Limb-salvage surgery with vascular reconstruction after lower extremity sarcoma resection: A systematic review and meta-analysis.

BACKGROUND: Limb-salvage surgery with vascular reconstruction is the current standard treatment when sarcoma involves major vessels of the lower extremity. However, the low incidence of sarcoma and rarity of limb-salvage surgery are limiting factors for the reliable study of limb-salvage surgery. Therefore, a systematic review was conducted to establish better management of lower extremity sarcoma based on currently available evidence. METHODS: A systematic review and meta-analysis of data on limb-salvage surgery with vascular reconstruction for lower extremity sarcoma were conducted using MEDLINE through PubMed, Scopus, CINARL, and Cochrane Database of Systematic Reviews. Overall limb-salvage rate was the primary outcome, and rates of perioperative complication and arterial patency were secondary outcomes. RESULTS: Among the 271 patients (18 studies) included in this study, 69.4% underwent arterial reconstruction with autologous graft, 22.0% underwent synthetic graft, and 8.6% underwent other reconstructive methods. Pooled overall limb-salvage rate was 89.8% [95% confidence interval (CI), 85.0-93.1%] after a mean follow-up of 19-74.7 months. Pooled overall perioperative complication and arterial patency rates were 49.5% (95% CI, 42.8-56.2%) and 85.4% (95% CI, 79.5-89.9%), respectively. CONCLUSIONS: Current evidence suggests that limb-salvage surgery with vascular reconstruction has a high limb-salvage rate; however, the high perioperative complication rate remains problematic. Early and appropriate interventions are required to optimize the complications of limb-salvage surgery.

Sclerotherapy for Venous Malformations of the Pharynx or the Tongue Base Without Tracheostomy: Treatment Protocol With Intubation and Outcomes.

Venous malformations (VMs) occurring in the tongue base or pharynx are rare, but can cause airway obstruction. Considering the potential issues or morbidity related to surgical resection in the tongue or pharynx region, sclerotherapy is often preferred. We perform sclerotherapy for such lesions without conducting tracheotomy, but keep patients intubated for a certain period. Outcomes of sclerotherapy, and benefits and cautions related with our protocol were investigated.Our subjects were 10 cases in 9 patients who underwent sclerotherapy for VMs of the tongue base (6 patients) or pharynx (3 patients) from 2008 to 2017. One patient underwent treatment sessions twice. The sclerosants used were absolute ethanol (ET) (3 cases), 5% ethanolamine oleate (EO) (4 cases), or both ET and 5%EO (3 cases).In 5 of 9 patients, postoperative MRI was performed, which revealed lesion volume reduction by 12% to 47%. The intubation period varied according to the sclerosant used: ET, 5 to 11 days; 5% EO, 2 to 12 days; and combination of ET and 5% EO, 8 days. Postoperative complications included fever of unknown (n = 2), acute psychosis (n = 3), vocal cord paralysis (n = 2), and bradycardia induced from the use of a sedative agent (n = 1). One patient complained of mild transient swallowing difficulty that lasted for a month postoperatively.Although our method mandatorily requires careful postoperative management in an ICU, including sedation with anesthetic agents and artificial respiration by intubation for a certain period of time, no serious complications or post-therapeutic morbidities occurred.

Risk Factors for Macroscopic Haemoglobinuria After Sclerotherapy Using Ethanolamine Oleate for Venous Malformations.

OBJECTIVES: Sclerotherapy is an essential component of the treatment for venous malformations, and ethanolamine oleate (EO) is known as a useful sclerosing agent. However, macroscopic haemoglobinuria (MH) and subsequent renal impairment are severe complications after sclerotherapy using EO. The present study aimed to clarify the MH risk factors for better peri-operative management of venous malformations. METHODS: Data collected during 130 procedures involving 94 patients who were undergoing sclerotherapy using EO for venous malformation were retrospectively analysed. Pre-operative and operative variables, including sex, age, pre-operative body mass index, location, depth, type of lesion, size, number of procedures, type of drainage vein, ratio of sclerosant to air, and injected total dose of 5% EO per body weight (BW), were examined. Univariable analysis and multivariable logistic regression were performed to determine the possible risk factors for MH. RESULTS: Following sclerotherapy, MH occurred in 27.7% of patients, but no patient developed post-operative renal impairment because of aggressive hydration and haptoglobin administration. On univariable analysis, diffuse lesion, lesion size ≥50 cm2, and total injected dose of 5% EO ≥ 0.18 mL/kg were found to be the MH risk factors. Multivariable logistic regression analysis identified a total injected dose of 5% EO ≥ 0.18 mL/kg as the significant independent factor contributing to MH risk. CONCLUSIONS: Macroscopic haemoglobinuria is a reversible complication if immediate and appropriate interventions with aggressive hydration and haptoglobin administration are performed; therefore, it should be closely monitored following sclerotherapy, especially when using 5% EO ≥ 0.18 mL/kg.

