Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study

IntroductionBeyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction.MethodThis retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients’ data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification.ResultsOne hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients.ConclusionbTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.     

Pelvic exenteration and composite sacral resection in the surgical treatment of locally recurrent rectal cancer

BackgroundThe incidence of rectal cancer recurrence after surgery is 5–45%. Extended pelvic resection which entails En-bloc resection of the tumor and adjacent involved organs provides the only true possible curative option for patients with locally recurrent rectal cancer.AimTo evaluate the surgical and oncological outcome of such treatment.Patients and methodsBetween 2006 and 2012 a consecutive series of 40 patients with locally recurrent rectal cancer underwent abdominosacral resection (ASR) in 18 patients, total pelvic exenteration with sacral resection in 10 patients and extended pelvic exenteration in 12 patients. Patients with sacral resection were 28, with the level of sacral division at S2–3 interface in 10 patients, at S3–4 in 15 patients and S4–5 in 3 patients.ResultsForty patients, male to female ratio 1.7:1, median age 45 years (range 25–65 years) underwent extended pelvic resection in the form of pelvic exenteration and abdominosacral resection. Morbidity, re-admission and mortality rates were 55%, 37.5%, and 5%, respectively. Mortality occurred in 2 patients due to perineal flap sepsis and massive myocardial infarction. A R0 and R1 sacral resection were achieved in 62.5% and 37.5%, respectively. The 5-year overall survival rate was 22.6% and the 4-year recurrence free survival was 31.8%.ConclusionExtended pelvic resection as pelvic exenteration and sacral resection for locally recurrent rectal cancer are effective procedures with tolerable mortality rate and acceptable outcome. The associated morbidity remains high and deserves vigilant follow up.     

A case of local recurrence of rectal cancer in which trans-sacral resection and perineal reconstruction by femoral posterior flap were performed

A 54-year-old woman underwent abdomino-perineal resection for rectal cancer. Six months after surgery, perineal pain and the tumor marker increased. Local recurrence of the pelvic cavity and lung metastases were diagnosed by computed tomography (CT) and positoron emission tomography (PET) using 18F-fluorodeoxygulucose (FDG). Local perineal pain continued and there was no increase in the neoplastic lesion of the lung, so surgical treatment was performed. After partial resection of the lung, local resection of the gluteus maximus and posterior wall of the vagina was performed with the patient in the Jack-knife position. To fill the defect, a femoral posterior flap was made and the perineal defect was reconstructed.     

Combined laparoscopic and transperineal endoscopic total pelvic exenteration for the vaginal stump recurrence of cervical cancer

Total pelvic exenteration (TPE) is sometimes required for radical treatment of locally advanced or recurrent gynecologic cancer [1]. However, TPE with a transabdominal approach requires highly advanced techniques in the case of repeated surgery due to the effects of primary surgery and/or chemoradiotherapy, especially when a transabdominal approach is used. Recent technical advances in transanal/transperineal endoscopic surgery have proved beneficial for complicated surgery in the deep pelvis [2]. Here we introduce our surgical procedure for combined laparoscopic and transperineal endoscopic TPE (TpTPE) for pelvic recurrence of cervical cancer. A 42-year-old woman was diagnosed with vaginal stump recurrence of cervical cancer involving the rectum, bladder, and ureters following hysterectomy and pelvic lymph node dissection as primary surgery and chemotherapy/chemoradiotherapy for previous recurrences. We decided to perform TpTPE with a combined laparoscopic approach. The GelPOINT advanced access platform was fixed through a perineal skin incision around the tightly closed anus, external urethral orifice, and vagina. With sufficient pneumopelvic pressure (12 mmHg), TpTPE was performed under a good surgical view without any effect of the primary surgery. A ureterostomy and sigmoid colostomy were created and a right gracilis muscle flap was used to reconstruct the pelvic defect. The total operative time and estimated blood loss were 887 minutes and 497 mL, respectively. Histopathological examination revealed recurrent cervical cancer invading the rectum, bladder, and bilateral ureters with negative surgical margins. The postoperative course was uneventful except for paralytic ileus. The patient was discharged on postoperative day 18. TpTPE is a technically feasible and effective approach for locally advanced pelvic tumors.     

