放疗对乳腺癌术后假体和自体组织乳房再造影响的研究进展

乳房的完整性和美观性影响女性的生理及心理健康。乳腺癌乳房切除术后即刻乳房再造,能够显著增加女性的自信心及提高女性生活质量。放疗作为乳腺癌的一种常规治疗方式,能够降低乳腺癌局部复发率及无病生存率,然而放疗会增加乳腺癌术后即刻乳房再造的并发症发生率及乳房再造的失败率。目前,实施最多的两种乳房再造术为自体组织乳房再造和假体乳房再造。本文主要针对放疗对自体组织乳房再造及假体乳房再造影响的研究进展进行综述。     

联合应用脱细胞真皮基质和假体置入的乳房再造术及出现术后并发症风险（摘要）

目的蜂窝状真皮基质（acellular dermal matrix，ADM）作为辅助手段应用于扩张器辅助或联合假体置入的乳房再造术，其可有效提供乳房下极足够的组织覆盖和支持。本研究将探讨联合应用ADM及假体置人的乳房再造术，其并发症发生的概率和因素。方法回顾性分析6年的乳腺癌术后即刻乳房再造术的临床资料。联合假体置人的再造乳房415只，按使用ADM和未使用ADM分为两组？记录并对比分析患者一般资料、并存疾病、肿瘤学数据、辅助疗法和并发症情况。结果本组283例患者，再造乳房415只（单侧151只，双侧132只）；269只再造术中联合应用扩张器、假体置入和ADM，余146只未应用ADM。应用ADM组血清肿和感染的发生概率较高（血清肿发生概率：应用ADM组为14．1％，未应用ADM组为2．7％，P=0．0003；感染发生概率：应用ADM组为8．9％，未应用ADM组为2．1％，P=0．0328）。多重对数回归分析显示，应用ADM与体质量指数在形成血清肿和感染方面，有显著统计学意义。应用ADM使血清肿的发生概率增加4．24倍（P=0．0018），感染的发生概率增加5．37倍（P=0．0006）。结论应用ADM可优化同期假体置人的乳腺癌术后即刻乳房再造术的效果：然而，其应用还可增加术后并发血清肿和感染的概率。严格对患者进行筛选，掌握好扩张器、假体体积，做好术后处理是取得良好术后效果的必要因素。     

即刻及延期乳房再造方法的选择

目的回顾总结乳腺癌根治术后应用单纯假体植入、Becker可扩张假体植入和单蒂腹部横形腹直肌肌皮瓣（TRAM）移植、扩大背阔肌肌皮瓣（ELDF）移植乳房再造术的经验,探讨手术的适应证、方法和效果。方法自2002年7月至2005年10月,共67例患者进行了乳腺癌根治术后乳房再造术。即刻乳房再造56例：单纯假体植入38例、Becker可扩张假体植入16例、单蒂TRAM移植2例。延期乳房再造11例：单蒂TRAM移植6例、ELDF移植4例、Becker可扩张假体植入1例。结果手术效果满意,优良率超过90％。5例患者出现轻微并发症：皮瓣局灶性坏死2例,保留的乳头乳晕部分坏死1例,血清肿2例。结论单纯假体植入用于即刻乳房再造,适用于乳房较小、行保留皮肤的乳腺癌根治术后的患者,不宜用于延期乳房再造;可扩张假体植入即刻乳房再造适用于乳房较大或改良乳腺癌根治术的患者,同时可扩张假体植入延期乳房再造可用于皮肤、肌肉保留较好的乳腺癌根治患者;TRAM和ELDF皮瓣移植乳房再造是自体组织移植,其安全性高,可用于即刻和延期乳房再造。     

超声检查在隆乳术及乳房再造术中的应用

超声检查在隆乳术及乳房再造术中的应用詹维伟燕山杨川现代隆乳术始于１９６３年的硅胶假体置入术，近期乳房再造术有采用横式腹直肌肌皮瓣（ＴＲＡＭ）再造的报道［１］。置入硅胶假体有包膜挛缩、假体破裂和硅胶肉芽肿等并发症发生［１，２］，而ＴＲＡＭ皮瓣乳房再造技...     

