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Geng Y, Ding N, Zou J, Zhou H, Zhu L. Management of a complicated colonexposed sacrococcygeal wound after pelvic exenteration: a case report. J Wound Care 2024; 33:315-318. [PMID: 38967340 DOI: 10.12968/jowc.2022.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
DECLARATION OF INTEREST This work was supported by the Naval Medical University and the University of Shanghai for Science and Technology Joint Projects (2020-RZ04), the Innovative Clinical Research Program of Shanghai Changzheng Hospital (2020YLCYJ-Y16), and the academic project of Naval Medical University (2022QN073). The authors have no conflicts of interest to declare.
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Affiliation(s)
- Yingnan Geng
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, Huangpu District, Shanghai, China
| | - Neng Ding
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, Huangpu District, Shanghai, China
| | - Jiefeng Zou
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, Huangpu District, Shanghai, China
| | - Haiyang Zhou
- Department of Colorectal Surgery, Second Affiliated Hospital of Naval Medical University, Huangpu District, Shanghai, China
| | - Lie Zhu
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, Huangpu District, Shanghai, China
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Falade IO, Knox JA, Piper ML, Hoffman WY, Hansen SL. Soft Tissue Reconstruction After Sacral Neoplasm Resection: The University of California San Francisco Experience. Ann Plast Surg 2024; 92:S320-S326. [PMID: 38689413 DOI: 10.1097/sap.0000000000003803] [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: 05/02/2024]
Abstract
PURPOSE Resection of sacral neoplasms such as chordoma and chondrosarcoma with subsequent reconstruction of large soft tissue defects is a complex multidisciplinary process. Radiotherapy and prior abdominal surgery play a role in reconstructive planning; however, there is no consensus on how to maximize outcomes. In this study, we present our institution's experience with the reconstructive surgical management of this unique patient population. METHODS We conducted a retrospective review of patients who underwent reconstruction after resection of primary or recurrent pelvic chordoma or chondrosarcoma between 2002 and 2019. Surgical details, hospital stay, and postoperative outcomes were assessed. Patients were divided into 3 groups for comparison based on reconstruction technique: gluteal-based flaps, vertical rectus abdominus myocutaneous (VRAM) flaps, and locoregional fasciocutaneous flaps. RESULTS Twenty-eight patients (17 males, 11 females), with mean age of 62 years (range, 34-86 years), were reviewed. Twenty-two patients (78.6%) received gluteal-based flaps, 3 patients (10.7%) received VRAM flaps, and 3 patients (10.7%) were reconstructed with locoregional fasciocutaneous flaps. Patients in the VRAM group were significantly more likely to have undergone total sacrectomy (P < 0.01) in a 2-stage operation (P < 0.01) compared with patients in the other 2 groups. Patients in the VRAM group also had a significantly greater average number of reoperations (2 ± 3.5, P = 0.04) and length of stay (29.7 ± 20.4 days, P = 0.01) compared with the 2 other groups. The overall minor and major wound complication rates were 17.9% and 42.9%, respectively, with 17.9% of patients experiencing at least 1 infection or seroma. There was no association between prior abdominal surgery, surgical stages, or radiation therapy and an increased risk of wound complications. CONCLUSIONS Vertical rectus abdominus myocutaneous flaps are a more suitable option for patients with larger defects after total sacrectomy via 2-staged anteroposterior resections, whereas gluteal myocutaneous flaps are effective options for posterior-only resections. For patients with small- to moderate-sized defects, local fasciocutaneous flaps are a less invasive and effective option. Paraspinous flaps may be used in combination with other techniques to provide additional bulk and coverage for especially long postresection wounds. Furthermore, mesh is a useful adjunct for any reconstruction aimed at protecting against intra-abdominal complications.
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Affiliation(s)
- Israel O Falade
- From the School of Medicine, University of California San Francisco, San Francisco, CA
| | - Jacquelyn A Knox
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA
| | - Merisa L Piper
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA
| | - William Y Hoffman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA
| | - Scott L Hansen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA
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Huang W, Hu X, Cai W, Cheng M, Fang M, Sun Z, Hu T, Yan W. Soft-tissue reconstruction with pedicled vertical rectus abdominis myocutaneous flap after total or high sacrectomy for giant sacral tumor. J Plast Reconstr Aesthet Surg 2024; 91:173-180. [PMID: 38417394 DOI: 10.1016/j.bjps.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/23/2023] [Accepted: 02/01/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND The large soft-tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft-tissue defect and achieve the preferred clinical outcome. METHODS A total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumors between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Participants were divided into two groups. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction, whereas 14 patients underwent a conventional wound closure. Patient's clinical characteristics, surgical duration, postoperative complications, and outcomes were compared between the two groups. RESULTS Patients in VRAM and non-VRAM groups were similar in baseline characteristics. The mean tumor size was 12.85 cm (range: 10-17 cm) in VRAM group and 11.79 cm (range: 10-14.5 cm) in non-VRAM group (P = 0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had a shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared with patients in non-VRAM group. Patients in the VRAM group had less wound infection and debridement than patients in non-VRAM group (15.4% vs 57.1%, P < 0.001). CONCLUSIONS This study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft-tissue defects after high or total sacrectomy using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay.
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Affiliation(s)
- Wending Huang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xianglin Hu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiluo Cai
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Mo Cheng
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Meng Fang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zhengwang Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Tu Hu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Wangjun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.
