 4) squamous cell carcinoma. Twenty-nine patients (85%) had a history of radiotherapy. Only one patient (3%) had major (Clavien-Dindo ≥ III) donor site complications (surgical site infection due to tumor recurrence). Eleven patients (32%) had at least one major recipient site complication (surgical site infection [n = 1], total [n = 2] or partial [n = 1] flap loss, perineal dehiscence [n = 2], hematoma [n = 1], fistula [n = 5]). No incisional or perineal hernias were observed during follow-up. Ninety-day survival was 100%. CONCLUSION Pedicled DIEP flap reconstructions performed by experienced surgical teams had good outcomes for perineal or vaginal reconstruction, with low abdominal morbidity, in patients with advanced pelvic malignancies who had undergone median laparotomy. The risks and benefits of this procedure should be carefully evaluated preoperatively using clinical and imaging data.
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Affiliation(s)
- Marc Pividori
- Department of Reconstructive and Plastic Surgery, Hospices Civils de Lyon, 103, Grande-Rue de la Croix-Rousse, 69317 Lyon, France; Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France.
| | - Dimitri Gangloff
- Department of Plastic Surgery, Institut Claudius Regaud Institut Universitaire du Cancer de Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse Cedex 9, France
| | - Gwenaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud Institut Universitaire du Cancer de Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse Cedex 9, France
| | - Thomas Meresse
- Department of Plastic Surgery, Institut Claudius Regaud Institut Universitaire du Cancer de Toulouse-Oncopole, 1 Avenue Irène Joliot-Curie, 31059 Toulouse Cedex 9, France
| | - Emmanuel Delay
- Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - Michel Rivoire
- Department of Surgical Oncology, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - Simon Perez
- Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - Richard Vaucher
- Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - Paul Frobert
- Department of Reconstructive and Plastic Surgery, Centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
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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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12
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Loreti A, Arelli F, Spallone D, Bruno E, Abate O. The use of the internal pudendal artery perforator flap after abdominoperineal reconstruction: A single center study. J Plast Reconstr Aesthet Surg 2023; 84:87-92. [PMID: 37327737 DOI: 10.1016/j.bjps.2023.05.015] [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: 08/09/2022] [Revised: 05/09/2023] [Accepted: 05/14/2023] [Indexed: 06/18/2023]
Abstract
Abdominoperineal resection (APR) is still a valuable option in the presence of cancer recurrences or salvage surgery. Primary perineal closure after conventional APR curries a high rate of wound complications. A multidisciplinary approach with perineal soft tissue reconstruction surgical time improves the immediate and long-term prognosis of these patients. The aim of the study is to report our experience with the use of the internal pudendal artery perforator flap in perineal region reconstruction after APR. We performed 11 perineal region reconstructions after conventional APR between September 2016 and December 2020. In 8 cases the reconstruction was performed on previously irradiated tissues while in 2 cases the radiotherapy was carried out on the perineal tissues solely for adjuvant therapy. A rotation perforating flap was harvested in 8 cases, an advance island flap in 2 cases, and a propeller type in one case. All 11 flaps survived with no immediate postoperative major complications. Only one case showed dehiscence of the donor site wound healed with conservative treatment. Average hospitalization time was 11 days internal pudendal artery perforator flap represents a valid and reliable reconstructive solution after APR showing low complication rates and minimal donor site morbidity even in patients with previous radiotherapy.
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Affiliation(s)
- Andrea Loreti
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
| | - Floriana Arelli
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
| | - Diana Spallone
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
| | - Edoardo Bruno
- Department of Surgery ''P.Valdoni'', Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Via Giovanni Maria Lancisi, 2, 00161 Roma, Italy.