Right hemicolectomy plus pancreaticoduodenectomy vs partial duodenectomy in treatment of locally advanced right colon cancer invading pancreas and/or only duodenum

IntroductionPancreatic or duodenal invasion by locally advanced right colon cancer is an unusual event whose management still represents a surgical challenge. This review aims to compare results of limited vs. extended resection in case of primary right colon cancer invading pancreas and/or duodenum.MethodsA systematic search in Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. All trials describing the surgical treatment of right colon cancer invading pancreas and/or duodenum were considered. A data extraction sheet was developed, based on the Cochrane Consumers and Communication Review Group's data extraction template.Results5-years overall survival was 52% after en bloc pancreaticoduodenectomy plus right hemicolectomy vs. 0 and 25% in case of duodenal resection with correction by direct suture or pedicled ileal flap, respectively. 30-day postoperative morbidity rate was slightly higher after en block resections (12.8%) with respect to duodenal local resection and direct suture or pedicled ileal flap repair (0 and 12.2%, respectively). After extended resection the rate of pancreatico-jejunal anastomotic leakage was 7.7%.ConclusionsIn patients with right colon cancer extended to the pancreas and/or duodenum surgical multivisceral resection is suggested when complete tumour removal (R0) is achievable. Even though no significant differences in postoperative morbidity and mortality have been shown, 5 y OS has improved in extended resections as compared to duodenal local resection with defect repair either by direct suture or by a pedicled ileal flap.     

Vertical rectus abdominis myocutaneous flap cover for lower abdomen, chest wall, groin and thigh defects following resection of malignant tumours

Vertical rectus abdominis mycutaneous (VRAM) flap provides a reliable flap cover for large soft tissue defects of chest wall, torso, groin, perineum and thigh. It has been mainly used in trauma and benign conditions. Between January 1994 through January 1999, eight patients with locally advanced malignant tumors underwent radical resection and reconstruction using pedicled VRAM flap. Inferiorly based VRAM flap was used in five patients and superiorly based VRAM flap in three patients. Defect size ranged from 144 to 900 CM2. (mean 386 cm2). Average blood loss for combined resection and reconstruction was 600ml. (range 400-800 ml.) Primary closure of both donor and recipient sites achieved in all patients. There was no wound infection, flap necrosis or abdominal hernia. There patients received postoperative radiotherapy and chemotherapy and two patients received radiotherapy only. All the the patients are alive and free of local recurrence at mean follow up 32 months. Results of our study shows that VRAM flap is versatile and sturdy flap with a wide are of rotation and it can reach diverse anatomical sites like torso, chestwall, thigh and perineum to cover large defects following radical resection for tumors.     

Locally recurrent rectal cancer successfully treated by total pelvic exenteration with combined ischiopubic rami resection: report of a case

A combined ischiopubic rami resection is extremely rare in the field of gastroenterologic surgery. We report a case of a locally recurrent rectal cancer that was successfully treated by total pelvic exenteration with combined ischiopubic rami resection. A 58-year-old male with locally recurrent rectal cancer and liver metastases was referred to our hospital. Computed tomography and magnetic resonance imaging showed a perineal tumor, which had invaded the prostate, urethra, and obturator internus muscle, and two liver metastases. Because the perineal tumor was very close to the dorsal vein complex and the pubic symphysis, it was considered difficult to approach and divide the dorsal vein complex, and still retain oncologic safety. To achieve R0 resection, total pelvic exenteration with ischiopubic rami resection, total emasculation and partial liver resection were performed. Pathological examination revealed that surgical margins were negative for cancer cells. Although reconstruction of the pelvic ring was not performed, his ambulatory function had recovered to an almost normal status at 6 months after the operation.     

