Rectus Abdominis Myocutaneous Flap Research Articles

Post-reconstruction dermatitis of the breast

Approximately one-third of women diagnosed with breast cancer undergo mastectomy with subsequent implant-based or autogenous tissue-based reconstruction. Potential complications include infection, capsular contracture, and leak or rupture of implants with necessity for explantation. Skin rashes are infrequently described complications of patients who undergo mastectomy with or without reconstruction. A retrospective analysis of breast cancer patients referred to the Dermatology Service for diagnosis and management of a rash post-mastectomy and expander or implant placement or transverse rectus abdominis myocutaneous (TRAM) flap reconstruction was performed. Parameters studied included reconstruction types, time to onset, clinical presentation, associated symptoms, results of microbiologic studies, management, and outcome. We describe 21 patients who developed a rash on the skin overlying a breast reconstruction. Average time to onset was 25.7 months after expander placement or TRAM flap reconstruction. Clinical presentations included macules and papules or scaly, erythematous patches and plaques. Five patients had cultures of the rash, which were all negative. Skin biopsy was relatively contraindicated in areas of skin tension, and was reserved for non-responding eruptions. Treatments included topical corticosteroids and topical antibiotics, which resulted in complete or partial responses in all patients with documented follow-ups. Our findings suggest that tension and post-surgical factors play a causal role in this hitherto undescribed entity: "post-reconstruction dermatitis of the breast." This is a manageable condition that develops weeks to years following breast reconstruction. Topical corticosteroids and antibiotics result in restoration of skin barrier integrity and decreased secondary infection.

Deep Inferior Epigastric Perforator Versus Free Transverse Rectus Abdominis Myocutaneous Flap: Complications and Resource Utilization.

Abdominal based breast reconstruction exists in a continuum from pedicled transverse rectus abdominis myocutaneous (TRAM) flap to deep inferior epigastric perforator (DIEP) free flap. DIEP flap has the advantage of complete rectus abdominis sparing during harvest, thus decreasing donor site morbidity. Aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes versus the free TRAM flap (fTRAM). We reviewed the Nationwide Inpatient Sample database (2010-2011) for all cases of DIEP and fTRAM breast reconstruction. Inclusion criteria were: female sex and patients undergoing DIEP or fTRAM total breast reconstruction. Male sex was excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay, and total charges (TCs). Bivariate and multivariate analyses were performed to identify independent risk factors of increased length of stay and TCs. Fifteen thousand eight hundred thirty-six cases were identified. Seventy percent were white, 97% were insured, and 83% of patients were treated in an academic teaching hospital setting. No mortalities were recorded. The DIEP cohort was more likely to be obese (P = 0.001). Free TRAM cohort was more likely to suffer pneumonia (P < 0.001; odds ratio [OR], 3.7), wound infection (P = 0.001; OR, 1.7), and wound dehiscence (P < 0.001; OR, 4.3). Type of reconstruction did not appear to affect risk of revision, hemorrhage, hematoma, seroma, or flap loss. Total charges were higher in the DIEP group (P < 0.001). Multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (P < 0.001; OR, 1.6), and DIEP was an independent risk factor for increased TCs (P < 0.01; OR, 1.5). There was no significant difference in postoperative complications. The fTRAM cohort was more likely to develop surgical site complications and have an increased length of stay, but TCs were higher for the DIEP group.

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center. A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption. In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre-enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre-enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6). The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day. Therapeutic, III.

Pyoderma gangrenosum with pathergy: A potentially significant complication following breast reconstruction

The failure of postoperative surgical site infection to resolve after appropriate antibiotic therapy should alert the clinician to other diagnoses. Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis that is typically characterized by necrotizing ulceration. PG can be exacerbated by minor trauma leading to exaggerated skin injury, a condition known as pathergy. We present a case series of PG arising after immediate reconstruction for breast oncological surgery from 1st January 2006 to 1st September 2014. 395 immediate breast reconstructions were performed in 335 patients. Three cases of post-surgical PG were identified (0.9%), all in the setting of mastectomy for breast cancer. Two cases underwent immediate reconstruction with pedicled transverse rectus abdominus myocutaneous flaps, and one underwent submuscular expander insertion. A mean delay of 6.3 days was observed from first presentation of symptoms to diagnosis of PG. Immunosuppressants commonly used included methylprednisolone, prednisone, and ciclosporin, with good success at halting disease progress. Significant scarring affected all three women. Once the disease was deemed quiescent, intravenous immunoglobulin used in the perioperative period for further surgical procedures provided favorable results. A diagnostic algorithm is suggested to guide surgeons in investigations and management when post-surgical PG is suspected.