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Yu Z, Jin S, Zang M, Zhu S, Li S, Han T, Chen Z, Liu Y. Successful Reconstruction of Complex Sacrococcygeal Defects Using Chimeric Perforator Propeller Flap. Ann Plast Surg 2023; 91:597-603. [PMID: 37823625 DOI: 10.1097/sap.0000000000003698] [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: 10/13/2023]
Abstract
BACKGROUND Complex soft tissue defects, which result from the surgical resection of sacral tumors, manifest as a combination of skin defects, dead space, infection, and prosthesis exposure. Because the traditional musculocutaneous flap lacks flexibility because of the close connection between the skin flap and the muscle component, the musculocutaneous flap is not suitable for reconstructing complex soft tissue defects where the dead space and skin defects are located at different sites. Furthermore, the perforator flap is also not appropriate for reconstructing complex defects because it lacks the muscular component. We considered the possibility of using the chimeric perforator propeller flap for reconstructing complex sacrococcygeal defects. METHODS This study included 7 patients who underwent, between July 2007 and July 2021, the reconstruction of complex soft tissue defects of the sacrococcygeal region using a chimeric perforator propeller flap. RESULTS Among the included cases, the etiologies were chordoma (n = 3), sacral tumor (n = 3), and squamous cell carcinoma (n = 1). In all the cases, vacuum-assisted closure therapy was used to treat wound infections before surgery. The average sizes of the skin and muscle flaps were 195.8 cm 2 (range, 100-350 cm 2 ) and 83.6 cm 2 (range, 60-140 cm 2 ), respectively. The superior gluteal artery was the source artery for the chimeric perforator propeller flap. The donor sites were primarily closed in all cases. One patient had delayed wound healing, and the secondary wound healed using conservative dressing changes. The other 6 flaps had no complications. The average follow-up time was 5.3 months (range, 1-9 months). Muscle weakness and compromised ambulation in the affected lower extremities were not observed in any of the patients. Furthermore, all 7 patients had no tumor recurrence, prosthesis exposure, and infection events in the sacrococcygeal region. CONCLUSIONS The chimeric perforator propeller flap may be an option for reconstructing complex soft tissue defects in the sacrococcygeal region.
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Affiliation(s)
- Zouzou Yu
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Rekonstruktion onkologischer Defekte der Perianalregion. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00575-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Guadarrama-Ortíz P, Montes de Oca-Vargas I, Choreño-Parra JA, Garibay-Gracián A, Capi-Casillas D, Román-Villagomez A, Salinas-Lara C, Palacios-Zúñiga U, Prieto-Rivera ÁD. Nerve preservation during partial sacrectomy by two-stage anterior and posterior approach: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21384. [PMID: 35855408 PMCID: PMC9265185 DOI: 10.3171/case21384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/20/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Preserving the neurological function of sacral nerves during total or partial sacrectomy is challenging.
OBSERVATIONS
The authors describe a case of an osseous desmoplastic fibroma of the sacrum in a 51-year-old woman. The patient attended the authors’ institution with loss of muscle strength and sensitivity impairment in both legs, gait instability, bowel constipation, urinary incontinence, and weight loss. Preoperative magnetic resonance imaging and positron emission tomography/computed tomography showed intrapelvic and posterior extension of the tumor but sparing of S1 and the sacroiliac and lumbosacral joints. After a multidisciplinary discussion of the case, a staged anterior–posterior approach to the sacrum was chosen. The abdominal approach allowed full mobilization of the uterus, ovaries, bladder, and colon and protection of iliac vessels. After tumor resection, a synthetic surgical mesh was placed over the sacrum to minimize soft tissue defects. Then, the posterior stage allowed the authors to perform a bicortical osteotomy, achieving wide tumor excision with minimal nerve root injury. Spinopelvic fixation was not necessary, because both sacroiliac and lumbosacral joints remained intact. A few days after the surgery, the patient restarted ambulation and recovered sphincter control.
LESSONS
Multidisciplinary planning and a staged abdominal and posterior approach for partial sacrectomy were fundamental to preserve neurological function in this case.
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Affiliation(s)
| | - Ingrid Montes de Oca-Vargas
- Department of Neurosurgery
- Programa de Servicio Social en Investigación, and
- Internado Médico de Pregrado, Centro Especializado en Neurocirugía y Neurociencias México (CENNM), Mexico City, Mexico
| | | | - André Garibay-Gracián
- Department of Neurosurgery
- Programa de Servicio Social en Investigación, and
- Facultad de Estudios Superiores (FES) Iztacala, Universidad Nacional Autónoma de México, Tlalnepantla de Baz, Mexico
| | - Deyanira Capi-Casillas
- Facultad de Estudios Superiores (FES) Iztacala, Universidad Nacional Autónoma de México, Tlalnepantla de Baz, Mexico
- Escuela Nacional de Medicina y Homeopatía, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Alondra Román-Villagomez
- Facultad de Estudios Superiores (FES) Iztacala, Universidad Nacional Autónoma de México, Tlalnepantla de Baz, Mexico
- Escuela Nacional de Medicina y Homeopatía, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Citlaltepetl Salinas-Lara
- Departamento de Neuropatología, Instituto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez”, Mexico City, Mexico; and
| | - Ulises Palacios-Zúñiga
- Servicio de Neurocirugía, Módulo de Columna, Hospital Regional 1° de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
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Impact of Multidisciplinary Intraoperative Teams on Thirty-Day Complications After Sacral Tumor Resection. World Neurosurg 2021; 152:e558-e566. [PMID: 34144170 DOI: 10.1016/j.wneu.2021.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the impact of multidisciplinary intraoperative teams on surgical complications in patients undergoing sacral tumor resection. METHODS We reviewed all patients with primary or metastatic sacral tumors managed at a single comprehensive cancer center over a 7-year period. Perioperative complication rates were compared between those treated by an unassisted spinal oncologist and those treated with the assistance of at least 1 other surgical specialty. Statistical analysis involved univariable and stepwise multivariable logistic regression models to identify predictors of multidisciplinary management and 30-day complications. RESULTS A total of 107 patients underwent 132 operations for sacral tumors; 92 operations involved multidisciplinary teams, including 54% of metastatic tumor operations and 74% of primary tumor operations. Patients receiving multidisciplinary management had higher body mass indexes (29.8 vs. 26.3 kg/m2; P = 0.008), larger tumors (258 vs. 55 cm³; P < 0.001), and higher American Society of Anesthesiologists scores (3 vs. 2; P = 0.049). Only larger tumor volume (odds ratio [OR], 1.007 per cm³; P < 0.001) and undergoing treatment for a malignant primary versus a metastatic tumor (OR, 23.4; P < 0.001) or benign primary tumor (OR, 29.3; P < 0.001) were predictive of multidisciplinary management. Although operations involving multidisciplinary teams were longer (467 vs. 231 minutes; P < 0.001) and had higher blood loss (1698 vs. 774 mL; P = 0.004), 30-day complication rates were similar (37 vs. 27%; P = 0.39). On multivariable analysis, only larger tumor volume (OR, 1.004 per cm³; P = 0.005) and longer surgical duration (OR, 1.002 per minute; P = 0.03) independently predicted higher 30-day complications. CONCLUSIONS Although patients managed with multidisciplinary teams had larger tumors and worse baseline health, 30-day complications were similar. This finding suggests that the use of multidisciplinary teams may help to mitigate surgical morbidity in those with high baseline risk.
