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Handchir Mikrochir Plast Chir 2018; 50(04): 259-268
DOI: 10.1055/s-0043-124187
Originalarbeit
Georg Thieme Verlag KG Stuttgart · New York

Epifaszial verlagerte tiefe inferiore epigastrische Gefäße als Anschlussgefäße für die mikrochirurgische Rekonstruktion komplexer onkochirurgischer Defekte des Abdomens und des Oberschenkels

The use of Deep Inferior Epigastric Vessels to Revascularise Free Flaps for Reconstruction of Complex Oncosurgical Defects of the Thigh and the Abdomen
F. Simunovic
1   Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg
,
U. Wittel
2   Klinik für Allgemein und Viszeralchirurgie, Universitätsklinikum Freiburg
,
B. Passlick
3   Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg
,
S. Wiesemann
3   Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg
,
M. Czerny
4   Klinik für Herz und Gefäßchirurgie, Universitätsklinikum Freiburg
,
M. Südkamp
4   Klinik für Herz und Gefäßchirurgie, Universitätsklinikum Freiburg
,
G. B. Stark
1   Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg
,
H. Bannasch
1   Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg
› Author Affiliations
Further Information

Publication History

08/28/2017

11/30/2017

Publication Date:
16 January 2018 (online)

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Zusammenfassung

Hintergrund Die Resektion großer Weichteilsarkome erfordert die Rekonstruktion mit freiem Gewebstransfer. Hierbei stellt die Selektion geeigneter Anschlussgefäße einen entscheidenden Faktor für den operativen Erfolg dar.

Patienten Wir berichten über vier Fälle mit sehr großen Tumoren und mit besonders komplexem anatomischem Bezug: zwei Sarkome in der Leiste mit Infiltration der Gefäß-Nervenstraße und zwei Sarkome in der Flanke mit ausgedehnter thorakoabdomineller und viszeraler Beteiligung. In allen Fällen erfolgten interdisziplinäre Operationen innerhalb eines multimodalen Therapieansatzes. In zwei Fällen wurde ein anterolateraler Oberschenkellappen (ALT) und in zwei ein myokutaner Latissimus Dorsi (LD) Lappen zur Defektdeckung benutzt. In allen Fällen erfolgte eine epifasziale Verlagerung der tiefen inferioren epigastrischen Gefäße zum mikrochirurgischen Gefäßanschluss.

Ergebnisse Die durchschnittliche Operationszeit betrug 694 ± 149 Minuten. Das mittlere Resektatgewicht war 3069 ± 1267 g. Drei Lappenplastiken heilten primär ein, in einem Fall kam es zu einer Spitzennekrose, welche operativ behandelt wurde.

Schlussfolgerung Die Verlagerung der tiefen inferioren epigastrischen Gefäßen nach epifaszial stellt in dieser selektionierten Gruppe eine gute Option zum Anschluss freier Lappen dar. Aufgrund der oberflächlichen Lage ist die Durchführung der Anastomose erleichtert. Insbesondere bei großen Defekten mit bestrahltem Lager erweitert diese technische Modifikation die rekonstruktiven Optionen.

Abstract

Background The resection of large soft-tissue sarcoma requires reconstruction with free flaps. The choice of recipient vessels is crucial for the success of surgery.

Patients We report four cases with large soft-tissue sarcomas with complex anatomical relationships: two tumors of the thigh surrounding the femoral neurovascular structures and two tumors of the abdomen with infiltration of the thorax and the abdomen. All cases received multimodal interdisciplinary treatment. The anterolateral thigh (ALT) flap and the latissimus dorsi (LD) flap were employed twice for defect coverage in this series. In all cases the deep inferior epigastric (DIE) vessels were transposed to the subcutaneous compartment and used as recipient vessels.

Results The mean duration of surgery was 694 ± 149 minutes. The mean weight of the tumor specimen was 3069 ± 1267 g. Three flaps healed primarily and one exhibited a minor necrosis, which was treated by excision and secondary suture. There were no cases of abdominal herniation due to the transposition of vessels.

Conclusion Transposition of DIE-vessels to the subcutaneus compartment is a good alternative for free flap revascularisation in this patient group. In this position, the vessels are easily accessed and used for microsurgery. This technical modification increases the reconstructive possibilities in large and previously irradiated surgical defects.

