Phantom rectal sensations following abdominoperineal excision of the rectum (APER) and vertical rectus abdominis myocutaneous (VRAM) flap perineal reconstruction

Aim

Phantom rectum is the sensation of an intact and/or functioning rectum, despite excision at surgery. Abdominoperineal excision of the rectum (APER) may be complemented by reconstructive operations and recently it was reported that patients undergoing APER and vertical rectus abdominis myocutaneous (VRAM) flap reconstruction are more prone to develop phantom sensations at an earlier timeframe and have more persistent symptoms than those who do not have perineal repairs. The aim of this study was to determine the prevalence of phantom rectal sensations in a cohort of these patients.

Method

Patients who underwent APER and VRAM flap reconstruction for anorectal carcinomas were identified from May 2008 to July 2012. Patients completed a questionnaire evaluating their experience of rectal symptoms post-surgery.

Results

Thirty-four of 47 eligible patients were enrolled in the study. PR sensations were experienced by 50 % of patients, the majority of which (65 %) were present for >1 year. The commonest sensation reported was the feeling of faeces in a normal rectum (24 %). Disturbances in quality of life were apparent in 44 %; notably, sleep was affected, patients expressed increased feelings of stress/sadness, heightened levels of anxiety and limitation of daily activities as consequences of PR symptoms. Few patients sought medical advice.

Conclusion

Fifty percent of patients experience PR sensations post-surgery, comparable with reported data for patients who have undergone APER alone. The addition of VRAM reconstruction does not significantly alter the prevalence of PR symptoms. This paper provides further evidence that phantom rectum occurs frequently and thus all patients undergoing excision of the rectum should be counselled appropriately.

     

Prone cylindrical abdominoperineal resection with subsequent rectus abdominis myocutaneous flap reconstruction performed by a colorectal surgeon

Purpose

Prone cylindrical abdominoperineal resection (APR) leads to reduced circumferential resection margin (CRM) involvement but is associated with a large perineal deficit. A rectus abdominis myocutaneous (RAM) flap can reduce the morbidity associated with the perineal wound. This is often performed in coordination with a plastic surgeon. We reviewed the outcome of prone APR carried out by a single colorectal surgeon using RAM flap without the involvement of plastic surgeons in a district general hospital.

Methods

Data were reviewed retrospectively for consecutive patients who have undergone prone cylindrical APR and RAM flap reconstruction between 2008 and 2011. Additional data were reviewed for all patients who have undergone supine APR between 2004 and 2008 for comparison.

Results

Twelve patients (seven females, five males) of median age of 69 years (range 50–84 years) underwent prone APR and RAM flap reconstruction. The CRM was negative in all cases. One patient had complete flap necrosis and subsequent flap removal, and three (25 %) patients experienced delayed flap healing. One patient died from bronchopneumonia following a cerebrovascular accident at day 14. In the preceding 4 years, nine patients (three females, six males) of median age of 70 years (range 32–83 years) underwent supine APR alone. The CRM was negative in all cases. Three patients suffered breakdown of the perineal wound requiring prolonged packing, and one developed a methicillin-resistant Staphylococcus aureus wound infection.

Conclusions

Prone APR and RAM flap reconstruction can be performed by colorectal surgeons in a district general setting with good outcomes, without the need for a plastic surgeon, thus increasing the feasibility of this treatment modality.     

Microvascular transverse rectus abdominis myocutaneous (TRAM) free flap for the management of a large thoracic empyema

A case is reported of the management of a postpneumonectomy space infection that followed pulmonary resection for complications related to a bronchial artery aneurysm. The control of sepsis and obliteration of the postpneumonectomy space was achieved with a free microvascular transverse rectus abdominis myocutaneous (TRAM) flap that was transferred to the thoracic cavity with minimal morbidity. The practical and theoretical aspects of free tissue transfer for the management of intrathoracic sepsis and its complications are discussed against the limited literature concerning the subject.     

Colonic flap with mucosa removed: a novel technique for pelvic reconstruction after exenteration of advanced pelvic malignancy

Background

Immediate reconstruction after pelvic exenteration is challenging. Several flap techniques, such as the vertical rectus abdominis musculocutaneous flap and the gracilis flap, have been reported. However, flap-specific complications have been documented. Instead of harvesting the myocutaneous flap from the abdomen or legs, our group has proposed a colonic flap for neovaginal reconstruction especially for rectal cancer with vaginal invasion. Nevertheless, the application of a colonic flap for individuals needing only vascularized tissue to fill up the pelvic dead space is problematic. The aim of this study was to demonstrate this novel technique.

