Surgical management of pressure ulcers in spinal cord injury patients

BACKGROUND

Pressure ulcers (PU) are a common yet debilitating injury within the spinal cord injury (SCI) population. This retrospective data analysis is intended to identify the contributing factors, review the current management protocol, and risk of recurrence of PU in SCI patients at Victoria's state referral centre for traumatic spinal cord injuries.

METHODS

A retrospective audit of the medical records of SCI patients with pressure ulcers was conducted for the period of January 2016 to August 2021. Patients aged 18 years and older who presented for surgical management of their PU were included in the study.

RESULTS

Among the 93 patients who met the inclusion criteria, there were a total of 195 surgeries for 129 PU. Ninety-seven percent were classified as grade of 3 or 4 and 53% had osteomyelitis on presentation. 58% were either current smokers or ex-smokers, and 19% were diabetic. Debridement alone was the most common type of surgical management (58%), followed by flap reconstruction (25%). Those who underwent flap reconstruction were admitted for 71 days longer, on average. 41% of the surgeries were associated with a post-operative complication, with the most prominent being an infection at 26%. Of the 129 PU, 11% recurred at least 4 months post initial presentation.

CONCLUSION

There are a multitude of a factors that impact prevalence, surgical complications, and recurrence of PU. This study provides insight into these factors to review our current practices and optimize surgical outcomes in the management of PU in the SCI population.

Health-related Quality of Life Measurement Tools for Lymphedema: A Review of the Literature

Lymphedema can significantly affect patients' health-related quality of life (HRQoL). Various quality of life scales have been developed to assess the extent of the disease burden. The purpose of this study is to review various HRQoL instruments that have been used in lymphedema studies and compare their qualities against the COSMIN checklist.

Methods

A systematic literature review search was conducted for clinical lymphedema studies published between January 1, 1984, and February 1, 2020, using Pubmed database. All clinical lymphedema studies which used HRQoL instruments as outcome measures were identified.

Results

One thousand seventy-six studies were screened-of which, 288 studies were individually assessed. Thirty-nine HRQoL instruments were identified in these clinical lymphedema studies. Of these, there are eight lymphedema-specific questionnaires that cover all HRQoL domains, all of which have been validated for use in lymphedema. We contrasted the two most popular questionnaires [LYMQOL and Upper Limb Lymphedema (ULL)-27] and compared their features.

Conclusion

There is currently no ideal lymphedema HRQoL measurement tool available based on the COSMIN criteria. However, our review suggested that LYMQOL and ULL-27 are the most used and most validated instruments at present, but each has their own limitations. We recommend the use of LYMQOL and ULL-27 for future studies to allow direct HRQoL comparison to current literature. Further research is required to develop an optimal HRQoL questionnaire that can ultimately become the gold standard HRQoL instrument for lymphedema.

Experience with NovoSorb® Biodegradable Temporising Matrix in reconstruction of complex wounds

BACKGROUND

The NovoSorb® Biodegradable Temporising Matrix (BTM) is a synthetic polyurethane dermal matrix used to reconstruct complex wounds including deep dermal and full-thickness burns, necrotising fasciitis and free flap donor site. We hope to further explore its potential applications in this series.

METHODS

Patients who received BTM application across four centres over an 18-month period were included. Patients were followed up to assess BTM and graft take, the aesthetic, the return of sensation and complications.

RESULTS

A total of 27 patients with 35 wounds were identified with a range of aetiologies. Thirty-three wounds had 100% integration of BTM at the time of sealing membrane removal. Seven wounds had partial graft loss that later healed by secondary intention. In two cases, re-epithelialisation occurred with BTM alone without split-skin graft.

CONCLUSION

BTM offers a safe and reliable reconstructive option in challenging wounds that would otherwise require more complex operations.

Neoadjuvant radiotherapy for locally advanced and high-risk breast cancer

INTRODUCTION

Neoadjuvant radiotherapy (NART) as part of a multi-modality approach for locally advanced breast cancer (LABC) requires further investigation. Importantly, this approach may allow for a single-staged surgical procedure, with mastectomy and immediate autologous reconstruction. Multiple other potential benefits of NART include improved pathological downstaging of breast disease, reduced overall treatment time, elimination of time period with breast tissue deficit and improved patient satisfaction.