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Asaad M, Mericli AF, Hanasono MM, Roubaud MS, Bird JE, Rhines LD. Free Vascularized Fibula Flap Reconstruction of Total and Near-total Destabilizing Resections of the Sacrum. Ann Plast Surg 2021; 86:661-667. [PMID: 33009144 DOI: 10.1097/sap.0000000000002562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vascularized bone grafts (VBGs) are associated with improved union and fewer instrumentation complications in the mobile spine. It is not known if VBGs are similarly efficacious after sacrectomy. METHODS We conducted a retrospective chart review of all patients who underwent total sacrectomy and immediate reconstruction with VBG between 2005 and 2019. Patient and surgical characteristics in addition to union and functional outcomes were analyzed. RESULTS We identified 10 patients (6 women and 4 men) with a mean age of 42 years (range, 12-71 years). All patients received iliolumbar instrumentation as well as a free fibula flap as a VBG. There were no complications at the fibula flap donor site or specifically related to the VBG. Bony union was achieved in 7 (88%) of 8 patients with an average union time of 6.3 months (range, 2-10 months). Surgical complications occurred in 5 patients, 4 patients required reoperation for wound dehiscence, and 1 patient required conversion to a 4-rod construct and bone grafting for instrumentation loosening and partial nonunion. Instrumentation failure developed in 1 patient, but no surgical intervention was required. One patient was able to walk independently without any limitation, 5 patients required a walker, 2 were wheelchair-bound except for short (<15 ft) distances, and 2 were lost to follow-up. CONCLUSIONS The free vascularized fibula flap is a safe and effective option for supplementing spinal reconstruction after destabilizing sacrectomy.
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Affiliation(s)
| | | | | | | | | | - Laurence D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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Horch RE, Ludolph I, Arkudas A. [Reconstruction of oncological defects of the perianal region]. Chirurg 2021; 92:1159-1170. [PMID: 33904942 DOI: 10.1007/s00104-021-01394-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 01/13/2023]
Abstract
In addition to the progressive development of surgical oncological techniques for malignant tumors of the rectum, anal canal and vulva, reconstructive procedures after oncological interventions in the perianal region represent a cornerstone in the postoperative quality of life of patients. Modern treatment modalities for rectal cancer with neoadjuvant chemoradiotherapy increase the survival rate and simultaneously reduce the risk of local recurrence to 5-10%, especially by cylindrical extralevatory extirpation of the rectum. The price for increased surgical radicality and improved oncological safety is the acceptance of larger tissue defects. Simple suture closure of perineal wounds often does not primarily heal, resulting in wound dehiscence, surgical site infections and formation of chronic fistulas and sinuses. The interdisciplinary one-stage or two-stage reconstruction of the perianal region with well-vascularized tissue has proven to be a reliable procedure to prevent or control such complications.
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Affiliation(s)
- Raymund E Horch
- Plastisch- und Handchirurgische Klinik und Labor für Tissue Engineering und Regenerative Medizin, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg FAU, Krankenhausstraße 12, 91054, Erlangen, Deutschland.
| | - Ingo Ludolph
- Plastisch- und Handchirurgische Klinik und Labor für Tissue Engineering und Regenerative Medizin, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg FAU, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - Andreas Arkudas
- Plastisch- und Handchirurgische Klinik und Labor für Tissue Engineering und Regenerative Medizin, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg FAU, Krankenhausstraße 12, 91054, Erlangen, Deutschland
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Asaad M, Rajesh A, Wahood W, Vyas KS, Houdek MT, Rose PS, Moran SL. Flap reconstruction for sacrectomy defects: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2020; 73:255-268. [DOI: 10.1016/j.bjps.2019.09.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/12/2019] [Accepted: 09/09/2019] [Indexed: 01/16/2023]
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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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Kiiski J, Kuokkanen HO, Kääriäinen M, Kaartinen IS, Pakarinen TK, Laitinen MK. Clinical results and quality of life after reconstruction following sacrectomy for primary bone malignancy. J Plast Reconstr Aesthet Surg 2018; 71:1730-1739. [PMID: 30236876 DOI: 10.1016/j.bjps.2018.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/02/2018] [Accepted: 08/19/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Sacrectomy is a rare and demanding surgical procedure that results in major soft tissue defects and spinopelvic discontinuity. No consensus is available on the optimal reconstruction algorithm. Therefore, the present study evaluated the results of sacrectomy reconstruction and its impact on patients' quality of life (QOL). METHODS A retrospective chart review was conducted for 21 patients who underwent sacrectomy for a primary bone tumour. Patients were divided into groups based on the timing of reconstruction as follows: no reconstruction, immediate reconstruction or delayed reconstruction. QOL was measured using the EQ-5D instrument before and after surgery in patients treated in the intensive care unit. RESULTS The mean patient age was 57 (range 22-81) years. The most common reconstruction was gluteal muscle flap (n = 9) and gluteal fasciocutaneous flap (n = 4). Four patients required free-tissue transfer, three latissimus dorsi flaps and one vascular fibula bone transfer. No free flap losses were noted. The need for unplanned re-operations did not differ between groups (p = 0.397), and no significant differences were found for pre- and post-operative QOL or any of its dimensions. DISCUSSION Free flap surgery is reliable for reconstructing the largest sacrectomy defects. Even in the most complex cases, surgery can be safely staged, and final reconstruction can be carried out within 1 week of resection surgery without increasing peri‑operative complications. Sacrectomy does not have an immoderate effect on the measured QOL.
