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Cuicchi D, Lecce F, Dalla Via B, De Raffele E, Mirarchi M, Cola B. Mortality and Morbidity. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Techniques and Outcome of Surgery for Locally Advanced and Local Recurrent Rectal Cancer. Clin Oncol (R Coll Radiol) 2015; 28:103-115. [PMID: 26683258 DOI: 10.1016/j.clon.2015.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 11/10/2015] [Accepted: 11/11/2015] [Indexed: 02/07/2023]
Abstract
Locally advanced primary rectal cancer is variably defined, but generally refers to T3 and T4 tumours. Radical surgery is the mainstay of treatment for these tumours but there is a high-risk for local recurrence. National Institute for Health and Care Excellence (2011) guidelines recommend that patients with these tumours be considered for preoperative chemoradiotherapy and this is the starting point for any discussion, as it is standard care. However, there are many refinements of this pathway and these are the subject of this overview. In surgical terms, there are two broad settings: (i) patients with tumours contained within the mesorectal envelope, or in the lower rectum, limited to invading the sphincter muscles (namely some T2 and most T3 tumours); and (ii) patients with tumours directly invading or adherent to pelvic organs or structures, mainly T4 tumours - here referred to as primary rectal cancer beyond total mesorectal excision (PRC-bTME). Major surgical resection using the principles of TME is the mainstay of treatment for the former. Where anal sphincter sacrifice is indicated for low rectal cancers, variations of abdominoperineal resection - referred to as tailored excision - including the extralevator abdominoperineal excision (ELAPE), are required. There is debate whether or not plastic reconstruction or mesh repair is required after these surgical procedures. To achieve cure in PRC-bTME tumours, most patients require extended multivisceral exenterative surgery, carried out within specialist multidisciplinary centres. The surgical principles governing the treatment of recurrent rectal cancer (RRC) parallel those for PRC-bTME, but typically only half of these patients are suitable for this type of major surgery. Peri-operative morbidity and mortality are considerable after surgery for PRC-bTME and RRC, but unacceptable levels of variation in clinical practice and outcome exist globally. To address this, there are now major efforts to standardise terminology and classifications, to allow appropriate comparisons in future studies.
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103
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Brodbeck R, Horch RE, Arkudas A, Beier JP. Plastic and Reconstructive Surgery in the Treatment of Oncological Perineal and Genital Defects. Front Oncol 2015; 5:212. [PMID: 26500887 PMCID: PMC4597132 DOI: 10.3389/fonc.2015.00212] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/17/2015] [Indexed: 12/19/2022] Open
Abstract
Defects of the perineum may result from ablative procedures of different malignancies. The evolution of more radical excisional surgery techniques resulted in an increase in large defects of the perineum. The perineogenital region per se has many different functions for urination, bowel evacuation, sexuality, and reproduction. Up-to-date individual and interdisciplinary surgical treatment concepts are necessary to provide optimum oncological as well as quality of life outcome. Not only the reconstructive method but also the timing of the reconstruction is crucial. In cases of postresectional exposition of e.g., pelvic or femoral vessels or intrapelvic and intra-abdominal organs, simultaneous flap procedure is mandatory. In particular, the reconstructive armamentarium of the plastic surgeon should include not only pedicled flaps but also free microsurgical flaps so that no compromise in terms of the extent of the oncological resection has to be accepted. For intra-abdominally and/or pelvic tumors of the rectum, the anus, or the female reproductive system, which were resected through an abdominally and a sacrally surgical access, simultaneous vertical rectus abdominis myocutaneous (VRAM) flap reconstruction is recommendable. In terms of soft tissue sarcoma of the pelvic/caudal abdomen/proximal thigh region, two-stage reconstructions are possible. This review focuses on the treatment of perineum, genitals, and pelvic floor defects after resection of malignant tumors, giving a distinct overview of the different types of defects faced in this region and describing a number of reconstructive techniques, especially VRAM flap and pedicled flaps like antero-lateral thigh flap or free flaps. Finally, this review outlines some considerations concerning timing of the different operative steps.
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Affiliation(s)
- Rebekka Brodbeck
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg , Erlangen , Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg , Erlangen , Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg , Erlangen , Germany
| | - Justus P Beier
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg , Erlangen , Germany
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Sagebiel TL, Viswanathan C, Patnana M, Devine CE, Frumovitz M, Bhosale PR. Overview of the Role of Imaging in Pelvic Exenteration. Radiographics 2015; 35:1286-94. [DOI: 10.1148/rg.2015140127] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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105
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Abstract
OPINION STATEMENT Squamous cell carcinoma (SCCA) of the anal canal is an underrecognized malignancy that is growing in annual incidence. Over the years, combined chemoradiation has been the mainstay of treatment for locally advanced SCCA of the anal canal. Currently, the human papilloma virus (HPV) vaccine is recommended to prevent the development of HPV and its associated precancerous lesion(s). Patients diagnosed with the human immunodeficiency virus (HIV+) are prone to develop anal cancer due to their high risk of contracting HPV infection. We will focus on the development and management of SCCA of the anal canal (both localized and metastatic), including special details on HIV-positive patients. Highlights will include the role of targeted therapy based on available literature. Our objective is to aid practicing physicians in formulating a treatment plan for both locally advanced and metastatic patients.