A Simple and Reliable Submental Intubation Technique for Maxillofacial Fractures.

In 1986, Altemir first reported the use of submental intubation to avoid tracheotomy in patients with panfacial and midfacial fractures for whom intermaxillary fixation is necessary, but orotracheal and nasotracheal intubations are not recommended. This novel technique allowed intraoperative access to perform dental occlusion and reconstruction of the nasal pyramid in patients with skull base fractures. Herein, we describe a refined technique based on Altemir's original procedure. Seven male patients with panfacial fractures underwent submental intubation using our refined technique. The technique was developed after encountering a technical error with Altemir's original procedure. In this new technique, we employed a 2-0 silk suture guide to allow the passage of both the endotracheal and cuff-inflation tubes through the same tunnel created from the oral cavity to the submental area. The success rate of the refined technique was 100%, and there were no intraoperative or postoperative complications. There was 20 seconds of ventilation outage time in total. Endotracheal and cuff-inflation tubes were easily and quickly passed through the same submental tunnel. Our refined technique is simple, easy, safe, fast, inexpensive, and does not require specific materials. Submental scars were smaller and relatively inconspicuous in this study, compared to those reportedly associated with other modified techniques.

Comparison of Donor Site Drainage Duration and Seroma Rate Between Latissimus Dorsi Musculocutaneous Flaps and Thoracodorsal Artery Perforator Flaps.

INTRODUCTION: Donor site seroma formation and prolonged drainage duration are common complications of using latissimus dorsi musculocutaneous (LDMC) flaps. The present retrospective study aimed to investigate the effect of types of back flap harvest on drainage duration and seroma formation rates. METHODS: Adult patients (n = 155) who underwent reconstruction with a latissimus dorsi flap from January 2010 to October 2015 were included in the study, of which 54 patients underwent breast reconstruction with a pedicled LDMC flap (LD breast group), 80 patients underwent an LDMC flap transfer for purposes other than breast reconstruction (LD nonbreast group), and 21 patients underwent soft tissue reconstruction with a thoracodorsal artery perforator (TAP) flap (TAP group). Flap size, drainage durations, and seroma formation rates at donor sites were compared among the 3 groups. RESULTS: Flap sizes significantly differed between the LD nonbreast group (median value, 185.5 cm) and the other 2 groups (119 cm in the LD breast group. 127.5 cm in the TAP group), with no significant difference observed between the LD breast and TAP groups. The mean drainage duration was 11.6 days for the LD breast group. 9.82 days for the LD nonbreast group, and 4.81 days for the TAP group. Drainage durations significantly differed among the groups. Seroma formation rate of the LD breast group (42.6%) was significantly higher than those of the other groups. CONCLUSIONS: The type of back flap harvest used significantly affected drainage duration and seroma formation rate in the present study. Lumbar fat extension with the use of a LDMC flap for breast reconstruction may lead to seroma formation. Thoracodorsal artery perforator flaps are associated with minimal risks of seroma formation and significantly shortened drainage duration compared with LDMC flaps.

Reconstruction of Complex Groin Defects After Sarcoma Resection.