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Affiliation(s)
- Juha Kiiski
- Department of Plastic Surgery, Helsinki University Central Hospital, Helsinki, Finland; Division of Plastic Surgery, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland.
| | - Hannu O Kuokkanen
- Department of Plastic Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Minna Kääriäinen
- Division of Plastic Surgery, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland
| | - Ilkka S Kaartinen
- Division of Plastic Surgery, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland; Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Toni-Karri Pakarinen
- Division of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland
| | - Minna K Laitinen
- Division of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland; Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
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Gao S, Zheng Y, Liu X, Tian Z, Zhao Y. Effect of early fasting and total parenteral nutrition support on the healing of incision and nutritional status in patients after sacrectomy. Orthop Traumatol Surg Res 2018; 104:539-544. [PMID: 29567321 DOI: 10.1016/j.otsr.2018.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 09/30/2017] [Accepted: 02/12/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgical site infection is one of the most common complications for patients after sacrectomy, which often accompanied by poor wound healing, sinus formation and serious metabolic disturbance. HYPOTHESIS We tried to avoid the surgical site infection caused by feces during early period after surgery through early fasting and total parenteral nutrition (TPN) support, then compared the clinical results of these patients with other patients that received enteral nutrition (EN) early after sacrectomy. METHODS Forty-eight patients after sacrectomy (the level of sacrectomy above S2) were randomly divided into two groups: TPN group and EN group. The patients of two groups received different nutrition support from the first day to the seventh day after surgery, then the factors such as nutritional and metabolic status after surgery, incidence of complications as well as the time of incision healing and hospitalization were observed. RESULTS The p-value of total serum protein, albumin, serum alanine aminotransferase, total bilirubin at seventh day after sacrectomy between TPN group and EN group is <0.0005. The p-value of hemoglobin at seventh day after sacrectomy between TPN group and EN group is 0.001. The p-value of total serum protein at fourteenth day after sacrectomy between TPN group and EN group is 0.003. The p-value of albumin and total bilirubin at fourteenth day after sacrectomy between TPN group and EN group is 0.001. The p-value of hemoglobin, serum alanine aminotransferase at fourteenth day after sacrectomy between TPN group and EN group is <0.0005. The incidence of gastrointestinal complication and delay of apparition of feces in EN group were lower than that in TPN group (p=0.041, p<0.0005). The incidence of surgical site infection, the time of incision healing and hospitalization in TPN group were lower than that in EN group (p=0.048, p=0.008, p<0.0005). CONCLUSIONS The method of fasting and supported by TPN during the early period after sacrectomy contribute to the incision healing, meanwhile, it shortens the hospitalization time and abates the incidence of complications in patients after sacrectomy. TYPE OF STUDY It is a comparative randomized study. LEVEL OF PROOF High-powered prospective randomized trial.
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Affiliation(s)
- S Gao
- Department of Orthopedics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, No. 7, Weiwu Road, 450003 Zhengzhou, Henan Province, People's Republic of China.
| | - Y Zheng
- Department of radiology, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe Road, 450052 Zhengzhou, Henan Province, People's Republic of China
| | - X Liu
- Department of Orthopedics, The Affiliated Tumor Hospital of Zhengzhou University, No. 127, Dongming Road, 450008 Zhengzhou, Henan Province, People's Republic of China
| | - Z Tian
- Department of Orthopedics, The Affiliated Tumor Hospital of Zhengzhou University, No. 127, Dongming Road, 450008 Zhengzhou, Henan Province, People's Republic of China
| | - Y Zhao
- Department of Orthopedics, The Affiliated Tumor Hospital of Zhengzhou University, No. 127, Dongming Road, 450008 Zhengzhou, Henan Province, People's Republic of China
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Use of S2-Alar-iliac Screws Associated With Less Complications Than Iliac Screws in Adult Lumbosacropelvic Fixation. Spine (Phila Pa 1976) 2017; 42:E142-E149. [PMID: 27254657 DOI: 10.1097/brs.0000000000001722] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To compare clinical and radiographic outcomes between the S2-alar-iliac (S2AI) and the iliac screw (IS) techniques in the adult population and clarify the clinical strength of S2AI screws. SUMMARY OF BACKGROUND DATA S2AI screws have been described as an alternative method for lumbosacropelvic fixation in place of ISs. The S2AI technique has several advantages with lower prominence, increased ability to directly connect to proximal instrumentation, less extensive dissection of tissue, and enhanced biomechanical strength over the IS technique. However, the clinical significance of these advantages remains unclear. METHODS A single-center retrospective review of patients who underwent lumbosacropelvic fixation yielded 25 IS group patients and 65 S2AI group patients. Baseline demographic information, postoperative complications, pain and functional outcomes, and screw-related outcomes were collected. RESULTS The S2AI group had lower rates of reoperation (8.8% vs. 48.0%, P < 0.001), surgical site infection (SSI) (1.5% vs. 44.0%, P < 0.001), wound dehiscence (1.5% vs. 36.0%, P < 0.001), and symptomatic screw prominence (0.0% vs. 12.0%, P = 0.02) than the IS group, whereas rates of L5-S1 pseudarthrosis, proximal junctional failure, and sacroiliac joint pain were similar in both groups. Statistically significant pain relief and functional recovery were achieved in both groups without any significant intergroup differences. On multivariate analyses, age [odds ratio (OR) = 0.91, P = 0.004] and S2AI instrumentation (OR = 0.08, P < 0.001) were protective of reoperation, whereas diabetes mellitus (OR = 10.9, P = 0.03) and preoperative diagnosis of tumor (OR = 12.3, P = 0.04) were associated with SSI, and S2AI instrumentation (OR = 0.09, P < 0.001) was protective of SSI. CONCLUSION The use of the S2AI technique over the IS technique was an independent predictor of preventing reoperation and SSI, while achieving similar clinical and functional outcomes. LEVEL OF EVIDENCE 4.