Methods

There were eight patients: three rectal cancers, one vulvar cancer with synchronous rectal cancer, one malignant nerve sheath tumor, one cervical cancer, one prostate cancer, and one rectal gastrointestinal stromal tumor. The operations included four total pelvic exenterations, three total pelvic exenterations with S3-sacrectomy, and one total pelvic exenteration with S3-sacrectomy and left nephrectomy. A colonic flap from which the mucosa was removed was used for immediate pelvic reconstruction in all patients. The flap detail involved harvesting the segment of sigmoid colon with low ligation of the inferior mesenteric artery, spatulation of the antimesenteric side of the flap, and mucosectomy. The flap was sutured to the pelvic sidewall with the mucosa-removed surface facing toward the pelvic defect.

Results

There were no intraoperative complications, and free surgical margins were achieved. Two patients developed a fluid collection, which was successfully treated with percutaneous drainage. Perineal wound complications were not found. None of the patients developed incisional hernias or perineal hernias at the follow-up.

Conclusions

Immediate pelvic reconstruction with mucosa-removed colonic flap is technically feasible and straightforward. This technique provides good outcomes.     

Repair of duodenal fistula with rectus abdominis musculo-peritoneal (RAMP) flap.

INTRODUCTION: Large duodenal defects/fistulae are difficult to repair, due to complex duodenal anatomy. Musculo-epithelial flaps are conventionally used for reconstruction of large soft tissue defects. We report the clinical use of rectus abdominis musculo-peritoneal (RAMP) flap for repair of duodenal fistulae. METHODS: Eight patients with duodenal fistulae underwent repair using right RAMP flap, based on the position of the superior epigastric artery. Feeding jejunostomy was done routinely to start early enteral feeding. RESULTS: Duodenal fistulae healed within 3-5 days in all the cases except one, in whom bile continued to leak for 30 days. One patient died within 12 hours of second surgery. Superficial wound infection was a common (n=3) cause of morbidity. CONCLUSION: RAMP flap for closure of duodenal defect is a simple, technically easy and dependable procedure, which can be performed quickly in critically ill patients. It can be used for repair of large duodenal defects with friable edges when omentum is not available or when other conventional methods are impractical.     

Vertical rectus abdominis myocutaneous flap and quality of life following abdominoperineal excision for rectal cancer: a multi-institutional study

Background

To obtain a clear surgical margin, abdominoperineal excision (APE) for rectal cancer frequently leaves a large perineal defect surrounded by irradiated tissue. A vertical rectus abdominis myocutaneous (VRAM) flap may facilitate healing of this wound. The current study aims to determine the effect of VRAM flap perineal reconstruction following APE on patient quality of life (QOL).

Methods

This is a retrospective cohort study from a prospectively collected database. Data on QOL were assessed via telephone questionnaire using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-C30, EORTC QLQ-C29 and the Cleveland Clinic QOL questionnaires.

Results

Twenty-seven patients underwent primary perineal closure, and 12 patients underwent a VRAM flap perineal reconstruction. The mean duration of follow-up was 16.8 months. Overall, there was no significant difference in the Cleveland Clinic QOL score between groups (VRAM vs. no VRAM: 0.7 ± 0.2 vs. 0.7 ± 0.2, p 0.735). Patients in the VRAM group had lower levels of fatigue (5.5 ± 9.9 vs. 23.6 ± 19.2, p 0.004). Patients in the VRAM group had reduced sore skin scores around the stoma site (11.0 ± 16.2 vs. 31.8 ± 31.1, p 0.036). VRAM flap was associated with an increased incidence of abdominal wall hernia (VRAM vs. no VRAM: 25 % vs. 0 %, p 0.024).

Conclusions

This study is limited by its non-randomized retrospective design and relatively small sample size. A significant difference in patient QOL was not demonstrated between VRAM flap and primary perineal closure after APE for rectal cancer. Further studies in this area are warranted.     