Management of the extensive thoracic defects after deep sternal wound infection with the rectus abdominis myocutaneous flap: A retrospective case series.

Deep sternal wound infection is a severe complication after open heart surgery. According to the different severity and dimensions of the deep sternal wound infection, the treatment method is different. In this study, we aimed to describe our experience with the rectus abdominis myocutaneous flap for large sternal wound management, especially when 1 or 2 internal mammary arteries were absent.Between October 2010 and January 2016, a retrospective review of 9 patients who suffered from the extensive thoracic defects after deep sternal wound infection was conducted. All of these sternal defects encompassed almost the full length of the sternum after debridement. Defect reconstruction was achieved by covering with a rectus abdominis myocutaneous flap. When the ipsilateral or bilateral internal mammary artery had been harvested previously, we took advantage of the inferior epigastric artery to provide additional blood supply to the rectus abdominis myocutaneous flap. Thus, this flap had a double blood supply.There was no recurrent infection in all 9 patients. Three patients received the rectus abdominis myocutaneous flap with a double blood supply. Flap complications occurred in 2 patients (22%). One patient who did not have the double blood supply flap suffered from necrosis on the distal part of the flap, which was then debrided and reconstructed with a split-skin graft. The other patient had a seroma at the abdomen donor site and was managed conservatively. None of the patients died during the hospital stay.This study suggests that the rectus abdominis myocutaneous flap may be a good choice to repair the entire length of sternal wound. When 1 or 2 internal mammary arteries have been harvested, the inferior epigastric artery can be anastomosed to the second intercostal artery or the internal mammary artery perforator to provide the rectus abdominis myocutaneous flap with a double blood supply.

Opportunistic Biopsy of Internal Mammary Lymph Nodes During Immediate Breast Reconstruction After Mastectomy for Breast Malignancies.

This study was designed to explore the clinicopathological factors associated with internal mammary lymph node (IMN) metastasis in radiologically IMN-negative breast malignancies and to discuss the clinical value of opportunistic biopsy during immediate breast reconstruction using free flaps, where the internal mammary vessels are the recipient. We retrospectively reviewed patients who received curative total mastectomy for breast malignancy followed by immediate reconstruction using transverse rectus abdominis myocutaneous (TRAM) free flap. Suspicious lymph nodes encountered during dissection of the third intercostal space for the recipient vessels were biopsied. Clinicopathological variables and the clinical impact associated with IMN metastasis were analyzed. Among 269 patients who underwent immediate reconstruction using a TRAM free flap, suspicious lymph nodes were identified and biopsied in 54 (20.1%) patients, and IMN metastasis was confirmed in 12 (22.2%) of these (4.5% of all reconstructions). Five patients were positive despite negative axillary lymph nodes and 11 underwent therapeutic plan modifications. Multivariate analysis revealed that IMN metastasis was independently associated with medial tumor location, invasive tumor >2 cm, and positive human epidermal growth factor receptor-2 status (P<0.05). Aggressive IMN evaluation and biopsy in a subset of patients during immediate breast reconstruction using a TRAM free flap provided an additional opportunity for accurate breast cancer staging and appropriate adjuvant treatment, while minimizing unnecessary complications.

P308 - Donor site complications and remnant of rectus abdominis muscle status following transverse rectus abdominis myocutaneous flap reconstruction

P308 - Donor site complications and remnant of rectus abdominis muscle status following transverse rectus abdominis myocutaneous flap reconstruction

Long-standing Crohn’s disease and its implication on anal squamous cell cancer management.