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Affiliation(s)
- Shahab Ahmed
- The Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 426, Houston, TX, 77030, USA,
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Fujino S, Miyoshi N, Ohue M, Noura S, Fujiwara Y, Yano M, Higashiyama M, Sakon M. Vacuum-assisted closure for open perineal wound after abdominoperineal resection. Int J Surg Case Rep 2015; 11:87-90. [PMID: 25942750 PMCID: PMC4446692 DOI: 10.1016/j.ijscr.2015.04.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/24/2015] [Accepted: 04/26/2015] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION In colorectal cancer surgery, surgical site infection (SSI) is a common complication, and especially, perineal wound complications after abdominoperineal resection (APR) remain to be serious clinical problems. Vacuum-assisted closure (VAC) therapy was first reported in another surgical field in 1997, and it is useful for treating complex wounds because it promotes granulation. VAC therapy has been recently used for open abdominal wounds. We introduced VAC for treating open perineal wound of APR and report the usefulness of it. PRESENTATION OF CASE We treated four patients. Firstly, in cases 1 and 2, we introduced VAC therapy to the management of SSI of the perineal wound after APR, and it was useful to control postoperative perineal wound infection. And also, in cases 3 and 4, we introduced VAC therapy to prevent perineal wound infection. Perineal wound infection did not happen. DISCUSSION A vertical rectus abdominis myocutaneous flap has been reported to decrease perineal wound complications including pelvic abscess and open perineal wound; however it results in significant operative blood loss, increased operative time, and additional surgical complications. In our cases, there were no complications relating to VAC therapy and it promoted rapid wound healing. Our results suggested that it is an effective treatment for APR in a high-risk case of an open perineal wound. CONCLUSION VAC therapy is a less invasive method and a useful treatment for open perineal wound of APR.
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Affiliation(s)
- Shiki Fujino
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Norikatsu Miyoshi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan.
| | - Masayuki Ohue
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Shingo Noura
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Yoshiyuki Fujiwara
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Masahiko Yano
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Masahiko Higashiyama
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Masato Sakon
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
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The Partial Myocutaneous Gluteal Flap Reconstruction of Extralevator Abdominoperineal Defects in Irradiated Patients. Ann Plast Surg 2015; 74:403-7. [DOI: 10.1097/sap.0b013e318298e60d] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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108
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Chong TW, Balch GC, Kehoe SM, Margulis V, Saint-Cyr M. Reconstruction of Large Perineal and Pelvic Wounds Using Gracilis Muscle Flaps. Ann Surg Oncol 2015; 22:3738-44. [DOI: 10.1245/s10434-015-4435-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Indexed: 11/18/2022]
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109
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Coltro PS, Ferreira MC, Busnardo FF, Olivan MV, Ueda T, Grillo VA, Marques CF, Nahas CS, Nahas SC, Gemperli R. Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions. J Plast Reconstr Aesthet Surg 2015; 68:252-61. [DOI: 10.1016/j.bjps.2014.09.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/25/2014] [Indexed: 12/21/2022]
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111
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Elawa S, Hallböök O, Myrelid P, Zdolsek J. Intestinal obstruction following harvest of VRAM-flap for reconstruction of a large perineal defect. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2015; 2:88-91. [PMID: 27252980 PMCID: PMC4793787 DOI: 10.3109/23320885.2015.1102640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/19/2015] [Indexed: 11/22/2022]
Abstract
A patient with locally advanced adenocarcinoma of the rectum was operated with abdominoperineal resection and perineal reconstruction with a vertical rectus abdominis musculocutaneous flap. Six days postoperatively, there was herniation of the small bowel, between the anterior and posterior rectus sheaths, to a subcutaneous location.
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Affiliation(s)
- Sherif Elawa
- Department of Hand Surgery, Plastic Surgery and Burns and
| | | | | | - Johann Zdolsek
- Department of Hand Surgery, Plastic Surgery and Burns and
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Zelken JA, AlDeek NF, Hsu CC, Chang NJ, Lin CH, Lin CH. Algorithmic approach to lower abdominal, perineal, and groin reconstruction using anterolateral thigh flaps. Microsurgery 2014; 36:104-14. [DOI: 10.1002/micr.22354] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/25/2014] [Accepted: 11/07/2014] [Indexed: 01/13/2023]
Affiliation(s)
- Jonathan A. Zelken
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Nidal F. AlDeek
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Nai-Jen Chang
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chih-Hung Lin
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
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Abstract
Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions.
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Affiliation(s)
- Timothy F Feldmann
- Department of Surgery, University of California Irvine, Orange County, California
| | - Monica T Young
- Department of Surgery, University of California Irvine, Orange County, California
| | - Alessio Pigazzi
- Department of Surgery, University of California Irvine, Orange County, California
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Comparison of vertical and oblique rectus abdominis myocutaneous flaps for pelvic, perineal, and groin reconstruction. Plast Reconstr Surg 2014; 134:315-323. [PMID: 25068330 DOI: 10.1097/prs.0000000000000324] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wound complications after perineal and groin obliterative procedures are a significant cause of morbidity, particularly following chemoradiation therapy. Vertical and, increasingly, oblique rectus abdominis myocutaneous flaps have been used to fill potential dead space and bring healthy, vascularized tissue into the defect. The authors compared the complications and outcomes of patients undergoing perineal or groin reconstruction with vertical or oblique rectus abdominis myocutaneous flaps. They hypothesized that the oblique flap offers outcomes similar to those of the vertical flap, without an increased risk of complications. METHODS All patients who underwent immediate reconstruction of perineal, pelvic, or groin defects using vertical (n=49) or oblique rectus abdominis myocutaneous (n=22) flaps over the past 10 years at the University of Washington Medical Center were reviewed retrospectively. Patient, disease, and obliterative procedure characteristics and donor- and recipient-site complications were compared. Statistical analysis was performed using the t test for continuous variables and Fisher's exact test for categorical variables. RESULTS There were no statistically significant differences in major or minor donor- or recipient-site complication rates, need for augmented fascial closure, need for additional flaps, flap loss, readmission, or reoperation rate between the two groups. CONCLUSIONS Immediate reconstruction of perineal or groin defects with oblique rectus abdominis myocutaneous flaps results in complication rates similar to those with reconstruction using with vertical flaps. Oblique flap reconstruction is a reasonable and safe alternative, providing several distinct advantages over the vertical flap, including greater arc of rotation, thinner skin paddle, less bulk, and limited fascial harvest. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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115
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Osborne MC, Maykel J, Johnson EK, Steele SR. Anal squamous cell carcinoma: An evolution in disease and management. World J Gastroenterol 2014; 20:13052-13059. [PMID: 25278699 PMCID: PMC4177484 DOI: 10.3748/wjg.v20.i36.13052] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/14/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
Anal cancer represents less than 1% of all new cancers diagnosed annually in the United States. Yet, despite the relative paucity of cases, the incidence of anal cancer has seen a steady about 2% rise each year over the last decade. As such, all healthcare providers need to be cognizant of the evaluation and treatment of anal squamous cell carcinoma. While chemoradiation remains the mainstay of therapy for most patients with anal cancer, surgery may still be required in recurrent, recalcitrant and palliative disease. In this manuscript, we will explore the diagnosis and management of squamous cell carcinoma of the anus.