Sexual and functional long-term outcomes following advanced pelvic cancer and reconstruction using vertical rectus abdominis myocutaneous and gluteal myocutaneous flap

IntroductionAfter extensive pelvic surgery for cancer two flap types are used at Skåne University Hospital (SUS), Sweden for perineal reconstruction: vertical rectus abdominis myocutaneous flap and gluteal flap with or without vaginal reconstruction. The objective was to study the long-term outcomes in patients treated for advanced pelvic cancer receiving a flap.MethodPatients with pelvic cancer subjected to surgery including perineal reconstruction between January 2010 and August 2016 at SUS were included retrospectively. Participating patients were scheduled for an out-patient visit. Questionnaires addressing quality of life, (QLQ-C30 and EQ-5D) and sexual function (FSFI and IIEF) were filled in. Sensitivity test, using monofilaments on the gluteal/posterior thigh area, neovaginal measurements using silicon gauges and muscular functionality tests (timed stands test and stairs test) were performed.ResultsThirty-six (24 women, 12 males) out of 71 invited patients conceded participation. Patients scored a median of 85/100 regarding global health using EQ-5D. All women reported sexual dysfunction and 75% (9/12) of men reported severe erectile dysfunction. Neovaginal measurements showed adequate reconstructions. Sensitivity test implied decreased sensitivity on the operated side compared to the unoperated side in patients with gluteal flap. Both physical tests demonstrated adequate muscular functionality in everyday life activities after reconstructions using gluteal flap.ConclusionThis long-term follow up after extensive surgery treating pelvic cancer with perineal flap reconstruction implies high quality of life, good muscular functionality and adequate neovaginal measurements. However sexual function is impaired among both sexes and sensitivity in the surgical area of the gluteal flap is decreased.     

Vaginal reconstruction after pelvic exenteration: when and which techniques?

Pelvic exenterations are commonly performed to treat locally advanced or recurrent tumours of the pelvic organs to achieve long-term survival. Those procedures may present complications. Reconstructive procedures have become an important part of radical pelvic surgery to improve quality of life. Various surgical procedure of vaginal reconstruction have been describe. Myocutaneous flaps are effective in the prevention of major morbidity with pelvic filling and physiological neovagina. Vertical rectus abdominis myocutaneous flap is the technique of choice with simple harvesting and large pelvic filling. Gracilis and gluteal thight flaps are particularly adapted in pelvectomy with perineal resection. Enteroclpoplasty and omental flap must be used in radical colpectomie or difficulty pelvic access.     

关于乳腺癌手术几个问题的探讨

乳腺癌手术经历了由小到大 ,再由大到小的曲折过程。目前关于乳腺癌手术方式的选择、切口的选择、皮瓣分离、腋窝淋巴结清除以及神经的保护等方面还存在一些问题。着重介绍近几年广为接受的针对上述问题的方法。     

Rectus abdominis myocutaneous flap in radical oncopelvic surgery: A safe and useful procedure

AIMS: The aim of this retrospective study was to evaluate the usefulness of rectus abdominis myocutaneous (RAM) flaps to treat locally advanced pelvic gynaecological or digestive tumours. METHODS: We reviewed 46 patients, who received RAM flaps after radical oncopelvic surgery, including: (a) total vaginal reconstruction (TVR); (b) partial vaginal reconstruction (PVR); (c) perineal reconstruction (PR). RESULTS: Between 1989 and 1998, 46 patients underwent pelvi-perineal reconstruction with RAM flaps after radical pelvic surgery for carcinoma of the cervix (n=22), anal carcinoma (n=11), rectal carcinoma (n=7), or other pelvic tumours types (n=6). There were two post-operative deaths. Overall surgical morbidity was 45, 6% (n=21). Specific morbidity of the RAM flap was 21, 7% (n=10). Global re-intervention rate was 13% (n=6). CONCLUSION: Rectus abdominis myocutaneous flap in radical oncopelvic surgery is useful for vaginal or perineal reconstruction and prevention of pelvic collections after extended resections with a low rate of associated morbidity.     

