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van Kessel CS, Waller J, Steffens D, Lee PJ, Austin KKS, Stalley PD, Solomon MJ. Improving Surgical Outcomes in Pelvic Exenteration Surgery: Comparison of Prone Sacrectomy With Anterior Cortical Sacrectomy Techniques. Ann Surg 2023; 278:945-953. [PMID: 37485983 DOI: 10.1097/sla.0000000000006040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVE To assess the effect of changing our sacrectomy approach from prone to anterior on surgical and oncological outcomes. BACKGROUND In patients with advanced pelvic malignancy involving the sacrum, pelvic exenteration (PE) with en-bloc sacrectomy is the only potential curative option but morbidity is high. Over time sacrectomy techniques have evolved from prone sacrectomy (PS) to abdominolithotomy sacrectomy (ALS, ≤S3) and high anterior cortical sacrectomy (HACS, >S3) to optimize surgical outcomes. METHODS A retrospective, single institution analysis of prospectively collected data for patients undergoing PE with en-bloc sacrectomy between 1994 and 2021 was performed. RESULTS A total of 363 patients were identified and divided into PS (n=77, 21.2%), ALS (n=247, 68.0%), and HACS (n=39, 10.7%). Indications were: locally advanced (n=92) or recurrent (n=177) rectal cancer, primary other (n=31), recurrent other (n=60), and benign disease (n=3). PS resulted in longer operating time ( P <0.01) and more blood loss ( P <0.01). Patients with HACS had more major nerve (87.2%) and vascular (25.6%) resections ( P <0.01). Vertical rectus abdominis myocutaneous flap repair was less common following HACS (7.7%) than ALS (25.5%) and PS (27.3%) ( P =0.040). R0 rate was 80.8%, 65.8%, and 76.9% following ALS, PS, and HACS, respectively ( P =0.024). Wound-related complications and re-operations were significantly reduced following ALS and HACS compared with PS. CONCLUSIONS Changing our practice from PS to an anterior approach with ALS or HAS has been safe and improved overall surgical and perioperative outcomes, while maintaining good oncological outcomes. Given the improved perioperative and surgical outcomes, it would be important for surgeons to learn and adopt the anterior sacrectomy approaches.
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Affiliation(s)
- Charlotte S van Kessel
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jacob Waller
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter J Lee
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Paul D Stalley
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, NSW, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Tork S, Jefferson RC, Janis JE. Acellular Dermal Matrices: Applications in Plastic Surgery. Semin Plast Surg 2019; 33:173-184. [PMID: 31384233 DOI: 10.1055/s-0039-1693019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Modern advances in tissue engineering have transformed the plastic surgeon's management strategies across a wide variety of applications. Comprehension of the fundamentals of biologic constructs is critical to navigating the available armamentarium. It is essential that plastic surgeons become familiar with some of the existing methods for utilizing biologics as well as the advantages and limitations to their use. In this article, the authors describe the basic science of biologics with a focus on acellular dermal matrices (ADMs), and review the recent evidence behind their use for a variety of reconstructive and aesthetic purposes. The review is organized by system and examines the common indications, techniques, and outcomes pertaining to the application of ADMs in select anatomic areas. The final section briefly considers possible future directions for using biologics in plastic and reconstructive surgery.
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Affiliation(s)
- Shahryar Tork
- Department of Plastic and Reconstructive Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Ryan C Jefferson
- Department of Plastic and Reconstructive Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Jeffrey E Janis
- Department of Plastic Surgery, University Hospitals, Wexner Medical Center, Ohio State University, Columbus, Ohio
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Surgery for chronic mesh infection occurred 10 years after sacrectomy - Mesh resection and mesentric leaf repair: A case report. Int J Surg Case Rep 2016; 30:215-217. [PMID: 28088711 PMCID: PMC5233786 DOI: 10.1016/j.ijscr.2016.10.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 11/21/2022] Open
Abstract
An 83-years old woman underwent sacrectomy combined with mesh reconstruction for chordoma suffered chronic mesh infection and bowel penetration 10 years after surgery. This is the first report of mesh infection after sacrectomy and its surgical strategy. We performed subtotal mesh resection and Mesenteric leaf repair for pelvic reconstruction. Mesentric leaf repair might be a useful procedure for pelvic reconstruction when the use of a mesh has to be avoided.