| | - Ornella Abate
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
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Fahy MR, Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angeles MA, Angenete E, Antoniou A, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Beynon J, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelan W, Chan KKL, Chang GJ, Chang M, Chew MH, Chok AY, Chong P, Clouston H, Codd M, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovich L, Daniels IR, Davies M, Delaney CP, de Wilt JHW, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Eglinton T, Enriquez-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fearnhead NS, Ferron G, Flatmark K, Fleming FJ, Flor B, Folkesson J, Frizelle FA, Funder J, Gallego MA, Gargiulo M, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther DN, Glyn T, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kazi M, Kelley SR, Keller DS, Ketelaers SHJ, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kristensen HØ, Kroon HM, Kumar S, Kusters M, Lago V, Lampe B, Lakkis Z, Larach JT, Larkin JO, Larsen SG, Larson DW, Law WL, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Maciel J, Manfredelli S, Mann C, Mantyh C, Mathis KL, Marques CFS, Martinez A, Martling A, Mehigan BJ, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, Mikalauskas S, McArthur DR, McCormick JJ, McCormick P, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Navarro AS, Negoi I, Neto JWM, Ng JL, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, Nugent T, Oliver A, O’Dwyer ST, O’Sullivan NJ, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock O, Pellino G, Peterson AC, Pinson J, Poggioli G, Proud D, Quinn M, Quyn A, Rajendran N, Radwan RW, Rajendran N, Rao C, Rasheed S, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Selvasekar C, Shaikh I, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Sorrentino L, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Spasojevic M, Sumrien H, Sutton PA, Swartking T, Takala H, Tan EJ, Taylor C, Tekin A, Tekkis PP, Teras J, Thaysen HV, Thurairaja R, Thorgersen EB, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Valente M, van Ramshorst GH, van Zoggel D, Vasquez-Jimenez W, Vather R, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Urrejola G, Wakeman C, Warrier SK, Wasmuth HH, Waters PS, Weber K, Weiser MR, Wheeler JMD, Wild J, Williams A, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline. Br J Surg 2022; 109:1251-1263. [PMID: 36170347 DOI: 10.1093/bjs/znac317] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/18/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022]
Abstract
This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.
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Fascia Lata Grafting Combined with Gluteal Flaps for Pelvic Floor Reconstruction after Oncologic Resection. Plast Reconstr Surg Glob Open 2022; 10:e4528. [PMID: 36246078 PMCID: PMC9556018 DOI: 10.1097/gox.0000000000004528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
Abstract
Although recent methods of pelvic reconstruction using myocutaneous flaps have reduced postoperative morbidities' including pelvic abscess, the complication rates are still high due to the presence of a large dead cavity and poorly vascularized tissues secondary to preoperative chemoradiation therapy. We aimed to evaluate the usefulness and benefit of fascia lata autografting for pelvic floor reconstruction as a supplemental procedure for gluteal flap closure of perineal wounds. Methods Our retrospective study included 144 consecutive patients who underwent rectal cancer resection with or without pelvic reconstruction, from 2010 to 2020. For reconstruction, fascia lata autografts were harvested from the thigh and affixed to the pelvic floor. The perineal wound was closed using gluteal advancement flaps. Results The study included 33 reconstructed and 111 nonreconstructed patients (average age: 69.5 years). The reconstructed group was more likely to have undergone preoperative chemotherapy (81.8% versus 40.5%, P < 0.001) and radiotherapy (78.8% versus 48.6%, P = 0.002), compared with the nonreconstructed group. Additionally, the reconstructed group underwent fewer abdominoperineal resections (63.6% versus 94.6%, P < 0.001) and more pelvic exenterations (36.4% versus 5.4%). The mean size of fascia lata autografts was 8.3 × 5.9 cm. There were significant differences between the reconstructed and nonreconstructed groups, in the incidences of complications (15.2% versus 33.3%, P = 0.044) and pelvic abscess (3.0% versus 16.2%, P = 0.049). Conclusion Combination of fascia lata autografts and gluteal flaps is considered an effective method of pelvic reconstruction for its low incidence of complications and stable outcomes.
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Khaw CW, Ebrahimi N, Lee P, McCarthy ASE, Solomon M. Long-term results of mesh pelvic floor reconstruction to address the empty pelvis syndrome. Colorectal Dis 2022; 24:1211-1215. [PMID: 35652246 DOI: 10.1111/codi.16203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/28/2022] [Accepted: 05/22/2022] [Indexed: 02/08/2023]
Abstract
AIM As the "empty pelvis syndrome" continues to pose challenges in patients undergoing radical pelvic exenteration, there remains an ongoing need to consider solutions to mitigate or avoid its associated morbidity. As such, this study aims to review the long-term outcomes of a proposed strategy of pelvic reconstruction with BioA mesh. METHOD We conducted a retrospective observational cohort study, reviewing cases of pelvic exenteration and/or pelvic bone resection involving BioA mesh pelvic reconstruction between 2017 and 2021 at our quaternary institution, identified from a prospectively collected database. The primary outcome was pelvic complications including perineal fistula, wound breakdown and pelvic collections. RESULTS Over a 4-year period, there were a total of 36 patients who had pelvic exenteration and/or pelvic bone resection with BioA mesh pelvic reconstruction. The overall pelvic complication rate was 36% (n = 13), including 11 symptomatic pelvic collections, two enteroperineal fistulas, and no cases of perineal hernia. Reoperation was required in two patients. There was no perioperative mortality. CONCLUSION Given that pelvic complications post BioA mesh reconstruction are of an acceptable rate and can be considered minor, using this technique is a safe and practical strategy in patients undergoing major pelvic surgery with or without pelvic bone resection.