576 Background: Anal squamous cell carcinoma (ASCC) is rare, accounting for 1% of gastrointestinal malignancies, but the incidence is rising. Risk factors for the development of ASCC in patients with Crohn’s disease (CD) include immunotherapy, increased duration of disease, and chronic fistulizing perianal disease. We sought to understand management strategies for ASCC in the setting of CD. Methods: A retrospective review from 2001-2016 was conducted for ICD-9/10 codes pertaining to Crohn’s disease (CD) (555.9/ K50) and ASCC (154.3/C44.520). Adult patients with a diagnosis of CD at the time of ASCC diagnosis were included. Results: A total of 7 patients (5 female) were included with a median age of 50 years. The majority presented with perianal pain (4) and bleeding (3). The mean duration of CD was 20 years, and all patients had perianal disease for &gt; 10 years. Five patients had perianal fistulizing disease at the time of ASCC presentation. Clinical stage at diagnosis of ASCC was stage 0 (n = 1), I (n = 1), II (n = 1), III (n = 2), IV (n = 1), and unknown (n = 1). All patients were treated with Nigro protocol which included radiation (50-55Gy), 5-fluorouracil, and mitomycin; 1 patient received cisplatin due to concurrent Non-Hodgkin’s Lymphoma. Three patients required fecal diversion during radiation due to significant perianal disease. Two patients experienced complications related to radiation including anal and vaginal stenosis and an anovaginal fistula. One additional patient required an APR with rectus abdominis myocutaneous flap for uncontrolled CD after treatment. During follow-up, 3 of the 7 patients undergoing definitive chemoradiation developed residual or recurrent disease and required salvage APR. All patients were alive at last follow-up, 2 with metastatic disease. 5-year disease free survival was 56%. Conclusions: Patients with ASCC in the setting of CD may be managed with the standard Nigro protocol, but complications from radiation are common in this setting. Three of seven patients required salvage surgery for residual or recurrent disease, and an additional patient required APR for palliation of CD symptoms. Given the aggressive nature of ASCC in this population, surveillance guidelines are necessary.

Groin and thigh reconstructions with pedicled rectus abdominis myocutaneous flaps.

Resection of tumors from the groin and thigh regions with safe margins often results in significant soft tissue defects, which preclude primary closure. This study presents a series of rectus abdominis myocutaneous flaps for irradiated thigh and groin wounds with the purpose of evaluating the efficacy and outcomes of these flaps in this population. From 2008 to 2015, all patients who underwent resection of thigh or groin region tumors and reconstruction with an inferiorly based rectus abdominis myocutaneous flap were retrospectively identified. Medical records of the patients were reviewed. A total of 27 patients, aged 20-67 years, were operated on for defects in the groin and upper thigh region. Nine patients underwent immediate reconstruction. The remaining 18 patients underwent late reconstruction. There was neither total flap loss nor partial flap loss. We chose to utilize 15 ipsilateral and 12 contralateral pedicles. The mean length of stay in hospital was 13.7 days. A rectus abdominis myocutaneous flap can be successfully used in patients with groin and upper thigh defects due to its predictable and robust vascular supply, bulky muscle content, wide arc of rotation, and large skin island.

A Comparison of Perioperative Blood Transfusions and Other Complications Following Transverse Rectus Abdominis Myocutaneous Flaps versus Deep Inferior Epigastric Perforator Flaps

Objective: Abdominal based free flaps such as the Transverse Rectus Abdominis Myocutaneous (TRAM) flap and Deep Inferior Epigastric Perforator (DIEP) flap are essential tools in the reconstructive armamentarium post mastectomy. These reconstructions are often prolonged, complex and associated with complications. This study aims to compare the complication rate, particularly focusing on perioperative transfusions, between TRAM and DIEP flaps performed by the senior author in our tertiary referral centre. Methods: A retrospective review was conducted of one hundred and seven consecutive TRAM and DIEP flaps from 2000 to 2014. The two groups were analysed for demographics, preoperative risk factors and post-operative complications including blood transfusions, haematomas, flap losses, redo-anastomoses, flap infections, abdominal wound sequelae and non-surgical complications. Results: Sixty-three patients underwent 67 free/muscle sparing TRAM flaps and 35 patients underwent 40 DIEP flaps. There were no statistically significant differences in patient demographics or preoperative risk factors between the two groups. Five TRAM flap cases (7.9%) required transfusion whilst no DIEP flap cases required transfusion. This difference was not found to be statistically significant (p = 0.16). However, free/muscle-sparing TRAM flaps were found to have a significantly higher overall complication rate compared to DIEP flaps (23.8% vs. 5.7%, p = 0.02). Conclusion: The current study demonstrated no difference in perioperative transfusion requirement between TRAM and DIEP cases. There was however a significantly higher rate of overall complications associated with TRAM flaps warranting the authors to conclude that care be taken when opting for this reconstructive method.