Plea for radical salvage surgery for recurrent cancer of the anal canal

Salvage abdomino-perineal resection is justified in case of failure of the conservative treatment of a cancer of the anal canal. This surgery must be offered if surgery could be complete. In case of R0 resection, more than a patient on two will be alive after 5 years. The rate of perineal complication is important and gives proof to accomplish associated procedure to fill up the perineal cavity as muscular flap taken from the abdominal wall, the perineal colostomy that avoids the iliac colostomy or the simple flap of gracilis. This linked procedure allows to diminish the length of healing and improves postoperative time.     

高龄直肠癌患者腹会阴联合切除术后会阴切口并发症发生的相关危险因素

探讨高龄直肠癌患者腹会阴联合切除术(APR)后会阴切口并发症发生的相关危险因素。方法采用回顾性病例对照研究的方法,分析中国医学科学院肿瘤医院结直肠外科2007年1月至2018年9月行APR的72例高龄(≥80岁)直肠癌患者的临床病理资料。采用单因素和多因素分析确定影响高龄直肠癌患者APR后会阴切口并发症发生的危险因素。结果72例患者中,男47例,女25例,年龄为(81.8±1.8)岁。术后会阴切口并发症发生率为23.6%(17/72),其中切口感染5例,切口脂肪液化4例,切口延迟愈合8例。所有患者均顺利出院,无围手术期死亡病例。单因素分析显示,术前血清白蛋白<35 g/L、术中置入氟尿嘧啶缓释剂/洛铂冲洗液、盆底修复、糖尿病和冠心病与高龄患者APR术后会阴切口并发症的发生均有关(均P<0.05)。多因素分析显示,未行盆底修复(OR=0.17,95%CI为0.04~0.82;P=0.027)和糖尿病(OR=4.32,95%CI为1.05~17.81;P=0.043)为高龄直肠癌患者APR后会阴切口发生的独立危险因素。结论行APR的高龄直肠癌患者应尽可能保留盆底腹膜,并予以关闭。围手术期血糖监测也是预防会阴切口并发症发生的有力保障。     

胸外侧筋膜皮瓣填充乳腺癌保留乳房手术后组织缺损的临床应用研究

目的探讨乳腺癌保留乳房手术中利用胸外侧筋膜皮瓣填充组织缺损的效果和可行性。方法在乳腺癌保留乳房手术中,先行肿瘤扩大切除术,切缘距离瘤缘至少0.5cm,同时切除肿瘤表面受侵的皮肤,设计三角形胸外侧筋膜皮瓣用以填充组织缺损,并利用此皮瓣切口完成腋窝淋巴结切除。结果共完成7例,切除肿瘤的最大直径为5.5cm,切缘均无癌残留,有3例切除乳头、乳晕复合体。平均手术时间3h,平均出血量300ml。术后未发生皮瓣坏死等并发症。术后平均随访19.5个月,均未出现复发,美容效果均为优良,患者对乳房外形的自我感觉均为满意。结论在乳腺癌保留乳房手术中,利用胸外侧筋膜皮瓣填充组织缺损的效果满意,可以使一部分失去保留乳房手术机会的妇女接受保留乳房手术治疗。     