METHODS

This is a retrospective multi-institutional review of patients with LABC and high-risk breast disease undergoing NART. Eligible patients sequentially underwent neoadjuvant chemotherapy (NACT) with or without HER2-targeted therapy, NART, followed by mastectomy with immediate autologous breast reconstruction (BR) 4- to 6 weeks post-completion of radiotherapy. Patient and tumour characteristics were analysed using descriptive statistics. Surgical complications were assessed using the Clavien-Dindo Classification (Ann Surg 2004; 240: 205).

RESULTS

From 3/2013 to 9/2019, 153 patients were treated with NART. The median age was 47 years (IQR 42-52), with median body mass index of 27. Eighteen patients experienced Grade 3 acute surgical complications. This included 13 Grade 3B breast-site events and 9 Grade 3B donor-site events, where further surgical intervention was required for management of wound infection, wound dehiscence, flap or mastectomy skin necrosis, haematoma and internal mammary venous anastomotic thrombosis. No autologous flap loss was observed.

CONCLUSION

Neoadjuvant radiotherapy facilitates a single-stage surgical procedure with mastectomy and immediate autologous BR, eliminating the delay to reconstructive surgery and thus shortening a woman's breast cancer journey. The findings of this review support the use of NART, with comparable rates of surgical complications to standard sequencing.

Reconstructing ‘dual-defect’ pressure sores in spinal patients

Background: Recurrent pressure sores and unstable scars over the bony prominences of the greater trochanter and ischium are a troublesome sequela of spinal injury. A reliable reconstruction is needed for patients with ‘dual-defect’ pressure sores in these locations. We modified the pedicled anterolateral thigh (ALT) flap to fit the reconstructive requirements of ‘dual-defect’ pressure sores.Methods: Eleven consecutive patients with concurrent pressure sores (> grade III) or unstable scar in one of the ‘dual-defect’ areas and an active pressure sore in the other were identified from the Victorian state tertiary referral centre for spinal injuries. We describe the technique and clinical experience of pedicled ALT flaps for reconstruction of ‘dual-defect’ pressure sores in this patient cohort. Preoperative status and minor and major postoperative complications were recorded. Results: Eleven consecutive pedicled myocutaneous ALT flaps were performed for reconstruction of ‘dual-defect’ pressure sores. Several key variations in the anatomical landmarks and the intra-operative flap raise technique that are integral to the use of the ALT flap for this application are described herein. The average dimensions of the cutaneous pressure sore defects were 6 x 4.9 cm (greater trochanter) and 8.2 x 6.7 cm (ischial). The average dimensions of the cutaneous paddle of the flaps raised were 27.3 x 8.4 cm. Two postoperative complications necessitated return to theatre but no incidences of flap loss were recorded. Conclusions: The modified pedicled myocutaneous ALT provides a robust reconstructive solution for resurfacing ‘dual-defect’ pressure sores in spinal patients. Further recommendations for future technical adaptations are made.

Neoadjuvant Radiotherapy: Changing the Treatment Sequence to Allow Immediate Free Autologous Breast Reconstruction

BACKGROUND

 Locally advanced breast cancer (LABC) is traditionally treated with a multimodal approach of chemotherapy, surgery, and postmastectomy radiotherapy (PMRT). The advantages of immediate breast reconstruction (IBR) are well described and include improved aesthetic outcomes, fewer surgical procedures, shorter treatment period, and a higher quality of life. However, this sequence makes immediate free autologous reconstruction more challenging as PMRT can have deleterious and unpredictable effects on the flap. We have reversed this treatment sequence with neoadjuvant chemotherapy and radiotherapy, followed by mastectomy and immediate free autologous reconstruction. To our knowledge, this is the first series to assess the outcomes of neoadjuvant radiotherapy on immediate free microvascular breast reconstruction.

METHODS

 A review of patients with LABC who underwent immediate free autologous breast reconstruction post neoadjuvant chemoradiotherapy between 2013 and 2017 was conducted. All reconstructions were performed by a single reconstructive team. The primary end points were flap failure and surgical complications. Secondary end points were pathological response rate and disease recurrence.