乳腺癌切除术后乳房再造

目的 探讨乳腺癌切除术后乳房再造的方法及时间.方法 总结30例不符合保乳条件的乳腺癌病例,乳房切除术后假体置人乳房再造16例,下腹部横行腹直肌肌皮瓣(TRAM瓣)乳房再造10例,背阔肌肌皮瓣乳房再造4例.其中即刻乳房再造27例,延期乳房再造3例.结果 16例假体置入乳房再造术后外观评价均为良,未出现术后并发症.10例TRAM瓣乳房再造术后发生皮瓣部分坏死2例,腹壁疝1例,术后外观评价7例为良.2例为较好,1例为差.4例背阔肌肌皮瓣再造术后外观评价为良.结论 乳房再造术是乳腺癌综合治疗不可忽视一部分,对于有强烈的保乳愿望,而又不符合保乳条件的患者,乳房再造术是一种较好的选择.即刻乳房再造优于延迟乳房再造.乳房再造的方法选择要因人而异.局部晚期乳腺癌患者可以选择性进行即刻乳房再造术.     

假体植入乳房再造手术后各种并发症的发病时间窗及影响因素分析

目的 描述和分析乳腺癌（BC）患者行假体植入为基础的乳房重建（IBBR）后各种并发症的发病时间窗及影响因素。方法 应用回顾性研究方法。从患者住院病历资料中提取需分析数据。对BC患者乳房再造术后并发症发病时间进行描述和归纳,COX分析探讨影响并发症发病的相关因素。结果 395例乳房再造手术共发生急性和长期并发症129例,并发症发病率32.66%。其中,73例患者（104例乳房）发生≥1种并发症。化疗是患者术后血肿发病的保护因素（P<0.05）。治疗性乳房切除手术指征、组织扩张器植入假体、假体植入胸肌前平面、IBBR术前放疗、肥胖、吸烟是患者术后血清肿发病的危险因素（P<0.05）。IBBR术前放疗是患者术后乳头乳晕/皮瓣坏死发病的危险因素（P<0.05）。治疗性乳房切除手术指征、腋窝淋巴结清扫术是患者术后手术区域感染发病的危险因素（P<0.05）。IBBR术前放疗、肥胖、腋窝淋巴结清扫术、重建支持材料Vicryl网片是患者术后假体丢失发生的危险因素（P<0.05）。假体植入胸肌前平面、IBBR术前放疗、化疗、肥胖是患者术后波纹/褶皱发病的危险因素（P<...     

乳腺癌改良根治一期乳房再造术后近期并发症的探讨

目的:探讨乳腺癌根治一期乳房再造术后近期发生的并发症及其原因.方法:收集本院2006年2月～2007年12月32例乳腺癌改良根治一期乳房再造病例.全组病例行乳房改良根治术乳房再造方法:一期行单蒂下腹部横行腹直肌肌皮瓣(TRAM)移植术3例,背阔肌肌皮瓣移植和假体植入6例,单纯假体植入术12例,乳房扩张假体植入术11例.结果:中位随访时间14个月,1例乳房局部血肿,1例术后10个月发生腹部切口疝:边缘局部坏死7例,乳头乳晕发生部分坏死2例,其中1例皮瓣坏死范围大导致假体露出.并发症的总发生率34.4%(11/32).结论:乳腺癌行改良根治性手术一期乳房再造术后并发症发发生率较高.乳癌改良根治手术时,要注意皮瓣及乳头乳晕区切除的宽度和剥离皮瓣的厚度:移植皮瓣时要注意移植的肌肉组织血运是否完整和有无遗留的微小血管未结扎;乳房再造术仅植入扩张器者,因局部张力小,对皮瓣血运影响小,并发症发生率低.     