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117
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Maricevich M, Maricevich R, Chim H, Moran SL, Rose PS, Mardini S. Reconstruction following partial and total sacrectomy defects: An analysis of outcomes and complications. J Plast Reconstr Aesthet Surg 2014; 67:1257-66. [DOI: 10.1016/j.bjps.2014.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 03/16/2014] [Accepted: 05/03/2014] [Indexed: 10/25/2022]
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Pelvic exenterations for specific extraluminal recurrences in the era of total mesorectal excision: is there still a chance for cure?: a single-center review of patients with extraluminal pelvic recurrence for rectal cancer from March 2004 to November 2010. Am J Surg 2014; 209:352-62. [PMID: 25524284 DOI: 10.1016/j.amjsurg.2014.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 12/05/2013] [Accepted: 01/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The benefits in terms of curative resection and survival of pelvic exenterations for specific extraluminal pelvic recurrences from rectal cancer in the era of total mesorectal excision were assessed. METHODS We conducted a single-center review of patients with extraluminal pelvic recurrence from colorectal cancer between March 2004 and November 2010. Twenty-seven pelvic exenterations (13 posterior and 14 total) were performed. Independent predicative factors such as age, sex, local control on first surgery, pelvic sidewall excision, initial International Union Against Cancer (UICC) staging, sphincter-preserving resection at first surgery, tumor presentation on computed tomography and magnetic resonance imaging (pelvis sidewall involvement, number of fixation sites, ureteral involvement), local disease-free interval, previous symptoms, and postoperative treatment were analyzed. RESULTS No operative mortality was noted in this series. Overall morbidity rate was 74%; 22% of the patients developed severe complications. Complete surgical clearance (R0) was obtained in 63% of the patients. The rate of R0 resections was lower in total pelvic exenteration (57%) than in posterior pelvic exenteration (69%). Three years overall survival and disease-free survival were 76% and 59%, respectively. Curative resection (R0) was the only independent prognostic factor for overall survival (P = .0016) and disease-free survival (P < .0001). CONCLUSION Pelvic exenterations for extraluminal pelvic recurrences from rectal cancer afford a high R0 resection rate with acceptable morbidity.
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Touny A, Othman H, Maamoon S, Ramzy S, Elmarakby H. Perineal reconstruction using pedicled vertical rectus abdominis myocutaneous flap (VRAM). J Surg Oncol 2014; 110:752-7. [DOI: 10.1002/jso.23692] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 05/21/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Ahmed Touny
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
| | - Haitham Othman
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
| | - Sherif Maamoon
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
| | - Samy Ramzy
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
| | - Hamdy Elmarakby
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
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Abstract
BACKGROUND An abdominoperineal resection is an invasive procedure that leaves the patient with vast pelvic dead space. Traditionally, the vertical rectus abdominus myocutaneous flap is used to reconstruct these defects. Oftentimes, this flap cannot be used because of multiple ostomy placements or previous abdominal surgery. The anterolateral thigh flap can be used; however, the efficacy of this flap has been questioned. OBJECTIVE We report a single surgeon's experience with perineal reconstruction in patients with cancer with the use of either the vertical rectus abdominus myocutaneous flap or the anterolateral thigh flap to demonstrate acceptable outcomes with either repair modality. DESIGN From 2010 to 2012, 19 consecutive patients with perineal defects secondary to cancer underwent flap reconstruction. A retrospective chart review of prospectively entered data was conducted to determine the frequency of short-term and long-term complications. SETTINGS This study was conducted at an academic, tertiary-care cancer center. PATIENTS Patients in the study were patients with cancer who were receiving perineal reconstruction. INTERVENTIONS Interventions were surgical and included either abdomen- or thigh-based reconstruction. MAIN OUTCOME MEASURES The main outcome measures included infection, flap failure, length of stay, and time to radiotherapy. RESULTS Of the 19 patients included in our study, 10 underwent anterolateral thigh flaps and 9 underwent vertical rectus abdominus myocutaneous flaps for reconstruction. There were no significant differences in demographics between groups (p > 0.05). Surgical outcomes and complications demonstrated no significant differences in the rate of infection, hematoma, bleeding, or necrosis. The mean length of stay after reconstruction was 9.7 ± 3.4 days (± SD) in the anterolateral thigh flap group and 13.4 ± 7.7 days in the vertical rectus abdominus myocutaneous flap group (p > 0.05). LIMITATIONS The limitations of this study include a relatively small sample size and retrospective evaluation. CONCLUSION This study suggests that the anterolateral thigh flap is an acceptable alternative to the vertical rectus abdominus myocutaneous flap for perineal reconstruction (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A134).
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O’Dowd V, Burke JP, Condon E, Waldron D, Ajmal N, Deasy J, McNamara DA, Coffey JC. Vertical rectus abdominis myocutaneous flap and quality of life following abdominoperineal excision for rectal cancer: a multi-institutional study. Tech Coloproctol 2014; 18:901-6. [DOI: 10.1007/s10151-014-1156-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 04/12/2014] [Indexed: 11/12/2022]
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Xin KY, Ng DWJ, Tan GHC, Teo MCC. Role of pelvic exenteration in the management of locally advanced primary and recurrent rectal cancer. J Gastrointest Cancer 2014; 45:291-7. [PMID: 24563189 DOI: 10.1007/s12029-014-9586-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIM A review of a single-centre experience of pelvic exenteration as a treatment modality for patients with locally advanced primary and recurrent rectal cancer. The perioperative outcomes, morbidity and long term oncological outcomes are reviewed. MATERIALS & METHODS Patients undergoing pelvic exenterations for recurrent and locally advanced rectal cancer between 1 January 2006 and 1 August 2012 were identified from a prospective database. All patients underwent pre-operative staging investigations with computed tomography (CT) scan of chest, abdomen and pelvis and pelvic magnetic resonance imaging (MRI). Patients with locally advanced primary rectal cancer were counselled for pre-operative chemoradiation. Structures such as the urinary bladder and female reproductive organs were resected en bloc where indicated with the lesion. Urological or plastic reconstructions were employed where indicated. The primary outcome measured was overall survival and secondary outcomes measured were time to local recurrence (LR) and systemic recurrence. Disease-free survival was examined by the Kaplan-Meier Method (Fig. 1). RESULTS Pelvic exenterations were performed in 13 patients with a median age of 59 (range 26-81). The rate of major post-operative complications was 8% (n = 1), where the patient had anastomotic leakage. There were no mortalities in the perioperative period. All patients were operated with curative intent and negative circumferential margins were shown in 9 out of 13 patients (70%). The DFS was 19.4 and the OS was 22.5 months. CONCLUSION An aggressive approach with en bloc resection of organs involved provides survival benefit to patients with locally advanced primary and recurrent rectal cancer with an acceptable morbidity profile.