BACKGROUND: Complex groin defects after sarcoma resection require reconstruction of multiple vital structures that can include the major vessels, the overlying skin, the abdominal wall, and the hip joint. We investigated the feasibility of limb preservation after complex groin reconstruction. METHODS: The subjects were 12 consecutive patients who underwent complex groin reconstruction after sarcoma resection. In all patients, the defect included a major artery (external iliac or femoral) and overlying skin. The defect included the abdominal wall in 5 patients and the hip joint in 2. Arterial reconstruction was performed with an autologous vein graft in 9 patients and with an expanded polytetrafluoroethylene graft in 3. Soft-tissue coverage was performed with a pedicled rectus abdominis musculocutaneous flap in 7 patients, a free latissimus dorsi musculocutaneous flap in three, and a free anterolateral thigh flap in 2. RESULTS: Postoperative complications occurred in 7 patients (58.3%). Limb salvage was possible in 8 patients (66.7%) with 39 months' median follow-up. Two patients required amputation because of wound problems, and 2 required amputation because of local recurrence of the tumor. CONCLUSIONS: Limb salvage is possible even after extensive resection of groin sarcoma, although the rate of postoperative wound complications is substantial. Proper selection of the arterial conduit and the soft-tissue flap, depending on the components of the defect, are mandatory for successful reconstruction.

Analysis of functional outcomes in patients with mandible reconstruction using vascularized fibular grafts.

BACKGROUNDS: Although a vascularized fibular graft (VFG) is the favored method for mandible reconstruction, only few functional reports have been published. In this study, surgical outcomes and functional results after mandible reconstruction were analyzed. PATIENTS AND METHODS: From 1999 through 2010, oromandibular defects after segmental mandibulectomy were reconstructed with VFG in 101 patients. Operative outcomes and subjective functional evaluation was performed. Of these, 44 patients could be evaluated for functional outcomes, and bite force was measured with an occlusal force meter in 24 patients. RESULTS: Major surgical complications required secondary revisional surgery developed in four patients. A normal diet was possible in 37 patients (84.1%), and a soft diet was possible in 7 patients (15.9%). Conversational ability was rated as excellent in 42 patients (95.5%). The mean bite force on the nonaffected side of the mandible was 187.7 N, and bite force decreased as the number of osteotomies in the VFG increased. Furthermore, bite force was significantly lower (P = 0.001) on the affected side (58.2 N), compared to nonaffected side (191.9 N). CONCLUSIONS: Although masticatory force decreases as the number of osteotomies increases, oral function after mandible reconstruction is satisfactory in most cases. Transfer of a VFG is a safe and reliable method for functional mandible reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery 37:101-104, 2017.

Predictive factors of dysphagia after lateral and superior oropharyngeal reconstruction with free flap transfer.

BACKGROUND AND OBJECTIVES: Lateral and superior oropharyngeal reconstruction is technically challenging and can be complicated by postoperative dysphagia. The aim of this retrospective study was to identify the predictive factors of dysphagia after lateral and superior oropharyngeal reconstruction with free flap transfer and to establish better management for cases with these predictive factors. METHODS: We performed a retrospective chart review of 109 patients who had undergone lateral and superior oropharyngeal reconstruction with free flap transfer for oropharyngeal cancer. Preoperative, operative, and postoperative variables were examined, and possible predicative factors for dysphagia were subjected to univariate analysis and multivariate logistic regression analysis. RESULTS: Dysphagia occurred in 16 patients (14.7%). Multivariate logistic regression analysis identified extensive tongue base resection, postoperative radiotherapy, and history of radiotherapy to the head and neck region as independent factors contributing to dysphagia after lateral and superior oropharyngeal reconstruction. Of these factors, extensive tongue base resection was the most important. CONCLUSIONS: Early intervention to minimize the risk of dysphagia should be performed for patients identified with these predictive factors.

Simultaneous reconstruction of the bone and vessels for complex femoral defect.

BACKGROUND: Several methods have been reported for intercalary reconstruction of femoral defects. Of these, free vascularized fibula grafts (FVFG) are preferred because of their durability, bone-healing potential, and tolerance to infection. If the bone tumor invades the femoral vessels, simultaneous vascular reconstruction also becomes necessary and significant technical hurdles make limb salvage difficult. CASE PRESENTATION: We present a 10-year-old girl who underwent limb-sparing surgery for a distal femur osteosarcoma. The femoral defect was 15 cm long, and the femoral vessel defect was 10 cm long. The femur was reconstructed with bilateral FVFG, and the femoral vessels were reconstructed with saphenous vein grafts. The grafts survived without vascular compromise, and the affected limb was preserved successfully. CONCLUSIONS: Combined use of bilateral FVFG and autologous vein grafts makes limb-sparing surgery for a large osteosarcoma of the femur possible.