The role of surgery in the palliation of advanced pelvic malignancy

Advanced pelvic malignancy, regardless of the cancer of origin, is often multivisceral and complex. The management of advanced pelvic malignancy is resource-intensive and requires multidisciplinary input. The definition of resectability is evolving with improving multimodal therapy, preoperative staging and optimisation, perioperative care, and advanced surgical techniques. Pelvic exenteration is a highly morbid procedure and has been shown to improve survival and quality of life when performed with a curative intent. Unresectable distant solid organ or lymph node metastases and an inability to achieve a clear resection margin preclude curative pelvic exenteration.Patients with advanced pelvic malignancy who are deemed palliative are mostly managed by non-operative treatment such as chemo-, radio-, immuno-, hormonal therapy, pain management and palliative care, as well as allied health and psychosocial support team. These patients may present with severe and debilitating symptoms including intractable pain, ulcerating/proliferating tumour, pelvic fistula/sepsis/bleeding, urinary and bowel obstruction/incontinence. Interventional radiological and surgical procedures such as percutaneous drainage, nephrostomy, intestinal and urinary diversion, intestinal bypass, and venting gastrostomy have an important role in symptom control and improving quality of life.Palliative pelvic exenteration should be carefully considered along with life expectancy, patient wishes and tumour characteristics. Comprehensive discussion with patient is crucial to achieve realistic expectations. These patients should not only be discussed in a multidisciplinary team meeting with palliative care input, but also be referred for a formal palliative care consultation. Tumour anatomical extent should be considered both for and against pelvic exenteration whether involving the posterior compartment i.e. sacrectomy; lateral compartment incorporating neurovascular bundle and the anterior compartment requiring pubic bone excision as all can be associated with high morbidity rates. Patient recovery may be protracted too if surgery is complicated by perineal wound or flap breakdown in cases necessitating wide perineal skin and soft tissue excision. Furthermore, evidence from quality of life and cost-effectiveness studies do not provide robust data to support pelvic exenteration with palliative intent. Whilst a relatively ‘straightforward’ central soft tissue pelvic exenteration may offer reasonable symptomatic relief in a patient with an acceptable life expectancy, palliative pelvic exenteration overall should only be considered in highly selected patients.     

Seven cases of pelvic exenteration combined with sacral resection for locally recurrent rectal cancer

Local recurrence of rectal cancer following abdominoperineal resection is rarely amenable to limited resection. Carcinoembryonic antigen assay is valuable for diagnosing most recurrent rectal cancers, but it is inadequate for early detection. Pelvic computed tomography examination is very valuable for the early detection and localization of recurrence in relation to pelvic structures and can also serve as a guide in percutaneous needle biopsy of the tumor. Seven patients with deeply invading recurrent lesions underwent pelvic exenteration combined with sacral resection. The ileal segment conduit was used for ureteral urinary diversion. The mean operation time and blood loss were 8.8 hours and 6,200 ml, respectively. No operative deaths were encountered. One patient is alive 22 months postoperatively with no evidence of disease, and another patient is alive 32 months postoperatively with pelvic wall recurrence. This procedure seems a reasonable treatment for palliation and full recovery in certain patients.     

46例阴茎癌的临床分析及总结——附文献复习

背景与目的:阴茎癌是一种少见的疾病,以鳞状细胞癌为主,主要通过淋巴途径转移.治疗包括局部原发癌切除和对转移淋巴结的处理及放疗、化疗等辅助治疗.本研究旨在探讨阴茎癌合理的治疗方法.方法:对中山大学附属第一医院1996年1月至2005年1月收治的46例阴茎癌患者的临床资料进行回顾性分析,46例患者中鳞状细胞癌44例,Paget病1例,疣状癌1例,对其中23例肿大淋巴结进行活检.结果:39例行阴茎部分切除术,4例行阴茎全切加会阴部尿道造口术治疗,1例Paget病患者行病灶切除植皮术,2例未接受手术治疗.10例淋巴结活检阳性的患者中有9例行腹股沟淋巴结清扫术,5例行同期盆腔淋巴结清扫术.41例患者获定期随访1～10年,1年、2年、5年、10年生存率分别为95.1%、95.1%、82.9%、31.7%.术后病理证实有盆腔淋巴结转移者2例均在2年内死于肺转移.结论:阴茎部分切除术是治疗阴茎癌合理有效的方法,且应尽早手术治疗.淋巴结转移是影响阴茎癌预后的重要因素,有腹股沟淋巴结转移者应早期行淋巴结清扫术治疗,以提高治疗效果.有盆腔淋巴结转移者预后差.     