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Optimizing the Adverse Event and HRQOL Profiles in the Management of Primary Spine Tumors. Spine (Phila Pa 1976) 2016; 41 Suppl 20:S212-S217. [PMID: 27753783 DOI: 10.1097/brs.0000000000001821] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVE To investigate if evidence-based principles of oncologic resection for primary spinal tumors are correlated with an acceptable morbidity and mortality profile and satisfactory health-related quality of life (HRQOL) measures. SUMMARY OF BACKGROUND DATA Respecting oncologic principles for primary spinal tumor surgery is correlated with lower recurrence rates. These interventions are, however, often highly morbid. METHODS A systematic literature review was performed to address the objectives by searching MEDLINE and EBMR databases. Articles that met our inclusion criteria were reviewed. GRADE guidelines were used for recommendation formulation. RESULTS A total of 25 articles addressing the morbidity and mortality profile of primary spinal tumor surgery were identified. For sacral tumors, complication rates of up to 100% have been reported and complication-related death ranged from 0% to 27%. Mobile spine tumor complication rates varied from 13% to 73.7% and complication-related death ranged from 0% to 7.7%. Seven articles examining HRQOL for this patient population were identified. The limited literature showed comparable patient HRQOL profiles to those with benign conditions such as degenerative disc disease. CONCLUSION Respecting oncologic principles for primary spinal tumors are correlated with high adverse event rates. We recommend that primary spinal tumor surgeries be performed in experienced centers with multidisciplinary support teams and that prospective adverse event collection be promoted (strong recommendation/very low certainty of the evidence). Oncologic resection of primary tumors of the spine is associated with HRQOL that more closely approximates normative values with increasing duration of follow-up, but decreases with disease recurrence. We recommend primary spinal tumor surgery be performed with a curative intent whenever possible, even at the expense of greater initial morbidity to optimize long-term HRQOL (strong recommendation/very low certainty of the evidence). LEVEL OF EVIDENCE N/A.
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Pelvic Reconstruction Surgery Using a Dual-Rod Technique with Diverse U-Shaped Rods After Posterior En Bloc Partial Sacrectomy for a Sacral Tumor: 2 Case Reports and a Literature Review. World Neurosurg 2016; 95:619.e11-619.e18. [PMID: 27544341 DOI: 10.1016/j.wneu.2016.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/05/2016] [Accepted: 08/06/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Spinopelvic reconstruction after sacrectomy for a sacropelvic tumor can result in various complications and requires a highly complicated surgical technique. We report 2 cases of pelvic reconstruction surgery using diverse U-shaped rods (USRs) after partial sacrectomy. CASE DESCRIPTION A partial sacrectomy was performed for 2 different cases: one case was a metastatic sacral tumor and the other was a chordoma. In the first case, reconstruction was completed with an inner straight rod and an outer USR. The other patient underwent reconstruction using an inner USR and an outer straight rod. In both cases, there was no instrument failure, and the lumbosacral junction was reconstructed in balance. One of the patients died of metastatic lung cancer, and the other patient is alive and has experienced no other complications. CONCLUSIONS A pelvic reconstruction technique using diverse USRs showed good spinopelvic stability without complications. This technique may be a surgical option for reconstructive surgery after partial sacrectomy.
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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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The Superior Rectal Artery as a Recipient Vessel for Free Flap Transfer After Partial Sacrectomy in Patients With Chordoma. Ann Plast Surg 2016; 76:315-7. [DOI: 10.1097/sap.0000000000000493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Interest of Laparoscopy for "En Bloc" Resection of Primary Malignant Sacral Tumors by Combined Approach: Comparative Study With Open Median Laparotomy. Spine (Phila Pa 1976) 2015. [PMID: 26208224 DOI: 10.1097/brs.0000000000001069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVE To compare laparoscopy with open median laparotomy for anterior approach in "en bloc" resection of primary malignant sacral tumors (PMST) in combined approach strategy. SUMMARY OF BACKGROUND DATA Wide margin surgical resection is the "gold standard" treatment of PMST. METHODS Two groups of patients suffering from PMST and operated for "en bloc" resection by combined approach (anterior and posterior) only differencing for the anterior approach were constituted: "laparoscopy" group (n = 11) and "laparotomy" group (n = 22). Intraoperative morbidity (blood loss, red blood cell transfusion (RBC transfusion), surgical procedure duration) and postoperative morbidity (surgical-site infection (SSI), perineal dysfunctions, local recurrence) were analyzed. Surgical margins were studied. Data of both groups were compared using nonparametric Mann-Whitney test for continuous data and Fisher test for categorical data. Overall survival (OS) and Disease-free survival (DFS) were analyzed by Kaplan-Meier method. RESULTS Blood loss during anterior approach was less important in "laparoscopy" group 71.9 mL (range 0-400 mL) as compared with 2140 mL (range 0-9000 mL) for "laparotomy" group (P = 0.019). Blood loss during posterior approach was not different between the 2 groups. Total blood loss including anterior and posterior approach was inferior in "laparoscopy" group 2208 mL (range 230-4800 mL) versus 5385.7 mL (range 1400-11500 mL) for "laparotomy" group (P = 0.026). We reported significant difference on blood transfusion (3.7 RBC transfusions (range 0-8) for "laparoscopy group" versus 10.1 RBC transfusions (range 0-35) for "laparotomy" group (P = 0.025)). Surgical duration, quality of surgical margins, perineal dysfunctions and SSI were equivalent for both groups. At a follow-up of 36.6 months for "laparoscopy" group and 115.3 months for "laparotomy" group, OS and DFS were equivalent. CONCLUSION Use of laparoscopy for anterior approach decreases intraoperative blood loss and intraoperative RBC transfusion without increasing surgical duration, without altering the quality of surgical margins and without impairing long-term outcomes. LEVEL OF EVIDENCE 4.