Introduction Sacrectomy to treat malignant tumors is often results in large pelvic defects to require reconstruction, using a prosthetic mesh. Importance is to avoid its direct contact of mesh with intestine to prevent adhesion between them. Presentation of case An 83-year old woman who was diagnosed with a mesh infection caused by a small bowel penetration 10 years after sacrectomy combined with mesh reconstruction for chordoma. In the first operation, because of incomplete re-peritonealization due to a large defect in the retroperitoneum, a mesh unavoidably was compelled to contact with the small intestine. We subtotally removed the mesh and performed mesentric leaf repair of the pelvic defect. The postoperative course was complicated by infection of the pelvis. She was discharged 59 days after surgery with a little purulent discharge from perineal wound, which was persisted for two years after operation. Discussion/Conclusion We used the mesenteric leaf to repair the pelvic defect at the operation. This procedure might be the best alternative, when the use of mesh has to be avoided like present case. To our knowledge, this is the first report of mesh infection after sacrectomy, so we report herein.
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Use of Biological Tissue Matrix in Postneurosurgical Posterior Trunk Reconstruction Is Associated with Higher Wound Complication Rates. Plast Reconstr Surg 2016; 138:104e-110e. [PMID: 27348672 DOI: 10.1097/prs.0000000000002244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients undergoing neurosurgical spine surgery for spinal tumors are increasingly undergoing soft-tissue reconstruction involving the use of biological tissue matrices. There are limited data available on the safety of these devices in posterior trunk reconstruction. METHODS A cohort study of patients undergoing oncologic spine surgery with subsequent plastic surgery soft-tissue reconstruction from 2002 to 2014 was conducted. Demographic, medical, and surgical variables were recorded. The primary outcome variable was development of a postoperative wound complication. Secondary outcome variables were specific complications, including infection, seroma, hematoma, dehiscence, and cerebrospinal fluid leak. The predictor variable was the presence or absence of biological matrix at the reconstruction site. RESULTS A total of 293 cases in 260 patients were included in this study. The cohorts were similar with regard to demographic, medical, and surgical variables. The incidence of all-cause wound complications in patients receiving biological matrix for reconstruction was 49.2 percent, whereas the all-cause complication rate for patients not receiving the matrix was 31.7 percent (p = 0.010). The rates of infection (34.9 percent versus 20.9 percent) and seroma (19.0 percent versus 10.0 percent) were also increased in patients receiving biological matrix. In multivariate analysis, biological matrix use remained a predictor of wound complications (p = 0.045), infection (p = 0.011), and seroma (p = 0.047). CONCLUSIONS The authors identified an increased risk of infection and seroma with the use of biological tissue matrix in posterior trunk reconstruction. Careful consideration of the risks and benefits of using these devices in this patient population is warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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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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Dasenbrock HH, Clarke MJ, Bydon A, Witham TF, Sciubba DM, Simmons OP, Gokaslan ZL, Wolinsky JP. Reconstruction of Extensive Defects From Posterior En Bloc Resection of Sacral Tumors With Human Acellular Dermal Matrix and Gluteus Maximus Myocutaneous Flaps. Neurosurgery 2011; 69:1240-7. [DOI: 10.1227/neu.0b013e3182267a92] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Sahakitrungruang C, Chantra K, Dusitanond N, Atittharnsakul P, Rojanasakul A. Sacrectomy for primary sacral tumors. Dis Colon Rectum 2009; 52:913-8. [PMID: 19502856 DOI: 10.1007/dcr.0b013e3181a0d932] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE En bloc resection with adequate margins has provided a chance for cure of primary sacral tumors. However, high sacral lesions are challenging because of the complexity of the surgical approach. The aims of this study were to describe a modification in technique and to evaluate the outcomes. METHODS This is a study of eight sacrectomies performed at King Chulalongkorn Memorial Hospital between February 2000 and July 2007. Cadaveric dissections were carried out prior to surgery. We have modified the technique by ligation of the branches of the external iliac veins, resulting in "isolation" of the external iliac veins. Spinopelvic reconstruction was performed for total and extended total sacrectomy. Closure of the sacral defect was done with use of the Hartmann stump and the gluteus maximus flaps. RESULTS Two total sacrectomies, one extended total sacrectomy, and five subtotal S1 sacrectomies were performed. En bloc resection with adequate margins was achieved in all patients. The patient who underwent extended total sacrectomy and one patient who underwent total sacrectomy had nonunion requiring removal of the spinopelvic instrumentation. Five patients who underwent subtotal sacrectomy were ambulating well postoperatively, except for one who had an S1 fracture after falling. No sacral hernias were observed. None of the patients developed recurrence of the primary tumor. Mean follow-up time was four years. CONCLUSIONS Sacrectomy for primary sacral tumors can be safely conducted, achieving tumor-free margins and acceptable functional and long-term outcomes.