The Superior Rectal Artery as a Recipient Vessel for Free Flap Transfer After Partial Sacrectomy in Patients With Chordoma.

Free flaps have rarely been used to reconstruct lumbosacral defects, primarily because of the lack of suitable recipient vessels in this region. We propose the novel use of the superior rectal artery as a recipient vessel for free flap transfer after partial or total sacrectomy. We transferred free flow-through latissimus dorsi musculocutaneous flaps, with the superior rectal vessels as recipient vessels, to reconstruct defects after partial sacrectomy in 2 patients with sacral chordoma. The flaps survived completely, and the wounds healed uneventfully in both patients. The superior rectal artery is easier to dissect and anastomose than are gluteal vessels and is less affected by patients' postoperative postural change than are extraperitoneal vessels. We believe that the superior rectal artery is a versatile recipient vessel for free flap transfer to reconstruct sacrectomy defects.

A "no-touch-technique" in mandibular reconstruction with reconstruction plate and free flap transfer.

OBJECTIVE: Mandibular reconstruction with a mandibular reconstruction plate (MRP) and free flap transfer can involve serious plate-related complications. The aim of our study is to present our new "no-touch-technique" which keeps an MRP not contaminated to saliva during the entire operation for the reduction of plate-related complications. PATIENTS AND METHODS: Data were retrospectively collected on 29 patients who had undergone segmental mandibulectomy for head and neck tumor and mandibular reconstruction with an MRP and free flap transfer from 2004 to 2013; 12 patients were reconstructed with our no-touch-technique from 2010 to 2013 (no-touch-technique group), and 17 patients with the conventional technique from 2004 to 2009 (conventional group). A rectus abdominis musculocutaneous flap or anterolateral thigh flap was transferred in all patients. The rates of perioperative recipient site complications including total flap necrosis, partial flap necrosis, wound infection, fistula formation and wound dehiscence, and reoperation for complications were compared between the groups. RESULTS: All flaps were successfully transferred although one venous thrombosis formation occurred in the conventional group. The rate of wound infection in the no-touch-technique group (8.3%) was significantly lower than that in the conventional group (47.1%) (P = 0.04). Additionally, the rate of fistula formation in the no-touch-technique group (8.3%) tended to be lower than that in the conventional group (29.4%) (P = 0.35). CONCLUSION: The results of our study showed that our no-touch-technique may be a safe and effective procedure for the prevention of perioperative plate-related complications for mandibular reconstruction with an MRP and free flap transfer.

Anterolateral thigh flap for axillary reconstruction after sarcoma resection.

BACKGROUND: Reconstruction of extensive axillary defects after sarcoma resection presents a challenging problem in reconstructive microsurgery. The purpose of this report was to investigate the feasibility of the free anterolateral thigh (ALT) flap for oncologic axillary reconstruction. METHODS: The extensive axillary defects in six patients with sarcoma was reconstructed using a free ALT flap. The defect size ranged from 15 × 11 to 28 × 25 cm2 . Five patients had recurrent cases and the ipsilateral latissimus dorsi flap had been already used in three patients. Two patients with a full-thickness defect underwent chest wall reconstruction with the iliotibial tract. RESULTS: All flaps survived completely and the wounds healed without complications in all patients. CONCLUSIONS: The free ALT flap is an ideal flap for axillary reconstruction after extensive sarcoma resection. It can be tailored to the requirements of the individual's defect and provides durable coverage for the axillary neurovascular bundle and intrathoracic structures. Flap harvesting in the lateral decubitus position enables a two-team approach. © 2015 Wiley Periodicals, Inc. Microsurgery 36:378-383, 2016.

Combined use of anterolateral thigh flap and pharyngeal flap for reconstruction of extensive soft-palate defects.