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Affiliation(s)
- Koh Ye Xin
- Department of Surgical Oncology, National Cancer Centre Singapore, 9 Hospital Drive, Singapore, 169612, Singapore
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Moran BJ, Moore TJ. Extralevator AbdominoPerineal Excision (ELAPE) for Advanced Low Rectal Cancer. COLORECTAL CANCER 2014. [DOI: 10.1002/9781118337929.ch6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Davidge KM, Raghuram K, Hofer SOP, Ferguson PC, Wunder JS, Swallow CJ, Zhong T. Impact of Flap Reconstruction on Perineal Wound Complications Following Ablative Surgery for Advanced and Recurrent Rectal Cancers. Ann Surg Oncol 2014; 21:2068-73. [DOI: 10.1245/s10434-014-3529-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Indexed: 11/18/2022]
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Abstract
BACKGROUND Abdominoperineal resection for low rectal adenocarcinoma is a common procedure with high morbidity, including perineal wound complications. OBJECTIVE The purpose of this study was to determine risk factors for perineal wound dehiscence and to investigate the effect of wound dehiscence on survival. DESIGN This was a retrospective medical chart review. SETTINGS The study was conducted in a tertiary care university medical center. PATIENTS Patients included in the study were those with low rectal adenocarcinoma who underwent abdominoperineal resection between January 2001 and June 2012. MAIN OUTCOMES MEASURES We assessed the incidence of perineal wound dehiscence, as well as survival, after surgery. RESULTS A total of 249 patients underwent abdominoperineal resection for rectal carcinoma. The mean age was 62.6 years (range, 23.0-98.0 years), 159 (63.8%) were male, and the mean BMI was 27.9 (range, 16.7-58.5). There were 153 patients (61.1%) who survived for 5 years after surgery. Sixty-nine patients (27.7%) developed wound dehiscence. Multivariable analysis revealed the following associations with dehiscence: BMI (OR, 1.09; 95% CI, 1.03-1.15; p = 0.002), IBD (OR, 6.6; 95% CI, 1.4-32.5; p = 0.02), history of other malignant neoplasm (OR, 3.1; 95% CI, 1.5-6.6), and abdominoperineal resection for cancer recurrence (OR, 2.8; 95% CI, 1.2-6.3; p = 0.01). In the survival analysis, wound dehiscence was associated with decreased survival (mean survival time for dehiscence vs no dehiscence, 66.6 months vs 76.6 months; p = 0.01). This relationship persisted in the multivariable analysis (HR, 1.7; 95% CI, 1.1-2.8; p = 0.02). LIMITATIONS This was a retrospective, observational study from a single center. CONCLUSIONS The adjusted risk of death was 1.7 times higher in patients who experienced dehiscence than in those who did not. Attention to perineal wound closure with consideration of flap creation should at least be given to patients with a history of malignant neoplasm, those with IBD, those with rectal cancer recurrence, and women undergoing posterior vaginectomy. Preoperative weight loss should also reduce dehiscence risk.
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126
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Ogura K, Miyamoto S, Sakuraba M, Chuman H, Fujiwara T, Kawai A. Immediate soft-tissue reconstruction using a rectus abdominis myocutaneous flap following wide resection of malignant bone tumours of the pelvis. Bone Joint J 2014; 96-B:270-3. [DOI: 10.1302/0301-620x.96b2.32514] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Resection of malignant bony tumours of the pelvis creates large bone and soft-tissue defects, and is frequently associated with complications such as wound dehiscence and deep infection. We present the results of six patients in whom a rectus abdominis myocutaneous (RAM) flap was used following resection of a malignant tumour of the pelvis. Bony reconstruction was performed using a constrained hip tumour prosthesis in three patients, vascularised fibular graft in two and frozen autograft in one. At a mean follow-up of 63 months (16 to 115), no patients had a problem with the wound. Immediate reconstruction using a RAM flap may be used after resection of a malignant tumour of the pelvis to provide an adequate volume of tissue to eliminate the dead space, cover the exposed bone or implants with well-vascularised soft tissue and to reduce the risk of complications. Cite this article: Bone Joint J 2014;96-B:270–3.