乳癌术后不同乳房再造术式的临床应用

目的探讨适合乳癌术后各种乳房再造术式的适应证。方法对我院2003至2005年收治的44例、45只乳癌术后乳房再造的患者,根据不同情况分别采用扩张器/假体置入(5只)、背阔肌肌皮瓣 假体置入(13只)、背阔肌肌皮瓣(3只)、DIEP皮瓣(6只)、单蒂TRAM瓣(10只)及劈开的双蒂TRAM瓣(8只)等方法进行乳房再造,分析各手术方法的适应证。结果应用皮瓣乳房再造40只,皮瓣全部成活;1只应用扩张器/假体乳房再造术后,注射壶部表皮坏死;1只应用背阔肌 假体乳房再造术后半年出现假体破裂伴局部感染;1只应用DIEP乳房再造术后,出现皮瓣下积液;2只部分皮瓣坏死。术后随访3个月至半年,医生及患者对乳房形态均较满意。所有应用腹部皮瓣的患者均无腹壁疝发生。结论6种乳房再造技术基本满足了我国女性乳癌术后各个时期各种条件再造乳房的要求,整形外科技术的改进以及新材料的应用扩大了乳房再造的适应证。     

超声检查在隆乳术及乳房再造术中的应用

现代隆乳术始于1963年的硅胶假体置入术,近期乳房再造术有采用横式腹直肌肌皮瓣(TRAM)再造的报道。置入硅胶假体有包膜挛缩、假体破裂和硅胶肉芽肿等并发症发生,而TRAM皮瓣乳房再造技术要求较高。因此,需有一种较理想的检查手段以提高隆乳再造技术及发现早期并发症,超声便是其中的一种方法,现就超声在隆乳术及乳房再造术中的应用作一简介。1 包膜挛缩的检测假体置入体内后,其周围可形成纤维组织包膜,少数包膜可显著增厚,导致挛缩。临床上常用触诊诊断,     

应用背阔肌与胸大肌联合肌瓣及假体置入即刻乳房再造

目的探讨经乳房外侧弧形切口皮下乳腺切除术后,带蒂转移背阔肌肌瓣,与胸大肌肌瓣形成联合肌瓣覆盖乳房假体,进行即刻乳房再造术的治疗效果。方法选择临床分期为Ⅰ期或Ⅱ期．肿瘤未侵及皮肤和胸肌的乳腺癌患者共30例,经乳房外侧弧形切口皮下切除乳腺腺体并清扫腋窝淋巴结,利用同一切口,切取背阔肌肌瓣带蒂转移,分离胸大肌下间隙,切断胸大肌下缘与胸壁附着处直至胸骨边缘,将转移的背阔肌肌瓣与胸大肌断缘缝合,组成联合肌瓣,形成宽大的包裹假体的腔隙．置入假体。结果30例再造乳房外形及手感良好,其中优22例（73．3％）,良8例（26．7％）。术后所有患者均随访半年以上,均无瘤生存。结论再造乳房形态美观,能够置入较大的假体,不增加背部的切口,适合于无淋巴结转移、对侧乳房无明显下垂的早期青年乳腺癌患者的即刻乳房再造。     

Closed Incision Negative Pressure Wound Therapy for Elective Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundPersistent wound drainage after total joint arthroplasty (TJA) increases the risk of surgical site infections (SSIs). Closed incision negative pressure wound therapy (ciNPWT) decreases infections in traumatic wounds, but evidence for its use after elective TJA is limited. The purpose of this meta-analysis of level I studies is to determine the effect of ciNPWT on risk of SSI and wound complications following TJA.MethodsMEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for randomized controlled trials comparing ciNPWT vs standard dressings after total hip (THA) and total knee arthroplasty (TKA). Studies exclusively involving THA for femoral neck fractures were excluded. Risk of SSI and noninfectious wound complications (blisters, seroma, hematoma, persistent drainage, dehiscence, and wound edge necrosis) following TJA were analyzed.ResultsSSI risk was lower with ciNPWT compared to standard dressings (3.4% vs 7%; relative risk [RR] 0.48, P = .007), specifically in revision THA and TKA (4.1% vs 10.5%; RR 0.41, P = .03). ciNPWT increased the noninfectious complication risk after primary TKA (RR 4.71, P < .0001), especially causing wound blistering (RR 12.66, P < .0001). ciNPWT decreased hospital length of stay by 0.73 days (P = .04) and reoperation rate (RR 0.28, P = .01).ConclusionciNPWT decreases SSI risk compared to standard dressings after revision TJA, but not primary TJA. ciNPWT is associated with >12-fold increased risk of wound blistering after primary TKA. ciNPWT plays a role in revision TJA management, but additional randomized controlled trials with uniform wound assessment methods must be performed to sufficiently power findings and draw conclusions on the use of ciNPWT after primary TJA.     