BACKGROUND: Functional reconstruction of extensive soft-palate defects is challenging for microsurgeons. The versatility of the combination of a free anterolateral thigh flap and a superiorly based pharyngeal flap for oncologic soft-palate reconstruction was investigated. METHODS: The combination of flaps was used for immediate reconstruction after total or subtotal resection of the soft palate in five consecutive patients from 2006 to 2011. RESULTS: All flaps survived completely. Palatal fistula and miniplate infection each developed in one patient but healed conservatively. Follow-up period ranged from 21 to 66 months. All patients tolerated a regular diet without significant aspiration or nasal regurgitation. Speech intelligibility was excellent in all patients, and none required a palatal prosthesis. CONCLUSIONS: The combination of an anterolateral thigh flap and a superiorly based pharyngeal flap is a versatile option for reconstructing extensive soft-plate defects. This method is simple and achieves reproducible results with limited donor-site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 36:291-296, 2016.

Early detection of local recurrence after soft tissue sarcoma resection and flap reconstruction.

PURPOSE: Flap reconstruction has become an essential component in soft tissue sarcoma treatment. However, the clinical features of local recurrence after soft tissue sarcoma resection and flap reconstruction remain unclear. The present study aimed to establish effective follow-up strategies after soft tissue sarcoma resection and flap reconstruction. METHODS: Data from patients who underwent soft tissue sarcoma resection and immediate flap reconstruction were retrospectively reviewed. Follow-up after surgery included history taking and physical examination during every visit to the hospital. Magnetic resonance imaging to evaluate the primary site was performed six months after the end of treatment then annually for ten years. The methods of detection of local recurrence were assessed. RESULTS: A total of 229 consecutive patients were included in the present study. During a median follow-up period of 40 months, 33 patients (14.4%) developed local recurrence. Twenty-three recurrences that occurred on the margin of the transferred flap were detected as palpable mass prior to radiological assessment; among the remaining ten recurrences that occurred in the deep layer of the transferred flap, six were detected by abnormal clinical findings and four were clinically occult and detected by surveillance radiological assessment. CONCLUSIONS: Surveillance radiological assessment has an important role in early detection of local recurrence that develops in the deep layer of the transferred flap. Therefore, meticulous clinical assessment combined with routine radiological study should be performed during follow-up evaluation for local recurrence after soft tissue sarcoma resection and flap reconstruction.

Flow-through divided latissimus dorsi musculocutaneous flap for large extremity defects.

Reconstructing large defects of the extremities is a challenging problem for reconstructive microsurgeons. The latissimus dorsi musculocutaneous flap (LDMCF) is widely used for this purpose, but a skin graft is needed when the defect is wider than available flaps. We used flow-through divided LDMCFs to reconstruct large defects of the extremities in 5 consecutive patients from 2010 through 2012. The semicircular skin island was split longitudinally, and 1 skin island was advanced over the other to close a round or oval defect without a skin graft. Postoperatively, all flaps survived completely, and the mean Enneking score was 90.0%. The flow-through divided LDMCF is a reliable and versatile option for reconstructing large defects of the extremities.

Flow-through anastomosis for both the artery and vein in leg free flap transfer.

OBJECTIVE: Free flap transfer is an essential part of limb-sparing surgery for leg sarcoma; however, this procedure is associated with a high failure rate. The aim of this study was to identify factors that contribute to microvascular compromise and flap failure for leg free flap transfer, while focusing on anastomotic techniques (end-to-end, end-to-side, and flow-through anastomoses). PATIENTS AND METHODS: Data from 56 consecutive patients who underwent leg free flap transfer after oncologic resection were retrospectively reviewed. Of these patients, flow-through anastomosis was performed with the artery in 29 and the vein in 24, whereas conventional techniques were performed in others. The variables contributing to microvascular compromise and flap failure were statistically analyzed. RESULTS: Venous thrombosis (four patients, 7.1%) was more frequent than arterial thrombosis (one patient, 1.8%) and (4 patients, 7.1%) resulted in flap loss. All anastomotic failures occurred in end-to-end anastomoses. All flow-through anastomoses achieved patency both for the artery and vein. No anastomotic failure or flap loss occurred in 22 flaps which were transferred with flow-through anastomosis for both the artery and vein. Flow-through venous anastomosis tended to have a lower rate of microvascular compromise and flap loss than conventional techniques (P = 0.13 and 0.25, respectively). CONCLUSION: The key to successful leg free flap transfer is to prevent venous failure; thus, flow-through venous anastomosis may be a breakthrough solution. Preferential use of flow-through anastomosis for both the artery and vein can provide predictable results in leg free flap transfer.