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Affiliation(s)
- K. Ogura
- National Cancer Center Hospital, Department
of Musculoskeletal Oncology, 5-1-1 Tsukiji, Chuo-ku, Tokyo
104-0045, Japan
| | - S. Miyamoto
- National Cancer Center Hospital, Department
of Plastic and Reconstructive Surgery, 5-1-1
Tsukiji, Chuo-ku, Tokyo
104-0045, Japan
| | - M. Sakuraba
- National Cancer Center Hospital East, Department
of Plastic and Reconstructive Surgery, 6-5-1
Kashiwanoha, Kashiwa, Chiba
277-8577, Japan
| | - H. Chuman
- National Cancer Center Hospital, Department
of Musculoskeletal Oncology, 5-1-1 Tsukiji, Chuo-ku, Tokyo
104-0045, Japan
| | - T. Fujiwara
- National Cancer Center Hospital, Department
of Musculoskeletal Oncology, 5-1-1 Tsukiji, Chuo-ku, Tokyo
104-0045, Japan
| | - A. Kawai
- National Cancer Center Hospital, Department
of Musculoskeletal Oncology 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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127
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Perineal Wound Complications, Risk Factors, and Outcome After Abdominoperineal Resections. Ann Plast Surg 2013; 71:209-13. [DOI: 10.1097/sap.0b013e31823fac2b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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128
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Harris DA, Williamson J, Davies M, Evans MD, Drew P, Beynon J. Outcome of salvage surgery for anal squamous cell carcinoma. Colorectal Dis 2013; 15:968-73. [PMID: 23522325 DOI: 10.1111/codi.12222] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 12/15/2012] [Indexed: 02/08/2023]
Abstract
AIM The purpose of this study was to examine factors related to treatment failure following chemoradiotherapy for squamous cancer and to compare the outcome of salvage surgery in one unit with national audit standards published by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) (ACPGBI position statement for management of anal cancer. Colorectal Disease 2011; 13(Suppl. 1): 1-52). METHOD Patients with squamous cell carcinoma of the anus treated with radical intent between 1997 and 2010 in a single tertiary referral oncology institute were prospectively identified. Multivariate analysis was used to establish factors associated with treatment failure. Cancer-specific end-points after salvage surgery were determined by Kaplan-Meier survival analysis. RESULTS Ninety-five patients received chemoradiotherapy with radical intent with a 5-year overall survival of 83% (all stages) at a median follow up of 35 months. Of these, 11 (12%) required salvage surgery, five of whom were Stage T4 at presentation. Six patients had failed to respond to chemoradiotherapy and five presented with recurrence at a median of 10 (10-36) months. Only Stage T4 disease at presentation was predictive of the need for salvage surgery (OR 5.6, CI 4.9-6.3, P = 0.015). There was no surgical mortality and no delayed perineal healing where a myocutaneous flap was used. The resection margin was involved in one (9%) patient. The 5-year survival rate was 64%. Audit standards for case selection, local control, survival and perineal complications were achieved. CONCLUSION Long-term survival was achieved in two- thirds of patients following salvage surgery after failed primary chemoradiotherapy for anal cancer in a multidisciplinary oncological unit. Stage T4 disease at presentation strongly predicted the need for subsequent salvage intervention.
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Affiliation(s)
- D A Harris
- Department of Colorectal Surgery, Singleton Hospital, Swansea, UK.
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129
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An Algorithmic Approach to Perineal Reconstruction After Cancer Resection—Experience From Two International Centers. Ann Plast Surg 2013; 71:96-102. [DOI: 10.1097/sap.0b013e3182414485] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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130
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Barker JA, Blackmore AE, Owen RP, Rate A. Prone cylindrical abdominoperineal resection with subsequent rectus abdominis myocutaneous flap reconstruction performed by a colorectal surgeon. Int J Colorectal Dis 2013; 28:801-6. [PMID: 23053678 DOI: 10.1007/s00384-012-1586-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2012] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Jonathan A Barker
- Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Greater Manchester, UK
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131
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Howell AM, Jarral OA, Faiz O, Ziprin P, Darzi A, Zacharakis E. How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy--primary closure or flap repair? Best evidence topic (BET). Int J Surg 2013; 11:514-7. [PMID: 23707627 DOI: 10.1016/j.ijsu.2013.05.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 04/03/2013] [Accepted: 05/14/2013] [Indexed: 11/17/2022]
Abstract
This best evidence topic was investigated according to a described protocol. The question posed was: should the irradiated perineal wound following abdominoperineal resection (APR) be closed with primary repair or a myocutaneous flap. Using the reported search 364 papers were found of which eight represented the best evidence to answer the clinical question. The conclusion drawn is that there is some limited evidence for recommending flap closure in abdominoperineal resection post radiotherapy. The best evidence available was from a systematic review of cohort studies and case series. Although no meta-analysis was performed, overall wound healing was improved using flap closure with a low frequency of flap necrosis. Other studies providing evidence were case-control series or cohort studies. Three papers prospectively compared vertical rectus abdominus muscle (VRAM) flap with primary closure; two of which demonstrated statistically significant improvement in complication rates with flap closure. Two retrospective case control series showed significant improvement in major wound complication rates in the flap group. Two studies retrospectively compared gracilis flap repair with primary closure and showed significantly lower incidence of major perineal complications. Most studies suffered from significant limitations, small sample sizes and no direct comparisons between matched groups with respect to type of anatomic flap, wound size, tumour recurrence or radiation dose. Whilst there is evidence that myocutaneous flap closure following APR in radiotherapy patients can reduce wound related complications, prospective randomized controlled trials are warranted.
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Affiliation(s)
- A M Howell
- Department of Surgery and Cancer, Imperial College London, United Kingdom
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132
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Showalter SL, Kelz RR, Mahmoud NN. Effect of technique on postoperative perineal wound infections in abdominoperineal resection. Am J Surg 2013; 206:80-5. [PMID: 23611838 DOI: 10.1016/j.amjsurg.2012.10.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 08/23/2012] [Accepted: 10/03/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Perineal wound infection (PWI) after abdominoperineal resection causes a burden for patients and health systems. We sought to determine the effect of patient positioning on the incidence of postoperative surgical site infection. METHODS We conducted a retrospective cohort study of patients who underwent APR in our hospital system over a 10-year period. Univariate analysis was performed to identify characteristics associated with position and PWI. A logistic model was developed to assess the relationship of position and PWI, with adjustment for confounders. RESULTS Patient characteristics were similar for the prone and lithotomy positions. Operative time was less for the prone than for the lithotomy position. The prone position was associated with a reduced risk of PWI. After adjustment for potential confounders, the prone position remained significantly associated with a reduction in PWI. CONCLUSIONS Positioning patients in the prone position results in a lower occurrence of postoperative PWI and shorter operative time. We advocate this technique for most indications of APR.