Controlling the controls: what is negative pressure wound therapy compared to in clinical trials?

Aim

Surgical site infections (SSIs) are common following colorectal operations. Clinical trials suggest that closed incision negative pressure wound therapy (ciNPWT) may reduce SSIs compared to a ‘standard of care’ group. However, wound management in the standard of care group may vary. The aim of this review was to assess the control arms in trials of ciNPWT for potential confounding variables that could influence the rates of SSI and therefore the trial outcomes.

Methods

A mapping review of the PubMed database was undertaken in the English language for randomized controlled trials that assessed, in closed surgical wounds, the use of ciNPWT compared to standard of care with SSI as an outcome. Data regarding wound care to assess potential confounding factors that may influence SSI rates were compared between the ciNPWT and standard of care groups. Included were the method of wound closure, control dressing type, frequency of dressing changes and postoperative wound care (washing).

Results

Twenty-seven trials were included in the mapping review. There was heterogeneity in ciNPWT duration. There was little control in the comparator standard of care groups with a variety of wound closure techniques and different control dressings used. Overall standard of care dressings were changed more frequently than the ciNPWT dressing and there was no control over wound care or washing. No standard for ‘standard of care’ was apparent.

Conclusion

In randomized trials assessing the intervention of ciNPWT compared to standard of care there was considerable heterogeneity in the comparator groups and no standard of care was apparent. Heterogeneity in dressing protocols for standard of care groups could introduce potential confounders impacting SSI rates. There is a need to standardize care in ciNPWT trials to assess potential meaningful differences in SSI prevention.     

Comparison of Surgical Site Complications With Negative Pressure Wound Therapy vs Silver Impregnated Dressing in High-Risk Total Knee Arthroplasty Patients: A Matched Cohort Study

BackgroundClosed incision negative pressure wound therapy (ciNPWT) may reduce surgical site complications following total joint arthroplasty. Although unlikely necessary for all patients, the criteria for utilizing ciNPWT in primary total knee arthroplasty (TKA) remain poorly defined. This study’s purpose was to compare the incidence of incisional wound complications, non-incisional complications (ie, dressing reactions), reoperations, and periprosthetic joint infections (PJIs) among a group of high-risk primary TKA patients treated with ciNPWT vs an occlusive silver impregnated dressing.MethodsOne hundred thirty high-risk primary TKA patients treated with ciNPWT were 1:1 propensity matched and compared to a historical control group treated with an occlusive silver impregnated dressing. High-risk criteria included the following: active tobacco use, diabetes mellitus, body mass index >35 kg/m², autoimmune disease, chronic kidney disease, Staphylococcus aureus nasal colonization, and non-aspirin anticoagulation.ResultsAge, gender, and risk factor profile were comparable between cohorts. The ciNPWT cohort had significantly fewer incisional wound complications (6.9% vs 16.2%; P = .031) and significantly more non-incisional complications (16.9% vs 1.5%; P < .001). No dressing reactions required clinical intervention. There were no differences in reoperations or periprosthetic joint infections (P = 1.000). In multivariate analysis, occlusive silver impregnated dressings (odds ratio 2.9, 95% confidence interval 1.3-6.8, P = .012) and non-aspirin anticoagulation (odds ratio 2.5, 95% confidence interval 1.1-5.6, P = .028) were associated with the development of incisional wound complications.ConclusionAmong high-risk patients undergoing primary TKA, ciNPWT decreased incisional wound complications when compared to occlusive silver impregnated dressings, particularly among those receiving non-aspirin anticoagulation. Although an increase in dressing reactions was observed, the clinical impact was minimal.     