Outcome analysis of breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps

QUESTIONS UNDER STUDY: With the reduction in breast cancer mortality in recent years the aesthetic outcome after treatment has gained increasing attention. The aim of this study was to assess the outcome quality of our single institution concept of free TRAM flap breast reconstruction with the aim of providing data to assist the patient's decision-making when breast reconstruction is an option. PRINCIPLES/METHODS: Thirty-two consecutive patients receiving immediate (n = 14) or delayed (n = 18) breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps were included. The selection of patients was based on their own wish and the availability of abdominal tissue, without excluding patients at risk for wound healing complications. Patient data were assessed prospectively and the aesthetic outcome was rated after the final result had been achieved. RESULTS: Ten patients sustained wound healing complications (4 of 9 smokers, 8 of 16 patients with a BMI over 25 kg/m2), 8 of them requiring revisional surgery. An average of 1.06 corrective procedures were performed per patient. The aesthetic outcome was judged to be good by 20 patients, fair by 5 and poor by 1 patient who sustained severe tissue loss. CONCLUSIONS: Our results revealed that a large measure of satisfaction is achievable from breast reconstruction with free TRAM flaps, in spite of the invasive nature of the procedure and the inclusion of patients at risk for wound healing complications. These data may be used in the decision-making process by patients eligible for breast reconstruction after mastectomy.     

Robotic supralevator total pelvic exenteration with lateral pelvic sidewall dissection for rectal cancer

Techniques in Coloproctology -     

重视直肠癌患者的全盆腔脏器切除与盆底缺损重建

全盆腔脏器切除术作为一种根治性手术,对于复发和晚期直肠癌患者的治疗有重要意义。但目前此术式在国内开展并不普遍。笔者就全盆腔脏器切除术的发展历史,目前的应用现状和手术的治疗要点等诸多方面加以阐述,以使医师们对此术式有更深入的理解,更好地指导临床应用。     

Acquired hemophilia A with rectus abdominis muscle and intrapelvic hematomas after aortic arch replacement

A 60-year-old man demonstrated a bleeding tendency at enterostomy about 7 months after aortic arch replacement. Abdominal muscle hematoma and pelvic hematoma were also detected. He was diagnosed as having acquired hemophilia A based on prolonged APTT (65.9 sec), reduced FVIII activity (>1%), and the presence of FVIII inhibitor (19.5 BU/ml). Severe anemia was recognized. Recombinant activated factor FVIII (9.6 mg) was administered 25 times, combined with steroid pulse therapy. Usually postoperative acquired hemophilia is recognized in the immediate postoperative period or about 3 months later, while in this case, acquired hemophilia appeared 7 months postoperatively.     

应用全盆底重建术治疗老年女性重度盆腔器官脱垂临床分析

目的 评价全盆底重建术治疗老年女性重度盆腔器官脱垂的疗效.方法 回顾性分析34例POP-QⅢ～Ⅳ期盆腔器官脱垂行全盆底重建术的老年患者临床资料,评价该手术疗效及对患者生活质量的影响.结果 所有手术均安全顺利进行,未见膀胱、直肠等损伤;手术时间（105±31.2） min,出血（185.4±65.9） mL;所有患者术后4～5d后均自主排尿.随访2年,复发率为0（0/34）;PFIQ评分由术前的（84.3±22.6）分降至术后2年的（11.2±6.5）分,PFDI评分由术前的（75.8±19.4）分降至术后2年的（12.4±5.3）分.结论 全盆底重建术用于纠正老年女性重度盆腔器官脱垂,手术安全,术后生活质量改善明显,值得临床推广应用.     

Pectoralis myocutaneous flap with T-tube drainage for cervical anastomotic leakage after salvage operation

We report a patient with complications of cervical esophageal anastomosis after esophagectomy for cancer. A 61-year-old woman with advanced cervical esophageal cancer underwent radical chemoradiotherapy (66 Gy, 5-fluorouracil, and cisplatin), after which salvage surgery was performed because of residual malignancy. Anastomotic leakage occurred at the right side of the pharyngojejunostomy, causing an abscess to form around the right carotid artery and internal jugular vein. The debrided abscess space was filled with a vascularized pectoralis major myocutaneous flap replenished around a T-tube, and continuous suction of the anastomotic drainage was performed through the T-tube. Treatment was successful, and the patient was discharged. We introduce a promising new method that proved effective and safe for treating a patient with leakage of the cervical esophagus anastomosis after salvage surgery following radical chemoradiotherapy.     