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Affiliation(s)
- Shayna L Showalter
- Department of Surgery, University of Pennsylvania, 4 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA
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133
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Toshniwal S, Perera M, Lloyd D, Nguyen H. A 12-year experience of the Trendelenburg perineal approach for abdominoperineal resection. ANZ J Surg 2013; 83:853-8. [DOI: 10.1111/ans.12137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2013] [Indexed: 01/21/2023]
Affiliation(s)
| | | | - David Lloyd
- Launceston General Hospital; Launceston Tasmania Australia
| | - Hung Nguyen
- Launceston General Hospital; Launceston Tasmania Australia
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134
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Gluteal fold flaps for perineal reconstruction. J Plast Reconstr Aesthet Surg 2013; 66:397-405. [DOI: 10.1016/j.bjps.2012.09.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 09/25/2012] [Indexed: 01/13/2023]
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135
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Ahmad NZ, Racheva G, Elmusharaf H. A systematic review and meta-analysis of randomized and non-randomized studies comparing laparoscopic and open abdominoperineal resection for rectal cancer. Colorectal Dis 2013; 15:269-77. [PMID: 22958456 DOI: 10.1111/codi.12007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Evidence supporting the role of laparoscopy in abdominoperineal resection (APR) is limited. This study compared the short-term and long-term outcomes and complications associated with open and laparoscopic APR. METHOD The Medline, Cochrane and Embase databases were searched for publications comparing open and laparoscopic APR. The rates of local and distant recurrence of rectal cancer were compared as the primary end-point. The occurrence of complications related to the two procedures was studied as the secondary end-point. The adequacy of cancer resection and postoperative recovery were also compared in a secondary analysis. Combined and separate analyses were performed for randomized and non-randomized studies. RESULTS Eight publications comparing open and laparoscopic APR were identified. The rates of local and distant disease recurrence were lower after laparoscopic surgery compared with open APR (odds ratio 2.736 and 1.994, 95% confidence interval 1.137-6.584 and 1.062-3.742, P = 0.025 and P = 0.032, respectively). Early postoperative complications were fewer after laparoscopic APR (OR 2.159, 95% CI 1.426-3.269, P = 0.000). No significant benefit of either technique was observed in the secondary analysis. CONCLUSION The long-term oncological benefits of laparoscopic APR are not convincingly superior to open surgery and need further validation. The laparoscopic approach is apparently associated with fewer postoperative complications, yet its role in improving the short-term outcomes is uncertain.
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Affiliation(s)
- N Z Ahmad
- Department of Surgery, Letterkenny General Hospital, Letterkenny, County Donegal, Ireland.
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136
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137
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Dynamic article: Vaginal and perineal reconstruction using rectus abdominis myocutaneous flap in surgery for locally advanced rectum carcinoma and locally recurrent rectum carcinoma. Dis Colon Rectum 2013; 56:175-85. [PMID: 23303145 DOI: 10.1097/dcr.0b013e31827a267c] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgery for locally advanced and recurrent rectal carcinoma sometimes requires partial resection of the perineum and/or vagina necessitating subsequent reconstruction. OBJECTIVE The aim of this study was to describe the surgical and functional outcomes of reconstructing the vagina and/or the perineum by using the vertical rectus abdominis myocutaneous flap and to evaluate the health status of patients who received reconstruction. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted at a tertiary referral hospital for locally advanced and recurrent rectal cancer. PATIENTS Patients receiving multimodality treatment for primary or recurrent locally advanced rectal carcinomas were included. MAIN OUTCOME MEASURES First, the surgical outcome was assessed. Second, 10 female patients who received vaginal reconstruction underwent a gynecological examination including biopsies. Finally, quality of life was assessed and compared with patients who underwent treatment for rectal carcinoma without a reconstruction. RESULTS Fifty-one patients underwent reconstruction of the dorsal vagina and/or the perineum with the use of a vertical rectus abdominis myocutaneous flap. In 13 patients, the flap was used to close a perineal defect; in 26 patients, to close a vaginal defect; and in 12 patients, to close both. In 3 patients, partial necrosis of the flap occurred that was treated conservatively. In 4 patients, stenosis of the introitus occurred, as found in the gynecological examination. Biopsies confirmed epithelialization of the vaginal wall. All groups reported good functioning and low symptom burden. After vaginal reconstruction, women reported equal or higher scores on global health status, emotional functioning, and body image. LIMITATIONS The lack of information on the health status of the patients before the start of treatment prohibits making causal inferences in health status over time. DISCUSSION Reconstruction of the perineum and/or dorsal vagina was successful in all patients. Surgeons and gynecologists who use the vertical rectus abdominis myocutaneous flap should be aware of stenosis of the vaginal introitus. Gynecological consultation at an early stage should be standard.
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138
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Is curative resection and long-term survival possible for locally re-recurrent colorectal cancer in the pelvis? Dis Colon Rectum 2013; 56:14-9. [PMID: 23222275 DOI: 10.1097/dcr.0b013e3182741929] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND A multimodality approach for locally recurrent colorectal cancer in the pelvis provides a significant survival advantage when negative margins are achieved. However, outcomes of surgical resection in patients who have locally re-recurrent disease in the pelvis are not well studied. Our aim was to assess the safety, feasibility of a negative margin resection, and survival outcomes in patients with pelvic locally re-recurrent colorectal cancer. DESIGN A retrospective review identified 406 patients who underwent surgery for locally recurrent colorectal cancer between 1997 and 2007. Patients who had locally re-recurrent disease in the pelvis who underwent curative-intent resection were identified. RESULTS Forty-seven patients (31 male) were identified. Median age was 57 years (range, 30-84 years). Median time to re-recurrence was 2.4 years (range, 0.5-5.6 years). Margin status following re-resection was R0 60%, R1 32%, and R2 8%. Nonbowel organs were resected en bloc in 81%, including 7 sacral resections. Intraoperative radiation was given to 77%. Morbidity occurred in 42%, with 6% requiring reoperation for complications. Thirty-day mortality was nil. Overall survival at 2 and 5 years was 83% and 33%. Disease-free survival at 2 and 5 years was 55% and 27%. Five-year survival for patients who had R0 and R1 resections was 37% and 42%, whereas no patients having an R2 resection survived beyond 2 years (p = 0.002). CONCLUSIONS In highly selected patients with re-recurrent colorectal cancer in the pelvis, we found that surgery could be performed safely and that a curative (R0) resection was possible in more than 50%. Two- and 5-year survival rates are comparable to results seen when surgery is done for first-time recurrences.