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Affiliation(s)
- Chern Wern Khaw
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nargus Ebrahimi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Peter Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Alexander S E McCarthy
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
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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: 2] [Impact Index Per Article: 1.0] [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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Trapero A, Pérez-García A, Thione A, Andresen-Lorca B, Alcalde IH, Ximénez EGG. VRAM FLAP TRANSPOSITION IN PELVIPERINEAL RECONSTRUCTION. A TECHNICAL NOTE. J Plast Reconstr Aesthet Surg 2022; 75:3877-3903. [DOI: 10.1016/j.bjps.2022.08.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 07/19/2022] [Accepted: 08/17/2022] [Indexed: 10/15/2022]
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The reconstructive strategy for pelvic oncological surgery with various types of MS-VRAM flaps. J Plast Reconstr Aesthet Surg 2022; 75:2090-2097. [PMID: 35300926 DOI: 10.1016/j.bjps.2022.02.014] [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: 05/18/2020] [Revised: 12/21/2021] [Accepted: 02/13/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Muscle-sparing vertical rectus abdominis myocutaneous (MS-VRAM) flaps are widely used in pelvic reconstruction. Aiming at optimal reconstructive outcomes, flap design and modification should be individualized to restore various kinds of defects. OBJECTIVE Summarize an empirical strategy about MS-VRAM selection for different pelvic and perineal reconstructions. METHODS Thirty patients who underwent total pelvic exenteration and pelvic reconstruction surgery from 2009 to 2017 were enrolled. The patients were divided into four groups according to the type of MS-VRAM-based flap used in the procedure: the modified long vertical flap (n = 10), the wrapping flap (n = 6), the de-epithelialized flap (n = 6), and the cork flap (n = 8). The follow-up period was 1 year after the surgery. Flap size, drainage volume, postoperative satisfaction, and complications were recorded, and postoperative photographs were collected. RESULTS All of the patients achieved satisfying effect under the targeted reconstruction strategy. Of the four groups, the accurate cork flap finally acquires higher satisfaction, the shortest hospital stay, and the least total drainage volume. Meanwhile, the incidence of complications was not increased compared with the other groups. CONCLUSIONS A new reconstructive strategy for pelvic reconstruction was established. Functional or non-functional reconstruction was accomplished by using various MS-VRAM flaps. Among them, the cork flap is the most economical flap to reconstruct pelvic floor defects with minimal tissue requirement and donor trauma.
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Vaginal reconstruction using a gluteal transposition flap after abdominoperineal excision for anorectal malignancy. Updates Surg 2022; 74:467-478. [PMID: 35124788 PMCID: PMC8995290 DOI: 10.1007/s13304-021-01211-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/20/2021] [Indexed: 11/17/2022]
Abstract
The purpose of this study is to present and evaluate a surgical method using gluteal flap for combined perineal and vaginal reconstruction after abdominoperineal excision (APE) with partial vaginectomy for anorectal malignancy. The method is a two-centre study of consecutive patients undergoing APE including partial vaginectomy for anorectal tumours, with immediate combined perineal and vaginal reconstruction using gluteal flaps. Follow-up data were retrieved via retrospective review of medical records, questionnaires and gynaecological examinations. Some 34 patients fulfilled the inclusion criteria. At the time of follow-up, 14 (78%) of the 18 patients alive responded to questionnaires. Seven (50%) of the survey responders agreed to undergo gynaecological examination. Major flap-specific complications (Clavien–Dindo > 2) were observed in 3 (9%) patients. Among survey responders, 11 (79%) had been sexually active preoperatively of which five (45%) resumed sexual activity postoperatively and three (27%) resumed vaginal intercourse. These three patients had all implemented an active vaginal health promotion strategy postoperatively. Perineo-vaginal reconstruction using gluteal flap after extended APE for anorectal malignancy is feasible. Although comparable to other methods of reconstruction, the rate of perineo-vaginal complications is high and post-operative sexual dysfunction is substantial. Postoperative strategies for vaginal health promotion may improve sexual function after vaginal reconstruction.
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