Closed incision negative pressure therapy: Results of recent trials and recommendations for clinical practice

BackgroundOpen abdominal surgery is associated with high rates of wound complications . Surgical site infection (SSI) is associated with prolonged length of stay, delayed treatment and high rates of readmission ^{(1, 3, 4)}. Negative pressure wound therapy over closed incisions (ciNPWT) is a novel approach to prevention of SSI. We reviewed the outcomes of studies comparing ciNPWT and standard therapy in open abdominal wounds to assess the efficacy of the current evidence base.AimTo assess the effect of negative pressure wound therapy used over closed incisions in open abdominal surgery.MethodsSearch of relevant terms was conducted on PubMed, Scopus and Cochrane to identify studies published between Jan 2006–Feb 2019. Studies were chosen based on specific inclusion criteria. Articles were screened to assess demographics, study design and outcomes.ResultsSeven retrospective and six prospective randomised controlled trials were identified for inclusion, totalling 3048 participants. 967 received ciNPWT and 2081 received standard treatment. Studies assessed a mix of surgeries (colorectal n = 6, pancreaticoduodenectomy n = 1, gynaecologic n = 1, acute care surgery n = 1, mixed open n = 2). ciNPWT was statistically significant in reducing SSI in 9 of 13 studies.ConclusionciNPWT in open abdominal surgery has demonstrated promising results for reducing SSI rate in some trials however, patient selection remains unclear. Recent randomized controlled trials have failed to demonstrate benefit overall with use of ciNPWT in open abdominal surgery. Further multicentre prospective trials are needed for cost-benefit analysis and appropriate patient-selection.     

Use of Closed Incisional Negative Pressure Wound Therapy After Revision Total Hip and Knee Arthroplasty in Patients at High Risk for Infection: A Prospective,Randomized Clinical Trial

Background

Continuous wound drainage after arthroplasty can lead to the development of a periprosthetic joint infection. Closed incisional negative pressure wound therapy (ciNPWT) has been reported to help alleviate drainage and other wound complications. The purpose of this prospective randomized controlled trial is to compare the use of ciNPWT with our standard of care dressing in revision arthroplasty patients who were at high risk to develop wound complications.

The wound adjuncts effect of closed incision negative pressure wound therapy on stopping groin surgical site wound infection in arterial surgery: A meta-analysis

A meta-analysis study was conducted to assess the influence of the wound adjuncts therapy of closed incision negative pressure wound therapy (ciNPWT) on stopping groin site wound infection (SWSI) in arterial surgery. A comprehensive literature examination till January 2023 was implemented and 2186 linked studies were appraised. The picked studies contained 2133 subjects with groin surgical wounds of arterial surgery in the picked studies' baseline, 1043 of them were using ciNPWT, and 1090 were using standard care. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of the wound adjuncts therapy of ciNPWT on stopping groin SWSI in arterial surgery by the dichotomous and continuous styles and a fixed or random model. The ciNPWT had a significantly lower SWSI (OR, 0.42; 95% CI, 0.33–0.55, P < .001), superficial SWSI (OR, 0.46; 95% CI, 0.33–0.66, P < .001), and deep SWSI (OR, 0.39; 95% CI, 0.25–0.63, P < .001) compared with the standard care in groin surgical wound of arterial surgery. The ciNPWT had a significantly, lower SWSI, superficial SWSI, and deep SWSI compared with the standard care in groin surgical wounds of arterial surgery. Although precautions should be taken when commerce with the consequences because some of the picked studies for this meta-analysis was with low sample sizes.     