Cosmetic reconstruction after resection of breast cancer: use of the ELD-MC flap and EVRAM flap

Breast reconstruction following the resection of breast cancer with inadequate residual chest-wall tissue may be performed with an implant or a myocutaneous flap, such as the latissimus dorsi or a rectus abdominis. Among a variety of operative procedures, each method has advantages and disadvantages. The insertion of a silicone-bag prosthesis is the easiest method, but the prosthetic implant sometimes has complications, such as unfavorable capsular contracture formation around the implant, rupture, infection, or exposure. We therefore use an extended latissimus dorsi myocutaneous (ELD-MC) flap with some amount of surrounding subcutaneous fat from the lumbar area, and avoid the use of any implant with an MC flap. Also, for the reconstruction and correction of infraclavicular and axillary depression, we use the extended vertical rectus abdominis myocutaneous (EVRAM) flap. This method uses the skin and fat on both sides of the umbilicus as a lenticular flap vascularized by only one of the rectus abdominis muscles. The patients are satisfied with the outcome because symmetry and good breast volume can be obtained. There have been no functional or anatomical defects of the donor area. No abdominal hernia after an EVRAM flap has resulted to date. Both the ELD-MC and EVRAM flaps can be successfully used for cosmetic breast reconstruction after the resection of breast cancer.     

柱状经腹会阴直肠癌联合切除术的初步研究

目的报道柱状经腹会阴直肠癌切除术和使用人类脱细胞真皮基质（HADM）进行盆底重建的初步应用结果。方法北京朝阳医院普外科自2008年1月至2009年4月,采用柱状经腹会阴直肠癌切除术治疗13例低位直肠癌。腹部操作直肠系膜的分离停止于肛提肌附着盆壁的平面。会阴操作采用俯卧折刀位,在进入盆腔之前环周解剖出肛提肌。切除尾骨和第五骶骨,切开Waldeyer筋膜进入盆腔,从后向前切断两侧肛提肌。在会阴横肌的后方切断盆底肌纤维并将直肠和肛管完整切除,标本呈圆柱状。盆底缺损使用HADM重建。结果所有患者无直肠穿孔,病理示环周切缘阴性。平均随访8个月,会阴伤口无裂开、膨出和疝的发生。会阴伤口感染1例,无症状血清肿1例,会阴疼痛3例,短期尿潴留5例。结论柱状经腹会阴直肠癌切除术可以降低Miles手术环周切缘阳性率和肠穿孔率,HADM盆底重建可以降低手术难度,不增加手术并发症的发生。     

Reconstruction of the Irradiated Extended Abdominoperineal Excision (APE) Defect for Locally Advanced Colorectal Cancer

Purpose

There is substantial evidence for neoadjuvant chemoradiotherapy and extended abdominoperineal excision (APE) for improving local recurrence rates and overall survival for rectal carcinoma. While oncologic outcomes are improved, the large irradiated defect in the pelvic floor can potentiate poor operative outcomes. We describe a reconstructive option, the inferior gluteal artery myocutaneous (IGAM) transposition flap, which can enable wide tumour resections by providing substantial non-irradiated tissue bulk.

Methods

Ten consecutive patients underwent either standard APE with direct primary closure or extended APE with IGAM transposition flap reconstruction between 2007 and 2009 for mStage I–IIIC disease. Patients underwent staging computed tomography and pelvic magnetic resonance imaging, and neoadjuvant chemoradiotherapy after multi-disciplinary team discussion. Eight patients underwent extended APE and IGAM transposition flap reconstruction due to locally advanced stage of their carcinoma. Oncologic, reconstructive and post-operative outcomes were assessed.

Results

All cases demonstrated good closure of the APE defect, with no intra-operative perforations and no immediate operative complications. Histological margins were clear (R0) in all specimens, with mean closest distance to margin 10.8 mm (range 4–20 mm). Mean follow-up was 11.3 months, with no locoregional recurrences. There was no donor site morbidity and no perineal hernia; patients reported high degrees of satisfaction with aesthetic outcome.

Conclusion

As the extended APE becomes increasingly utilized for rectal carcinoma, a reliable reconstructive option is increasingly important. The IGAM island transposition flap imports well-vascularized, non-irradiated tissue to reconstruct the defect, provides tissue bulk and potentiates good oncologic and reconstructive outcomes.