Pedicled and free flaps for intrathoracic fistula management.

Intrathoracic fistulae are among the potential sequelae of radiation therapy, empyema and abscess clearance and surgical tumour resections. Interdisciplinary plastic-reconstructive flap surgery is a helpful tool for the successful treatment of intrathoracic fistulae. From February 2006 to April 2016, 13 patients (3 females and 10 males) underwent flap surgery for bronchial (n = 5), tracheal (n = 2), oesophageal (n = 2), post-pneumonectomy bronchopleural fistula (n = 2), tracheo-oesophageal (n = 1), gastrobronchial (n = 1) and oesophagobronchial (n = 1) fistulae. Patient characteristics, identified pathogenic micro-organisms, treatment and decision criteria, long-term outcome and postoperative complications were evaluated by analysing patient charts and surgical reports. The mean age of the 13 patients who underwent reconstructive surgery was 55.5 years (range: 42-66 years). The median follow-up time was 31.4 months (range: 2-96 months). American Society of Anaesthesiologists classification was II for 1 patient, III for 8 patients and IV for 4 patients. In total, 18 flaps were performed (7 latissimus dorsi pedicled flaps, 7 pectoralis major pedicled flaps, 2 rectus abdominis myocutaneous flaps, 1 free temporo-parietal fascia flap and 1 intercostal muscle flap). A second flap was indicated in 5 cases (38.5%) due to fistula recurrence; of these, 1 patient developed a bronchial fistula after successful reconstruction of a gastrobronchial fistula. Eight of the 13 patients (61.5%) were evaluated postoperatively at regular intervals for at least 1 year and showed no signs of fistula recurrence. Our study showed that plastic-reconstructive flap surgery, although associated with significant morbidity and mortality, can be a life-saving tool for intrathoracic fistula reconstruction. DRKS00010447.

Three-layer primary closure of the bipedicled TRAM flap donor site for unilateralbreast reconstruction: a 15-year experience with 124 consecutive patients.

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains widely used as a breast reconstruction technique. The bipedicled TRAM flap is not as preferable as it was formerly, mainly because of its donor site complications. However, in a number of situations, a bipedicled TRAM flap may be the only alternative. Therefore, a three-layer primary closure technique used with bipedicled TRAM flap breast reconstructions that can avoid donor site complications without using a mesh is presented. A retrospective study was performed that included patients who underwent bipedicled TRAM flap breast reconstruction with the three-layer primary closure technique. Between 2000 and 2015, 124 breast reconstruction patients were reviewed for donor site morbidity. During the 15-year study period, 106 patients had conventional bipedicled TRAM flaps and 18 had bipedicled TRAM flaps with a surgical delay procedure. For all groups, none of the patients developed abdominal wall hernia, but three patients had bulging. Partial flap loss was the most common flap complication, present in 6 flaps (4.8%). The suturing technique studied provided abdominal wall closure without the use of a mesh even when utilizing a bilateral pedicle with very low complication rates.