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Kim JE, Pang J, Christensen JM, Coon D, Zadnik PL, Wolinsky JP, Gokaslan ZL, Bydon A, Sciubba DM, Witham T, Redett RJ, Sacks JM. Soft-tissue reconstruction after total en bloc sacrectomy. J Neurosurg Spine 2015; 22:571-81. [DOI: 10.3171/2014.10.spine14114] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Total en bloc sacrectomy is a dramatic procedure that results in extensive sacral defects. The authors present a series of patients who underwent flap reconstruction after total sacrectomy, report clinical outcomes, and provide a treatment algorithm to guide surgical care of this unique patient population.
METHODS
After institutional review board approval, data were collected for all patients who underwent total sacrectomy between 2002 and 2012 at The Johns Hopkins Hospital. Variables included demographic data, medical history, tumor characteristics, surgical details, postoperative complications, and clinical outcomes. All subtotal sacrectomies were excluded.
RESULTS
Between 2002 and 2012, 9 patients underwent total sacrectomy with flap reconstruction. Diagnoses included chordoma (n = 5), osteoblastoma (n = 1), sarcoma (n = 2), and metastatic colon cancer (n = 1). Six patients received gluteus maximus (GM) flaps with a prosthetic rectal sling following a single-stage, posterior sacrectomy. Four required additional paraspinous muscle (PSM) or pedicled latissimus dorsi (LD) fasciocutaneous flaps. Three patients underwent multistage sacrectomy with an anterior-posterior approach, 2 of whom received pedicled vertical rectus abdominis myocutaneous (VRAM) flaps, and 1 of whom received local GM, LD, and PSM flaps. Flap complications included dehiscence (n = 4) and infection (n = 1). During the 1st year of follow-up, 2 of 9 patients (22%) were able to ambulate with an assistive device by the 1st postoperative month, and 6 of 9 (67%) were ambulatory with a walker by the 3rd postoperative month. By postoperative Month 12, 5 of 9 patients (56%)—or 5 of 5 patients not lost to follow-up (100%)—were able to able to ambulate independently.
CONCLUSIONS
The authors' experience suggests that the GM and pedicled VRAM flaps are reliable options for softtissue reconstruction of total sacrectomy defects. For posterior-only operations, GM flaps with or without a prosthetic rectal sling are generally used. For multistage operations including a laparotomy, the authors consider the pedicled VRAM flap to be the gold standard for simultaneous reconstruction of the pelvic diaphragm and obliteration of dead space.
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Affiliation(s)
- Jennifer E. Kim
- Departments of 1Plastic and Reconstructive Surgery and
- 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - John Pang
- Departments of 1Plastic and Reconstructive Surgery and
| | | | - Devin Coon
- Departments of 1Plastic and Reconstructive Surgery and
| | - Patricia L. Zadnik
- 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Jean-Paul Wolinsky
- 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Ziya L. Gokaslan
- 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Ali Bydon
- 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel M. Sciubba
- 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Timothy Witham
- 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
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Clarke MJ, Vrionis FD. Spinal tumor surgery: management and the avoidance of complications. Cancer Control 2015; 21:124-32. [PMID: 24667398 DOI: 10.1177/107327481402100204] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Complication avoidance is paramount to the success of any surgical procedure. In the case of spine tumor surgery, the risk of complications is increased because of the primary disease process and the radiotherapy and chemotherapeutics used to treat the disease. If complications do occur, then life-saving adjuvant treatment must be delayed or withheld until the issue is resolved, potentially impacting overall disease control. METHODS We reviewed the literature and our own best practices to provide recommendations on complication avoidance as well as the management of complications that may occur. Appropriate workup of suspected complications and treatment algorithms are also discussed. RESULTS Appropriate patient selection and a multidisciplinary workup are imperative in the setting of spinal tumors. Intraoperative complications may be avoided by employing proper surgical technique and an understanding of the pathological changes in anatomy. Major postoperative issues include wound complications and spinal reconstruction failure. Preoperative surgical planning must include postoperative reconstruction. Patients undergoing spinal tumor resection should be closely monitored for local tumor recurrence, recurrence along the biopsy tract, and for distant metastatic disease. Any suspected recurrence should be closely watched, biopsied if necessary, and promptly treated. CONCLUSIONS Because patients with spinal tumors are normally treated with a multidisciplinary approach, emphasis should be placed on the recognition of surgical complications beyond the surgical setting.
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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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Clarke MJ, Zadnik PL, Groves ML, Dasenbrock HH, Sciubba DM, Hsu W, Witham TF, Bydon A, Gokaslan ZL, Wolinsky JP. En bloc hemisacrectomy and internal hemipelvectomy via the posterior approach. J Neurosurg Spine 2014; 21:458-67. [PMID: 24926933 DOI: 10.3171/2014.4.spine13482] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Traditionally, hemisacrectomy and internal hemipelvectomy procedures have required both an anterior and a posterior approach. A posterior-only approach has the potential to complete an en bloc tumor resection and spinopelvic reconstruction while reducing surgical morbidity. METHODS The authors describe 3 cases in which en bloc resection of the hemisacrum and ilium and subsequent lumbopelvic and pelvic ring reconstruction were performed from a posterior-only approach. Two more traditional anterior and posterior staged procedures are also included for comparison. RESULTS In all 3 cases, an oncologically appropriate surgery and spinopelvic reconstruction were performed through a posterior-only approach. CONCLUSIONS The advantage of a midline posterior approach is the ability to perform a lumbosacral reconstruction, necessary in cases in which the S-1 body is iatrogenically disrupted during tumor resection.