Free flow-through anterolateral thigh flap for complex knee defect including the popliteal artery.

Reconstruction of complex knee defects including the popliteal artery presents a challenging problem in reconstructive microsurgery. Reconstruction of the popliteal artery and soft-tissue coverage should be performed simultaneously for limb salvage. We present the one-stage reconstruction of a complex knee defect including the popliteal artery using a free flow-through anterolateral thigh (ALT) flap as a bypass flap in two patients with sarcomas. In both patients, the popliteal artery and vein were reconstructed using branches of the lateral circumflex femoral arterial system. The flaps survived without vascular compromise and the limbs were preserved successfully. Free flow-through ALT flap enables simultaneous leg revascularization and soft-tissue coverage with a single free flap. The lateral circumflex femoral arterial system has many branches with large diameters, making it suitable for reconstruction of multiple infrapopliteal arteries.

Accompanying artery of sciatic nerve as recipient vessel for free-flap transfer: a computed tomographic angiography study and case reports.

Suitable recipient vessels for free-flap transfer are hard to find in the posterior thigh. To investigate the versatility of accompanying artery of sciatic nerve as a recipient vessel in this region, we performed computed tomographic angiographic study of 20 consecutive healthy thighs in 10 patients. The presence and internal diameter of the accompanying artery were studied. The accompanying artery of the sciatic nerve was present in 11 thighs (55%) and the internal diameter of the artery at the mid-thigh level ranged from 2.1 to 3.2 mm. We used this artery as a recipient vessel for free flaps transferred to reconstruct extensive thigh defects in three patients with sarcomas. In all patients the flaps survived without vascular compromise. No sensory or motor dysfunction in the sciatic nerve distribution occurred in any patients. We believe that the accompanying artery of the sciatic nerve may be a recipient vessel for free-flap transfer in selected patients.

Combined use of the cephalic vein and pectoralis major muscle flap for secondary esophageal reconstruction.

Secondary reconstruction of thoracic esophageal defects is a challenging problem for microsurgeons. Because of previous surgeries and coexisting disease, gastric pull-up, and creation of a pedicled colon conduit are often impossible. Transfer of a supercharged pedicled jejunum flap or free jejunal interposition is usually the last resort; however, identifying appropriate recipient vessels and adequately covering the reconstructive conduit are often difficult. We performed secondary thoracic esophageal reconstruction with combined use of the cephalic vein as a recipient vein and the pectoralis major muscle flap for coverage in three patients. Two patients underwent transfer of a supercharged pedicled jejunum flap, and the other patient underwent free jejunal interposition. No wound complications occurred, and all patients could resume oral intake. The cephalic vein is a more reliable recipient vein than is the internal mammary vein. The skin graft-covered pectoralis major muscle flap provides secure external coverage to prevent anastomotic leakage even in complicated cases. Combined use of the cephalic vein and the skin graft-covered pectoralis major muscle flap is a versatile option for secondary thoracic esophageal reconstruction.

Efficient design of a latissimus dorsi musculocutaneous flap to repair large skin defects of the upper back.

Closing large skin defects of the upper back is a challenging problem. We have developed an efficient design for a latissimus dorsi musculocutaneous flap for reconstruction in this region. The longitudinal axis of the skin island was designed to be perpendicular to the line of least skin tension at the recipient site so that primary closure of the flap donor site changed the shape of the recipient site to one that was easier to close. We used this method for four patients with skin cancers or soft-tissue sarcomas of the upper back in 2011 and 2012. The size of skin defects after wide excision ranged from 11 × 10 to 25 × 20 cm(2) , and all skin defects could be covered by the flaps and all wounds of donor site could be closed without skin grafts. No wound complications occurred in any patient. Functional and aesthetic outcomes were satisfactory in all patients. This flap design is effective for reconstructing large skin defects of the upper back.