A New Method of Umbilical Transposition : The Combination of Sandglass Style Incision and Horizontal H-shaped Incision with Elevating Rectus Abdominis Myocutaneous Flap

A New Method of Umbilical Transposition : The Combination of Sandglass Style Incision and Horizontal H-shaped Incision with Elevating Rectus Abdominis Myocutaneous Flap

術前化学療法により扁平上皮癌から形質転換が疑われた舌紡錘細胞癌の1例

There have been few reports on cases of spindle cell squamous cell carcinoma of the oral cavity. In this paper, we report a case of spindle cell squamous carcinoma arising in the tongue. A 76-year-old male with tongue squamous cell carcinoma was referred to our hospital. After two courses of neoadjuvant chemotherapy, subtotal resection of the tongue, unilateral radical neck dissection, and reconstruction with free transverse rectus abdominis myocutaneous flap were performed. Pathological diagnosis of the surgical specimen was spindle cell squamous carcinoma （pT3N0M0, Stage Ⅲ）. Recurrence of primary tumor was detected about four months after the operation and it showed extremely rapid growth. Palliative radiotherapy （two courses with 24Gy/8 fractions and 20Gy/5fractions） effectively controlled the patient’s quality of life. It is thought that although spindle cell squamous carcinoma clinically shows a response to radiotherapy or chemotherapy, some tumor cells （low sensitivity cancer stem cells） may resist and survive. So, radical resection with wider surgical free margin may be essential.

Pedicled transverse rectus abdominis myocutaneous flap: A method for tunnelling with Dilson Luz vascular dilation wands for breast reconstruction.

Pedicled transverse rectus abdominis myocutaneous flap: A method for tunnelling with Dilson Luz vascular dilation wands for breast reconstruction.

The Effects of Perioperative Tamoxifen Therapy on Microvascular Flap Complications in Transverse Rectus Abdominis Myocutaneous/Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Tamoxifen is an important adjunct therapy in breast cancer treatment; however, it has been implicated in increasing microvascular flap complications. Current recommendations on stopping tamoxifen are conflicting and do not address tamoxifen therapy that is continued perioperatively. The purpose of this study is to determine whether tamoxifen taken at the time of free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap breast reconstruction affects thrombotic complication rates. A retrospective review of microvascular breast reconstruction with TRAM/DIEP flaps over the last 20 years was carried out at a single institution. Patients were divided into 2 cohorts: those receiving tamoxifen at the time of reconstruction (tamoxifen cohort) and those not taking tamoxifen (control). Demographic information, procedural characteristics, and rates of microvascular flap complications were compared. Forty-three patients (56 flaps) received tamoxifen at the time of microvascular breast reconstruction, and 185 patients (267 flaps) did not. Patients in the tamoxifen cohort had a lower mean age of 48.9 years (P = 0.013). A greater percentage of patients in the tamoxifen cohort had preoperative radiation (P < 0.0001) and chemotherapy (P = 0.018) and underwent delayed reconstruction (P < 0.0001). There were no significant differences between the 2 cohorts with regard to flap complications including both arterial and venous thrombosis, flap failure, and other local flap complications. Patients receiving tamoxifen during TRAM/DIEP flap breast reconstruction did not have increased rates of flap thrombosis or failure; therefore, stopping tamoxifen prior to these procedures may not be necessary.

Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center: Is There a Significant Difference Between Immediate and Delayed?

There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population. A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes. Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications (P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey. Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module.

The protective effect of cilostazol on transverse rectus abdominis myocutaneous flap in rats

Objective: Transverse Rectus Abdominis Myocutaneous (TRAM) flap is commonly used in breast reconstruction. The aim of this study is to demonstrate the effects of cilostazol on TRAM flap viability in a rat TRAM model.Methods: Twenty-four Wistar rats were used. They were divided into four groups. Rats in Group 1 were applied TRAM flap. In Group 2, cilostazol 30 mg/kg was administered to rats via oral gavage 3 hours before the flap surgery. After the flap surgery, cilostazol 30 mg/kg was administered via oral gavage twice a day for 7 days. In Group 3 before the flap surgery, cilostazol 30 mg/kg was administered via oral gavage twice a day for 7 days, and treatment continued for 7 more days after the flap surgery. In Group 4 before the flap surgery, cilostazol 30 mg/kg was administered via oral gavage twice a day for 7 days and treatment was discontinued after the flap surgery.Result: The mean necrosis rate in Group 1 was 41.69%, in Group 2 it was 27.0%, in Group 3 it was 6.66%, and in Group 4 it was 11.2%. The necrosis rate in Group 1 was found to be statistically significantly higher than other groups (p < .01), the necrosis rate in Group 2 was found to be statistically significant higher than Groups 3 and 4 (p < .01), and the necrosis rate in Group 4 was found to be statistically significant higher than Group 3 (p < .01).Conclusion: Cilostazol treatment seemed to increase the viability of TRAM flap, especially when administered as adjuvant therapy.