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Varga PP, Szoverfi Z, Lazary A. Surgical resection and reconstruction after resection of tumors involving the sacropelvic region. Neurol Res 2014; 36:588-96. [PMID: 24766410 DOI: 10.1179/1743132814y.0000000370] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Surgical management of tumors in the sacropelvic region is a challenging field of spine surgery because of the region's complex local anatomy and biomechanics. Recent developments in anesthesia and intensive care have allowed us to perform extended surgeries focused on the en bloc resection of sacropelvic tumors. Various techniques for the resection and for the reconstruction were published in the last decade. METHODS Sacropelvic tumor resection techniques and methods for the biomechanical and soft-tissue reconstruction are reviewed in this paper. RESULTS The literature data is based on case reports and case-series. Several different techniques were developed for the lumbopelvic stabilization after sacropelvic tumor resection according to three different reconstruction principles (spinopelvic fixation (SPF), posterior pelvic ring fixation (PRF), and anterior spinal column fixation (ACF)); however, long-term follow-up data and comparative studies of the different techniques are still missing. Soft-tissue reconstruction can be performed according to an algorithm depending on the surgical approach, but relatively high complication rates are reported with all reconstruction strategies. The clinical outcome of such surgeries should ideally be evaluated in three dimensions; surgical-, oncological-, and functional outcomes. The last and most important step of the presurgical planning procedure is a careful presentation of the surgical goals and risks to the patient, who must provide a fully informed consent before surgery can proceed. DISCUSSION Sacropelvic tumors are rare conditions. In the last decade, growing evidence was published on resection and reconstruction techniques for these tumors; however, experience at most medical centers is limited due to the low numbers of cases. The formation of international expert groups and the initiation of multicenter studies are strongly encouraged to produce a high level of evidence in this special field of spine surgery.
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Abstract
OBJECTIVES The objective of the authors was to provide an up-to-date review about the epidemiology, diagnosis, and surgical management of the malignant primary sacral tumors. METHODS A PubMed search was conducted using a combination of the following items: (('Spinal Neoplasms'[Mesh]) AND 'Sacrum'[Mesh]) NOT ('Metastasis' OR 'Metastases' OR 'Benign'). The literature review and the author's own surgical experiences were used to assess the current treatment strategies of the malignant sacral tumors. RESULTS Twenty case series were identified, which studies discuss in detail the surgical strategies, the postoperative complications, the functional and oncologic outcome, and the recurrence-free and disease-specific survival of this rare patient category. DISCUSSION Sacral tumors are rare pathologies. Their management generates a complex medical problem, as they usually are diagnosed in advanced stages with extended dimensions involving the sacral nerves and surrounding organs. The evaluation and complex treatment of these rare tumors require a multidisciplinary approach, optimally at institutions with comprehensive care and experience. Although conventional oncologic therapeutic methods should be used as neoadjuvant or adjuvant therapies in certain histological types, en bloc resection with wide surgical margins is essential for long-term local oncologic control. This is often technically difficult to achieve, as just a few centers in the world perform sacral tumor surgeries on a regular basis, and have enough wide experience. Therefore international cooperation and organization of multicenter tumor registries are essential to develop evidence based treatment protocols.
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“En bloc” resection of sacral chordomas by combined anterior and posterior surgical approach: a monocentric retrospective review about 29 cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1940-8. [DOI: 10.1007/s00586-014-3196-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 01/08/2014] [Accepted: 01/10/2014] [Indexed: 11/24/2022]
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Mendel E, Nathoo N, Scharschmidt T, Schmidt C, Boehmler J, Mayerson JL. Creation of false pedicles and a neo-pelvis for lumbopelvic reconstruction following en bloc resection of an iliosacral chondrosarcoma with lumbar spine extension: technical note. J Neurosurg Spine 2014; 20:327-34. [PMID: 24405467 DOI: 10.3171/2013.11.spine13211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
En bloc resection with negative tumor margins remains the principal treatment option for control or cure of primary pelvic chondrosarcomas, as current adjuvant therapies remain ineffective. Iliosacral chondrosarcomas with involvement of the sciatic notch are sufficiently challenging tumors. However, when there is concomitant lumbar extension requiring resection of the pedicles to maintain negative surgical margins, transpedicular screw fixation is not possible, making reconstruction of the lumbopelvic junction extremely challenging. A patient with an iliosacral chondrosarcoma with lumbar spine extension is presented in this report to illustrate a novel lumbopelvic spinal construct. Following combined external pelvectomy and hemisacrectomy with contralateral L3-5 hemilaminectomy and ipsilateral pediculotomy, bicortical transvertebral body screws were substituted for the missing pedicles, resulting in the creation of "false pedicles," which were further supplemented with an autologous vascularized fibular strut graft from the amputated lower limb and applied to the lateral aspect of the vertebral bodies. The creation of false pedicles allowed for a robust reconstruction of the lumbopelvic junction, including maintaining pelvic ring integrity with a "neo-pelvis", creating a functional load-bearing construct adequate for early mobilization and ambulation. The biomechanical dynamics of this unique construct are also discussed.
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Yamada Y, Laufer I, Cox BW, Lovelock DM, Maki RG, Zatcky JM, Boland PJ, Bilsky MH. Preliminary Results of High-Dose Single-Fraction Radiotherapy for the Management of Chordomas of the Spine and Sacrum. Neurosurgery 2013; 73:673-80; discussion 680. [DOI: 10.1227/neu.0000000000000083] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
En bloc wide-margin excision significantly decreases the risk of chordoma recurrence. However, a wide surgical margin cannot be obtained in many chordomas because they arise primarily in the sacrum, clivus, and mobile spine. Furthermore, these tumors have shown resistance to fractionated photon radiation at conventional doses and numerous chemotherapies.
OBJECTIVE:
To analyze the outcomes of single-fraction stereotactic radiosurgery (SRS) in the treatment of chordomas of the mobile spine and sacrum.