Novel technique with bladder peritoneum to prevent empty pelvic syndrome after laparoscopic pelvic exenteration for gynecologic malignancies: Three case reports

Rationale:Pelvic exenteration (PE) is a radical surgical procedure for treating locally recurrent or uncontrolled pelvic malignancies. The consequent postoperative pelvic dead space presents a challenge to extirpative surgeons. Many methods have been utilized for pelvic floor reconstruction to reduce related postoperative complications, however, none of them have been widely accepted.Patient concerns:Here, we report 3 cases of patients who underwent PE. Case 1 was a 36-year-old woman who presented to our hospital with abnormal vaginal bleeding. Case 2 was a 50-year-old woman with recurrence of stage IIB squamous cell carcinoma of the cervix. Case 3 was a 54-year-old woman with uncontrolled stage IIB adenocarcinoma of the cervix. The last 2 patients were both treated with radiotherapy and chemotherapy previously.Diagnosis:Biopsy results revealed adenocarcinoma of the vagina, squamous cell carcinoma of the cervix, and adenocarcinoma of the cervix in Case 1, 2, and 3 respectively.Interventions:We describe a safe and effective approach that employs the preservation of the bladder peritoneum to eliminate the pelvic dead space following laparoscopic PE, with or without partial utilization of the greater omentum.Outcomes:Three patients with gynecologic cancer underwent this operation and developed no intraoperative or postoperative complications.Conclusion:Our experience suggests that laparoscopic PE using the bladder peritoneal barrier to cover the denuded pelvic cavity is a reasonable choice to decrease the risk of empty pelvic syndrome.     

Long-term follow-up of patients with jejunal pouch reconstruction after total gastrectomy. A randomized prospective study

BACKGROUND: Fifty-one patients were operated on during 1988-1992 and randomized after total gastrectomy to one of two reconstruction types. Twenty patients with jejunal pouch reconstruction and 14 patients with Roux-en-Y reconstruction (67% of all) survived at least 3 years after total gastrectomy. We studied symptoms, eating capacity, and nutrition in these patients during the clinical follow-up; 21 patients were assessed by mail questionnaire 8 years after total gastrectomy. METHODS: Postoperative symptoms, number of meals, and eating capacity were assessed by standard questionnaire during 3 years' follow-up. Weight loss and nutritional laboratory variables were measured, and upper intestinal endoscopy with biopsy was performed during the follow-up. Eight years after the operation symptoms, ability to eat, and number of meals consumed were studied by means of a mail questionnaire. RESULTS: Three years postoperatively dumping (64% compared with 10%, P < 0.05) and early satiety (86% compared with 5%, P < 0.05) were commoner in the Roux-en-Y group. In the pouch group eating capacity was better (96% of normal compared with 67%, P < 0.05), and the patients ate fewer meals per day (mean, 2.7 versus 5.3, P < 0.05) at 3 years. Mean weight loss at 3 years was 9.9 kg in the Roux-en-Y group compared with 1.5 kg in the pouch group (P < 0.05). 25 (OH) vitamin D concentration tended to be higher in the pouch group (47.3 nmol/l compared with 33.9 nmol/l). In the Roux-en-Y group serum alkaline phosphatase activity increased significantly during the 3 postoperative years (from mean 163 U/l to 248 U/l, P < 0.01) and tended to be higher (248 U/l compared with 216 U/l in the pouch group). None of the patients developed oesophagitis or pouchitis during the follow-up. One patient developed a bezoar in the pouch 5 years after gastrectomy. CONCLUSIONS: Pouch reconstruction after total gastrectomy is associated with diminished postoperative symptoms, better eating capacity, and decreased weight loss compared with Roux-en-Y reconstruction. Jejunal pouch reconstruction is thus the recommended surgical method after total gastrectomy.     

Reconstruction with bilateral gluteus maximus myocutaneous rotation flap after wide local excision for perianal extramammary Paget's disease

PURPOSE: Extramammary Paget's disease is a rare dermatosis. Wide local excision is recommended in patients with perianal extramammary Paget's disease. After wide local excision, it is necessary to do reconstruction, with preservation of bowel function. We present here two cases of perianal Paget's disease, in which the patients were treated by reconstruction with bilateral gluteus maximus myocutaneous rotation flap after wide local excision. PATIENTS AND METHODS: A 55-year-old woman and 58-year-old man were admitted with anal pain and bleeding. Histologic examination of the perianal lesion revealed the presence of typical Paget's cells, and no underlying carcinoma and no distant metastasis was detected in either patient. Wide local excision, including the rectal mucosa, was performed, with reference to intraoperative frozen sections. Surgical defect was overlapped with bilateral gluteus maximus myocutaneous rotation flap, and the anus was reconstructed. RESULTS: Postoperative bowel function and quality of life were well preserved, and flaps healed satisfactorily. Patients have had no recurrence and have been able to return to work. CONCLUSION: Bilateral gluteus maximus rotation flap may be useful after wide local excision of perianal extramammary Paget's disease without underlying invasive carcinoma.