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

Phantom rectum is the sensation of an intact and/or functioning rectum, despite excision at surgery. Abdominoperineal excision of the rectum (APER) may be complemented by reconstructive operations and recently it was reported that patients undergoing APER and vertical rectus abdominis myocutaneous (VRAM) flap reconstruction are more prone to develop phantom sensations at an earlier timeframe and have more persistent symptoms than those who do not have perineal repairs. The aim of this study was to determine the prevalence of phantom rectal sensations in a cohort of these patients. Patients who underwent APER and VRAM flap reconstruction for anorectal carcinomas were identified from May 2008 to July 2012. Patients completed a questionnaire evaluating their experience of rectal symptoms post-surgery. Thirty-four of 47 eligible patients were enrolled in the study. PR sensations were experienced by 50% of patients, the majority of which (65%) were present for >1year. The commonest sensation reported was the feeling of faeces in a normal rectum (24%). Disturbances in quality of life were apparent in 44%; notably, sleep was affected, patients expressed increased feelings of stress/sadness, heightened levels of anxiety and limitation of daily activities as consequences of PR symptoms. Few patients sought medical advice. Fifty percent of patients experience PR sensations post-surgery, comparable with reported data for patients who have undergone APER alone. The addition of VRAM reconstruction does not significantly alter the prevalence of PR symptoms. This paper provides further evidence that phantom rectum occurs frequently and thus all patients undergoing excision of the rectum should be counselled appropriately.

Limb-sparing surgery with vascular reconstruction for malignant lower extremity soft tissue sarcoma

BackgroundThe standard of care for lower extremity soft tissue sarcoma (STS) is limb-sparing surgery. A small subset of these patients will require concomitant vascular reconstruction to ensure adequate resection and to preserve limb viability and function. The aim of this study was to evaluate outcomes in these patients with respect to wound healing and postoperative functional status. MethodsOutcomes for a total of 154 patients treated for malignant lower extremity STS during an 8-year period between 2005 and 2013 were entered in a prospective registry. Treatment was by medical management in 3 patients (2%), limb-sparing surgery with vascular reconstruction (LSVR) in 9 patients (6%), and limb-sparing surgery without vascular reconstruction (LS) in 142 patients (92%). The registry and patient records and the intraoperative records were consulted to determine the primary outcomes of patient survival and time for complete wound healing. The functional status of patients was assessed using the Musculoskeletal Tumor Society (MSTS) functional assessment score before surgery and at 6 and 12 months after surgery. ResultsMean follow-up time was 74.7 months for the LSVR group and 53.4 months for the LS group. The mean time to complete wound healing was significantly longer in LSVR vs LS patients (88 days vs 34 days, respectively; P = .002), and overall survival was lower in LSVR patients (P = .01). Seven of the 9 LSVR patients required a total of 12 additional procedures to achieve wound healing, including 9 procedures to drain seromas (incision and drainage) with vacuum-assisted closure in 4 cases. Plastic surgery intervention was required in three patients, including one skin graft, one gracilis pedicle flap, and one vertical rectus abdominis myocutaneous flap. There was no significant difference in the mean MSTS scores preoperatively, at 6 months, and at 1 year after surgery between the two groups (27, 25, and 29 for LSVR vs 28, 31, and 31 for LS, respectively; P = .63, .11, and .67, respectively). ConclusionsThe need for vascular reconstruction during limb-sparing surgery for lower extremity malignant STS is rare in a high-volume sarcoma center. Overall survival was lower in these patients, and the time to complete wound healing is prolonged and requires multiple secondary interventions. However, postoperative functional status as assessed by the MSTS is acceptable and comparable to that of patients not requiring vascular reconstruction.