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139
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Chokshi RJ, Kuhrt MP, Arrese D, Martin EW. Reconstruction of total pelvic exenteration defects with rectus abdominus myocutaneous flaps versus primary closure. Am J Surg 2013; 205:64-70. [DOI: 10.1016/j.amjsurg.2012.04.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 04/18/2012] [Accepted: 04/18/2012] [Indexed: 10/28/2022]
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140
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Jacombs ASW, Rome P, Harrison JD, Solomon MJ. Assessment of the selection process for myocutaneous flap repair and surgical complications in pelvic exenteration surgery. Br J Surg 2012. [PMID: 23188415 DOI: 10.1002/bjs.9002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study aimed to explore and quantify the selection process to guide the decision on closure type (myocutaneous flap repair (MFR) or primary closure) for people undergoing pelvic exenteration. METHODS This was a retrospective analysis of a prospectively maintained database with review of hospital records for verification and capture of missing data. Associations between four risk factors (previous radiotherapy, previous abdominoperineal resection, need for total exenteration, need for sacrectomy) were assessed individually and collectively as predictors of closure type and wound complications. RESULTS A total of 203 pelvic exenteration procedures were reviewed (75 primary and 122 recurrent cancers). Thirty-nine patients (19·2 per cent) had MFR and 164 (80·8 per cent) primary closure. Patients who had MFR were significantly more likely to exhibit each risk factor, confirming the selective decision process. MFR had higher rates of complications across all four risk factors, individually and combined. In the primary closure group, there was a significant correlation between the number of risk factors and the proportion of patients with a complication (r = 0·25, P = 0·008). In contrast, no such relationship was found for the MFR group (r = 0·01, P = 0·973). Among patients who had any complication, the primary closure group had significantly lower rates of any wound dehiscence (15 of 64 versus 17 of 28; P < 0·001) and total infection (16 of 64 versus 14 of 28; P = 0·019) compared with the MFR group. CONCLUSION Rates of wound and septic complications after pelvic exenteration were low in patients with fewer than two risk factors who had a primary closure. MFR had significantly higher complication rates, and should be reserved for patients with two or more risk factors or extensive skin involvement.
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Affiliation(s)
- A S W Jacombs
- Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia
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141
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Takahashi H, Haraguchi N, Nishikawa S, Miyazaki S, Suzuki Y, Mizushima T, Nishimura J, Takemasa I, Yamamoto H, Mimori K, Ishii H, Doki Y, Mori M. Biological and clinical availability of adipose-derived stem cells for pelvic dead space repair. Stem Cells Transl Med 2012. [PMID: 23197692 DOI: 10.5966/sctm.2012-0085] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Adipose-derived stem cells (ADSCs) are a very attractive cell source for regenerative and reconstructive medicine. Although ADSCs have already been used in cardiovascular disease and cosmetic surgery, they have not yet been used in gastroenterological surgery. In this study, we clarified the utility of the combined application of ADSCs and resected intraperitoneal fatty tissues as a sealant for the pelvic dead space that sometimes causes severe and fatal complications in colorectal and gynecological surgeries. In pelvic dead space model mice, mouse ADSCs efficiently maintained transplanted intraperitoneal fatty tissues without any incidence of adhesion to surrounding organs. In vivo and in vitro analyses revealed that transplanted ADSCs differentiated into endothelial cells by expressing the angiogenic factors vascular endothelial growth factor and hepatocyte growth factor. Mouse and human ADSCs contained a CD45(-)CD34(+) subset possessing high colony formation and sphere formation abilities. In addition, the CD45(-)CD34(+) subset consisted of two characteristic subsets: the CD34(+)CD90(+) angiogenic subset and the CD34(+)CD90(-) adipogenic subset. Grafts of human ADSCs with fat transplanted into mice were efficiently maintained for more than 12 months without volume reductions. A comparative study of graft maintenance efficacy between cultured human ADSCs and freshly isolated ADSCs indicated that the cultivation of ADSCs decreased their graft maintenance ability. These findings suggested that the angiogenic and adipogenic subsets act in coordination with each other and are essential for efficient graft maintenance.
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Affiliation(s)
- Hidekazu Takahashi
- Department of Gastroenterological Surgery, Osaka University, Osaka, Japan
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142
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Salgado CJ, Chim H, Skowronski PP, Oeltjen J, Rodriguez M, Mardini S. Reconstruction of acquired defects of the vagina and perineum. Semin Plast Surg 2012; 25:155-62. [PMID: 22547973 DOI: 10.1055/s-0031-1281485] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Successful reconstruction of vaginal and perineal defects requires close communication and cooperation between the extirpative and reconstructive surgeon. A variety of reconstructive options is available, dependent on the nature of the defect and extent of the ablative surgery. In all cases, obliteration of pelvic dead space and separation of intraabdominal contents from the perineum are important considerations to ensure uncomplicated perineal wound healing. The decision for vaginal reconstruction is also contingent upon the age, sexual function, and wishes of the patient. In this article, we review options for vaginal and perineal reconstruction in acquired defects.
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143
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Bognár G, Novák A, István G, Lóderer Z, Ledniczky G, Ondrejka P. [Perineal soft-tissue reconstruction with vertical rectus abdominis myocutan (VRAM) flap following extended abdomino-perineal resection for cancer]. Magy Seb 2012; 65:388-395. [PMID: 23086826 DOI: 10.1556/maseb.65.2012.5.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Perineal wound healing problems following extended abdomino-perineal resection of ano-rectal cancer represent a great challenge to the surgeon. Perineal soft-tissue reconstruction with a myocutan flap was thought to reduce surgical wound healing complications. A review of the relevant literature was carried out on perineal soft-tissue reconstruction with rectus abdominis myocutan (VRAM) flap following extended abdomino-perineal rectal resection for cancer. The more commonly used neoadjuvant chemo- and radiotherapy as well as extended surgical radicality resulted in increased perioperative risks, therefore combined procedures between the colorectal and plastic surgical teams are inevitable. This case report illustrates the above trend.