METHODS:
Twenty-four patients with chordoma of the sacrum and mobile spine were treated with high-dose single-fraction SRS (median dose, 2400 cGy). Twenty-one primary and 3 metastatic tumors were treated. Seven patients were treated for postoperative tumor recurrence. In 7 patients, SRS was administered as planned adjuvant therapy, and in 13 patients, SRS was administered as neoadjuvant therapy. All patients had serial magnetic resonance imaging follow-up.
RESULTS:
The overall median follow-up was 24 months. Of the 24 patients, 23 (95%) demonstrated stable or reduced tumor burden based on serial magnetic resonance imaging. One patient had radiographic progression of tumor 11 months after SRS. Only 6 of 13 patients who underwent neoadjuvant SRS proceeded to surgery. This decision was based on the lack of radiographic progression and the patient's preference. Complications were limited to 1 patient in whom sciatic neuropathy developed and 1 with vocal cord paralysis.
CONCLUSION:
High-dose single-fraction SRS provides good tumor control with low treatment-related morbidity. Additional follow-up is required to determine the long-term recurrence risk.
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Affiliation(s)
- Yoshiya Yamada
- Departments of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ilya Laufer
- Departments of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
- Departments of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Brett W. Cox
- Departments of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - D. Michael Lovelock
- Departments of Medical Physics, and Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Robert G. Maki
- Departments of Orthopedics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Joan M. Zatcky
- Departments of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Patrick J. Boland
- Department of Neurologic Surgery, Weill Cornell Medical College, New York, New York
| | - Mark H. Bilsky
- Departments of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
- Departments of Medicine, Pediatrics, and Orthopedics, Mount Sinai School of Medicine, New York, New York
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Weitao Y, Qiqing C, Songtao G, Jiaqiang W. Use of gluteus maximus adipomuscular sliding flaps in the reconstruction of sacral defects after tumor resection. World J Surg Oncol 2013; 11:110. [PMID: 23701700 PMCID: PMC3664623 DOI: 10.1186/1477-7819-11-110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 05/16/2013] [Indexed: 12/15/2022] Open
Abstract
Background While performing sacrectomy from a posterior approach enables the en bloc resection of sacral tumors, it can result in deep posterior peritoneal defects and postoperative complications. We investigated whether defect reconstruction with gluteus maximus (GLM) adipomuscular sliding flaps would improve patient outcomes. Methods Between February 2007 and February 2012, 48 sacrectomies were performed at He Nan Cancer Hospital, Zhengzhou City, China. We retrospectively examined the medical records of each patient to obtain the following information: demographic characteristics, tumor location and pathology, oncological resection, postoperative drainage and complications. Based on the date of the operation, patients were assigned to two groups on the basis of closure type: simple midline closure (group 1) or GLM adipomuscular sliding reconstruction (group 2). Results We assessed 21 patients in group 1 and 27 in group 2. They did not differ with regards to gender, age, tumor location, pathology or size, or fixation methods. The mean time to last drainage was significantly longer in group 1 compared to group 2 (28.41 days (range 17–43 days) vs. 16.82 days (range 13–21 days, P < 0.05)) and the mean amount of fluid drained was higher (2,370 mL (range 2,000–4,000 mL) vs. 1,733 mL (range 1,500–2,800 mL)). The overall wound infection rate (eight (38.10%) vs. four (14.81%), P < 0.05) and dehiscence rate (four (19.05%)] vs. three (11.11%), P < 0.05) were significantly higher in group 1 than in group 2. The rate of wound margin necrosis was lower in group 1 than in group 2 (two (9.82%) vs. three (11.11%), P < 0.05). Conclusions The use of GLM adipomuscular sliding flaps for reconstruction after posterior sacrectomy can significantly reduce the risk of infection and improve outcomes.
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Affiliation(s)
- Yao Weitao
- Bone and soft tumor department, He Nan Cancer Hospital, The Affiliated Hospital of Zheng Zhou University, 127 Dong Ming Road, Zheng Zhou City 450000, China.
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Clarke MJ, Dasenbrock H, Bydon A, Sciubba DM, McGirt MJ, Hsieh PC, Yassari R, Gokaslan ZL, Wolinsky JP. Posterior-Only Approach for En Bloc Sacrectomy. Neurosurgery 2012; 71:357-64; discussion 364. [DOI: 10.1227/neu.0b013e31825d01d4] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
En bloc resection of primary sacral tumors has a demonstrated survival benefit. Total and high sacral amputations are traditionally performed by using a staged anterior and subsequent posterior approach. However, we have found that en bloc resection and biomechanical reconstruction of the spinal column is possible from a posterior-only approach in many cases.
OBJECTIVE:
To assess our series of posterior-only sacrectomies, emphasizing postoperative complications and overall surgical and oncologic outcome.
METHODS:
Sixty-nine consecutive patients underwent sacral resections for tumor at our institution between 2004 and 2009. Medical records of all patients were reviewed, and patients were excluded if they had an intentional intralesional resection, hemipelvectomy, or a previous operation. The records of the resulting 36 consecutive patients who underwent primary posterior-only en bloc sacral resections were retrospectively reviewed.
RESULTS:
Of the posterior-only patients, all underwent midline posterior approaches for en bloc sacral resection. Sacral amputation was defined by the by sacral root preservation: total (2 cases), high (8 cases), middle (9 cases), low (12 cases), and distal (5 cases). Chordoma was the most common tumor type (30 cases), and surgical margins were marginal in 34 cases and contaminated in 2. Overall, there were 13 complications, including 9 wound infections/revisions. The extent of sacrectomy, and thus the extent of roots sacrificed, correlated with functional outcome.
CONCLUSION:
It may be possible to perform a posterior-only approach to en bloc sacral resections/reconstructions in patients with tumors that do not extend beyond the lumbosacral junction or invade the bowel requiring bowel resection and diversion.
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Affiliation(s)
| | | | - Ali Bydon
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Daniel M. Sciubba
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Patrick C. Hsieh
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Reza Yassari
- Albert Einstein College of Medicine, Bronx, New York
| | - Ziya L. Gokaslan
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jean-Paul Wolinsky
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
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