Healing,Inflammation, and Fibrosis: Negative Pressure Wound Therapy: Mechanism of Action and Clinical Applications

Negative pressure wound therapy (NPWT) promotes healing by evenly applying negative pressure on the surface of the wound. The system consists of a sponge, a semiocclusive barrier, and a fluid collection system. Its effectiveness is explained by four main mechanisms of action, including macrodeformation of the tissues, drainage of extracellular inflammatory fluids, stabilization of the environment of the wound, and microdeformation. Rarely will complications linked to NPWT occur, but special care must be taken to prevent events such as toxic shock syndrome, fistulization, bleeding, and pain. New NPWT modalities have been recently developed to make NPWT suitable for a wider variety of wounds. These include NPWT with instillation therapy (NPWTi-d), different cleansing options, and application of NPWT on primarily closed incisions. Finally, vacuum-assisted wound closure therapy has been demonstrated to be efficient for various clinical settings, such as the management of diabetic foot ulcers, pressure ulcerations, chronic wounds, and skin grafts.     

Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction

The presence of a preexisting subcostal incision alters the approach to breast reconstruction and is thought to predispose to donor site skin complications and flap loss. The purpose of this study was to determine whether the presence of a subcostal scar affects breast or donor site morbidity adversely after transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. Twenty-six patients with a right subcostal incision (group A) underwent TRAM flap breast reconstruction (13 immediate, 13 delayed). The average age was 51 years, and the patients had an average body mass index of 25.3. There were 15 right, 10 left, and 1 bilateral reconstruction (4 free flaps, 22 pedicled). Outcome measures were compared with 126 age- and risk-matched patients (group B) who underwent TRAM flap reconstruction without any preexisting abdominal scar. The average age in group B was 46.7 years, and the patients had an average body mass index of 24.8. The average length of stay in group A was 5.9 days, compared with 4.8 days in group B ( < 0.05). There were no significant differences in breast-related complications. Donor site complications were higher in group A, with abdominal wall skin necrosis being significantly higher in patients with a subcostal incision (25%) compared with those patients without abdominal wall scars (5%; = 0.02). Multivariate analysis revealed a 6.5-fold increase in donor site complications in patients with a subcostal incision and a smoking history ( < 0.05). When adjusted for radiation treatment, the increased incidence in donor site complication rate was only marginally significant ( = 0.08). TRAM flap breast reconstruction in patients with preexisting right subcostal scars is effective with certain technical modifications; however, there is a slight predisposition to increased abdominal wall complications. Smoking influenced outcome further in patients with a subcostal incision, stressing the importance of proper patient selection.     

Are high‐risk patient and revision arthroplasty effective indications for closed‐incisional negative‐pressure wound therapy after total hip or knee arthroplasty? A systematic review and meta‐analysis

To determine the effective indications of closed‐incisional negative‐pressure wound therapy (ciNPWT) following total hip or knee arthroplasty, this systematic review and meta‐analysis was conducted. The systematic search was performed on MEDLINE, Embase, and Cochrane Library, and 11 studies were included. The studies comparing between ciNPWT and conventional dressings were categorised into following subgroups based on patient risk and revision procedures: routine vs high‐risk patient; primary vs revision arthroplasty. Pooled estimates were calculated for wound complication and surgical site infection (SSI) rates in the subgroup analyses using Review Manager. In high‐risk patients, the overall rates of wound complication (odds ratio [OR] = 0.38; 95% confidence interval [CI] 0.15‐0.93; P = .030) and SSI (OR = 0.24; 95% CI = 0.09‐0.64; P = .005) were significantly lower in the ciNPWT; however, there were no differences in routine patients. In cases involving revision arthroplasties, the overall rates of wound complication (OR = 0.33; 95% CI = 0.18‐0.62; P < .001) and SSI (OR = 0.26; 95% CI = 0.11‐0.66; P = .004) were significantly lower in the ciNPWT; however, there were no differences in cases involving primary arthroplasties. In summary, ciNPWT showed a positive effect in decreasing the rates of wound complication and SSI in high‐risk patients and in revision arthroplasties.