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Affiliation(s)
- Gábor Bognár
- Semmelweis Egyetem II. sz. Sebészeti Klinika 1125 Budapest.
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144
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Saleh DB, Liddington MI, Loughenbury P, Fenn CW, Baker R, Burke D. Reconstruction of the irradiated perineum following extended abdomino-perineal excision for cancer: an algorithmic approach. J Plast Reconstr Aesthet Surg 2012; 65:1537-43. [PMID: 22749765 DOI: 10.1016/j.bjps.2012.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Revised: 05/05/2012] [Accepted: 05/09/2012] [Indexed: 01/02/2023]
Abstract
Our unit has implemented an algorithm for irradiated perineal reconstruction incorporating current evidence and a new technique in line with the advent of laparoscopic tumour excision. Our approach attempts to maintain the benefits patients derive from minimally invasive oncological surgery. Four consecutive patients had uterine retroversion to obturate pelvic deadspace and reconstruct the posterior vaginal wall. Age range was 41-84 years and mean follow-up of 21 months with mean in-patient stay of 7 days. All patients had neoadjuvant radiotherapy or chemoradiation for low rectal/anorectal adenocarcinoma. All patients had laparoscopic Extended APER and contiguous posterior vaginal wall excision and reconstruction with uterine retroversion and z-plasty skin closure. One patient required ultrasound aspiration of a pre-sacral seroma at two months. No patients returned to theatre for major complications. We highlight one minor and no major complications associated with an algorithmic approach incorporating our method of uterine retroversion and z-plasty parallel to traditional flap reconstruction methods.
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Affiliation(s)
- D B Saleh
- Department of Plastic Surgery, Leeds General Infirmary, Great George St., Leeds, UK.
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Creagh TA, Dixon L, Frizelle FA. Reconstruction with Vertical Rectus Abdominus Myocutaneous flap in advanced pelvic malignancy. J Plast Reconstr Aesthet Surg 2012; 65:791-7. [DOI: 10.1016/j.bjps.2011.11.063] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 09/15/2011] [Accepted: 11/10/2011] [Indexed: 01/06/2023]
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146
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Ali S, Moftah M, Ajmal N, Cahill RA. Single port-assisted fully laparoscopic abdominoperineal resection (APR) with immediate V-RAM flap reconstruction of the perineal defect. Updates Surg 2012; 64:217-21. [DOI: 10.1007/s13304-012-0158-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 04/25/2012] [Indexed: 11/28/2022]
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147
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Wallace WD, White TJ, Lynch AC, Heriot AG. A century of abdominoperineal excision for rectal cancer. COLORECTAL CANCER 2012. [DOI: 10.2217/crc.11.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
SUMMARY Abdominoperineal excision (APE) for rectal cancer was described by Miles over 100 years ago. The technique and approach have undergone a number of modifications, however, the essence of the procedure remains essentially unchanged. Management of rectal cancer has changed significantly over the century as surgery and adjuvant therapies have evolved, with improved outcome and a marked decline in incidence of APE. It has been widely recognized that tumors requiring APE are associated with higher rates of local recurrence and positive resection margins compared with anterior resection. The modern challenge remains in obtaining oncological equivalence for both procedures. This article reviews the history and evolution of APE, assesses its current status and explores modern perspectives on optimizing the surgical approach.
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Affiliation(s)
- William D Wallace
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, St Andrew’s Place East Melbourne, Victoria, Australia
| | - Timothy J White
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, St Andrew’s Place East Melbourne, Victoria, Australia
| | - A Craig Lynch
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, St Andrew’s Place East Melbourne, Victoria, Australia
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148
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Hainsworth A, Al Akash M, Roblin P, Mohanna P, Ross D, George ML. Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps2. Br J Surg 2012; 99:584-8. [PMID: 22231559 DOI: 10.1002/bjs.7822] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2011] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Perineal wound complications following abdominoperineal excision (APE) for low rectal tumours remain an important cause of morbidity and prolonged hospital stay, particularly after chemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator (IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors' previous experience and published literature on myocutaneous flaps.
Methods
A series of patients who underwent immediate IGAP flap reconstruction after APE between April 2008 and December 2010 were examined retrospectively to determine patient demographics, length of operation, complications (perineal wound and general) and length of hospital stay.
Results
Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwent immediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvant chemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APE plus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patients had multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacral resection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and four major flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Median length of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAP flaps. Late complications occurred in two patients who had vaginal reconstruction and developed perineal hernias requiring revisional surgery.
Conclusion
Although operating times are long, the IGAP flap is robust, with no flap necrosis observed in this series.
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Affiliation(s)
- A Hainsworth
- Department of Colorectal, St Thomas' Hospital, London, UK
| | - M Al Akash
- Department of Colorectal, St Thomas' Hospital, London, UK
| | - P Roblin
- Department of Plastic Surgery, St Thomas' Hospital, London, UK
| | - P Mohanna
- Department of Plastic Surgery, St Thomas' Hospital, London, UK
| | - D Ross
- Department of Plastic Surgery, St Thomas' Hospital, London, UK
| | - M L George
- Department of Colorectal, St Thomas' Hospital, London, UK
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Rosich-Medina A, Ariyaratnam J, Koo B, Turner W, Fearnhead N, Durrani A, Davies R. The utility of CT angiography in planning perineal flap reconstruction following radical pelvic surgery. Int J Surg 2012; 10:217-20. [DOI: 10.1016/j.ijsu.2012.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 03/15/2012] [Accepted: 03/16/2012] [Indexed: 10/28/2022]
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150
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Sagebiel TL, Faria SC, Aparna Balachandran, Sacks JM, You YN, Bhosale PR. Pelvic Reconstruction with Omental and VRAM Flaps: Anatomy, Surgical Technique, Normal Postoperative Findings, and Complications. Radiographics 2011; 31:2005-19. [DOI: 10.1148/rg.317115112] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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