RESULTS

 A total of 40 women with an average age of 48.1 (36-61) and average body mass index of 25.6 (18-37) were included. The most common choice of flap was immediate deep inferior epigastric perforator (DIEP, 31), followed by transverse or diagonal upper gracilis (5), muscle-sparing transversus abdominis (3), and stacked DIEP (1). Our major complication rate was 12.5% and minor complication 15%. There were no cases of local recurrence and only three cases (7.5%) of distant disease progression.

CONCLUSION

 From our experience, this treatment sequence allows patients to have an immediate gold standard reconstruction without an increase in surgical morbidity. It affords the benefits of IBR without concern in delaying adjuvant therapy and appears to be safe from an oncological perspective.

Abstract P2-11-16: The safety and pathological impact of neoadjuvant radiotherapy for local advanced breast cancer undergoing mastectomy and autologous reconstruction

Introduction

Delayed breast reconstructions are preferred if post mastectomy radiotherapy is indicated due to lower complication rates compared to immediate permanent implant or autologous reconstructions (AR) but cosmetic outcomes are inferior. Radiotherapy has a deleterious effect on implants and autologous tissue and often an interim tissue expander is place which has inherent pain and complications.

However, neoadjuvant radiotherapy (NART) prior to surgery allows for definitive oncological surgery to be performed with an immediate AR in a single operation and the avoidance of a temporary expander. The aim of this study is to assess the safety and downstaging impact of NART.

Methods

This is a prospective review of patients who underwent NART at GenesisCare Victoria, the Austin and the Alfred hospital. 59 LABC patients (median age 49.2 years) were divided into two groups; clinically staged and pathologically staged for reporting. There were 15 pathologically staged patients (pStage 2A-3C) and 43 clinically staged patients (cStage 2A-3B). All patients initially underwent NACT, followed by NART (median dose 50.4Gy in 28 fractions) to the breast, supraclavicular fossa and level 3 axilla with or without coverage of their Level 1 and 2 axilla, and/or internal mammary nodes. Approximately 6 weeks after completing NART, patients underwent definitive surgery and AR.

Results

All patients completed their NART with minimal toxicity and no break in treatment. 55 patients had a skin-sparing mastectomy (SSM) and 3 patients had a modified radical mastectomy. All clinically staged patients underwent an AD. ARs with a DIEP flap were performed in the majority of patients (51). The average length of hospitalisation was 6.2 days.

The Miller Payne (MP) scoring index was used to record pathological responses in clinically staged patients. Overall 36 patients achieved significant downstaging of their disease, with MP scores of 5/5 for 20 and 4/5 for 16. Only 1 patient failed to achieve any downstaging with a MP score of 1/5. All 12 Her2 positive patients, 3/5 Triple negative patients and 5/26 Luminal A/B patients achieved a MP score of 5/5. All patients achieved R0 resection margins. This included 6 patients who had initial cT4 disease (cT4a X2, cT4b X1 and cT4d X3). 15 patients had initial cN2/3 disease and all successfully underwent their axillary dissections with R0 resections achieved. 10/15 had no involved axillary nodes with significant scarring seen in 6. 5/15 had residual involved nodes with significant scarring seen in 3 patients.

Post surgical toxicities were graded using Clavien-Dindo classification. 8 significant grade 3 toxicities were seen in 6 patients, with no grade 4 or 5 toxicities. No patients developed DVT or PE. No flap losses were seen.

Median follow up is 23 months. Cosmesis was rated as good to excellent in all cases. 1 patient developed simultaneous loco-regional and distant recurrence with another 3 patients developing distant metastases only.

Conclusion

This review demonstrated that NART is a safe technique, which has not lead to an increase in surgical complication rates or resulted in a detriment in cosmetic outcome. NART can achieve a shorter, simpler reconstructive journey for patients.

Citation Format: Baker C, Chao MW, Jassal S, Neoh D, Bevington E, Hyett A, Grinsell D, Loh SW, Zantuck N, Stoney D, Foley C, Law M, Chew G, Yu V, Cheng M, Guerrieri M, Taylor K, Chipman M, Cokelek M, Lim Joon D, Foroudi F. The safety and pathological impact of neoadjuvant radiotherapy for local advanced breast cancer undergoing mastectomy and autologous reconstruction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-16.