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Abhinav K, Shaaban M, Raymond T, Oke T, Gullan R, Montgomery A. Primary reconstruction of pelvic floor defects following sacrectomy using Permacol™ graft. Eur J Surg Oncol 2009; 35:439-43. [DOI: 10.1016/j.ejso.2008.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2007] [Accepted: 03/13/2008] [Indexed: 10/22/2022] Open
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Hiles M, Record Ritchie RD, Altizer AM. Are biologic grafts effective for hernia repair?: a systematic review of the literature. Surg Innov 2009; 16:26-37. [PMID: 19223383 DOI: 10.1177/1553350609331397] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Biologic grafts for hernia repair are a relatively new development in the world of surgery. A thorough search of the Medline database for uses of various biologic grafts in hernia shows that the evidence behind their application is plentiful in some areas (ventral, inguinal) and nearly absent in others (parastomal). The assumption that these materials are only suited for contaminated or potentially contaminated surgical fields is not borne out in the literature, with more than 4 times the experience being reported in clean fields and the average success rates being higher (93% vs 87%). Outcomes prove to be highly dependent on material source, processing methods and implant scenarios with failure rates ranging from zero to more than 30%. Small intestinal submucosa (SIS) grafts have an aggregate failure rate of 6.7% at 19 months whereas acellular human dermis (AHD) grafts have a failure rate of 13.6% at 12 months. Chemically cross-linked grafts have much less published data than the non-cross-linked materials. In particular, the search found 33 articles for SIS, 32 for AHD, and 13 for cross-linked porcine dermis. Furthermore, the cumulative level of evidence for each graft material was fairly low (2.6 to 2.9), and only 1 material (SIS) had level 1 evidence reported in any hernia type (inguinal and hiatal). Together, biologic grafts have published evidence showing success rates better than 90% overall and more than 2000 years of cumulative implant time. Improvements in materials, techniques, and patient selection are likely to improve these numbers as this field of surgery matures.
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Affiliation(s)
- Michael Hiles
- Cook Biotech Incorporated, West Lafayette, Indiana 47906, USA.
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Korn JM, Connolly MM, Walton RL. Single-stage sacral coccygectomy and repair using human acellular dermal matrix (AlloDerm®) with bilateral gluteus maximus flaps for hernia prophylaxis. Hernia 2008; 13:329-32. [DOI: 10.1007/s10029-008-0449-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 10/13/2008] [Indexed: 10/21/2022]
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Miranda EP, Anderson AL, Dosanjh AS, Lee CK. Successful management of recurrent coccygeal hernia with the de-epithelialised rectus abdominis musculocutaneous flap. J Plast Reconstr Aesthet Surg 2007; 62:98-101. [PMID: 17889632 DOI: 10.1016/j.bjps.2007.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2006] [Revised: 10/30/2006] [Accepted: 08/07/2007] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Little data exist about the optimal management of the rare coccygeal hernia. A novel method of repair is reported. METHODS A 46-year-old woman presented with a symptomatic coccygeal hernia after resection of the coccyx for a tumour. She had previously been reconstructed with an on-lay polytetrafluorethylene (PTFE) mesh but subsequently developed a hernia. A de-epithelialised vertical rectus abdominis musculocutaneous flap was elevated and passed through the hernia defect. The de-epithelialised dermis was secured to the levator ani and to the periosteum of the sacrum via access through a posterior approach. The gluteal skin was closed primarily over the inset flap. RESULTS The de-epithelialised rectus abdominis musculocutaneous flap is a viable option for the treatment of coccygeal hernia. RELEVANCE The de-epithelialised rectus abdominis flap has several advantages over other techniques including mesh repair and anterior or posterior flap repairs of the coccygeal hernia. The transposed muscle blocks herniation through the pelvic floor and does not create the dead space that is associated with posterior flap repairs such as the bilateral gluteal advancements. It also has the advantages of the posterior approach mesh repair, as the de-epithelialised dermis provides significant strength when secured like mesh to healthy local tissue.
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Affiliation(s)
- E P Miranda
- Department of Surgery, University of California San Francisco, CA 94143, USA.
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