Schlüsselwörter

Weichteilsarkom - interdisziplinäre Plastische Chirurgie - freie Lappen - Rekonstruktion der Leiste und des Abdomens - Anschlussgefäße - Mikrochirurgie

Key words

soft-tissue sarcoma - interdisciplinary plastic surgery - free flaps - reconstruction of the thigh and the abdomen - recipient vessels - microsurgery
 

  • Literatur

  • 1 Bannasch H. et al. The diagnosis and treatment of soft tissue sarcomas of the limbs. Dtsch Arztebl Int 2011; 108 (03) 32-8
    PubMedGoogle Scholar
  • 2 Koulaxouzidis G, Simunovic F, Bannasch H. Was gibt es Neues zu Weichteilsarkomen der Extremitäten?. Was gibt es Neues in der Chirurgie? Jahresband 2013. ed. Jähne. et al. 2013. Ecomed MEDIZIN;
    Google Scholar
  • 3 Mueller CK, Schultze-Mosgau S. Radiation-induced microenvironments – the molecular basis for free flap complications in the pre-irradiated field?. Radiother Oncol 2009; 93 (03) 581-5
    CrossrefPubMedGoogle Scholar
  • 4 Rockwell WB. et al. The deep inferior epigastric artery: anatomy and applicability as a source of microvascular arterial grafts. Plast Reconstr Surg 2007; 120 (01) 209-14
    CrossrefPubMedGoogle Scholar
  • 5 Koulaxouzidis G, Simunovic F, Bannasch H. Soft Tissue Sarcomas of the Arm – Oncosurgical and Reconstructive Principles within a Multimodal, Interdisciplinary Setting. Front Surg 2016; 3: 12
    PubMedGoogle Scholar
  • 6 Tanabe KK. et al. Influence of surgical margins on outcome in patients with preoperatively irradiated extremity soft tissue sarcomas. Cancer 1994; 73 (06) 1652-9
    CrossrefPubMedGoogle Scholar
  • 7 Kainhofer V. et al. The width of resection margins influences local recurrence in soft tissue sarcoma patients. Eur J Surg Oncol 2016; 42 (06) 899-906
    CrossrefPubMedGoogle Scholar
  • 8 Lintz F. et al. Critical study of resection margins in adult soft-tissue sarcoma surgery. Orthop Traumatol Surg Res 2012; 98 (Suppl. 04) 9-18
    CrossrefPubMedGoogle Scholar
  • 9 Lehnhardt M. et al. [Soft tissue sarcoma of the upper extremities. Analysis of factors relevant for prognosis in 160 patients]. Chirurg 2012; 83 (02) 143-52
    CrossrefPubMedGoogle Scholar
  • 10 Daigeler A. et al. Long-term outcome after local recurrence of soft tissue sarcoma: a retrospective analysis of factors predictive of survival in 135 patients with locally recurrent soft tissue sarcoma. Br J Cancer 2014; 110 (06) 1456-64
    CrossrefPubMedGoogle Scholar
  • 11 Steinau HU. et al. [Surgical margins in soft tissue sarcoma of the extremities]. Pathologe 2011; 32 (01) 57-64
    CrossrefPubMedGoogle Scholar
  • 12 Bannasch H. et al. Oncosurgical and reconstructive concepts in the treatment of soft tissue sarcomas: a retrospective analysis. Arch Orthop Trauma Surg 2009; 129 (01) 43-9
    CrossrefPubMedGoogle Scholar
  • 13 Lehnhardt M. et al. [Importance of specialized centers in diagnosis and treatment of extremity-soft tissue sarcomas. Review of 603 cases]. Chirurg 2009; 80 (04) 341-7
    CrossrefPubMedGoogle Scholar
  • 14 Gerrand CH. et al. Classification of positive margins after resection of soft-tissue sarcoma of the limb predicts the risk of local recurrence. J Bone Joint Surg Br 2001; 83 (08) 1149-55
    PubMedGoogle Scholar
  • 15 Steinau HU. et al. Limb salvage and reconstructive procedures in soft tissue sarcomas of the extremities. Recent Results Cancer Res 1995; 138: 31-9
    PubMedGoogle Scholar
  • 16 Fortner JG, Kim DK, Shiu MH. Limb-preserving vascular surgery for malignant tumors of the lower extremity. Arch Surg 1977; 112 (04) 391-4
    CrossrefPubMedGoogle Scholar
  • 17 Nambisan RN, Karakousis CP. Vascular reconstruction for limb salvage in soft tissue sarcomas. Surgery 1987; 101 (06) 668-77
    PubMedGoogle Scholar
  • 18 Koperna T. et al. Vascular reconstruction for limb salvage in sarcoma of the lower extremity. Arch Surg 1996; 131 (10) 1103-7 discussion 1108
    CrossrefPubMedGoogle Scholar
  • 19 Ghert MA. et al. The surgical and functional outcome of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma of the extremity. Ann Surg Oncol 2005; 12 (12) 1102-10
    PubMedGoogle Scholar
  • 20 Tsukushi S. et al. Results of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma in the lower extremity: comparison between only arterial and arterovenous reconstruction. J Surg Oncol 2008; 97 (03) 216-20
    CrossrefPubMedGoogle Scholar
  • 21 Sun PY. et al. Outcome of peripheral venous reconstructions during tumor resection. J Vasc Surg Venous Lymphat Disord 2017; 5 (02) 185-193
    PubMedGoogle Scholar
  • 22 Muramatsu K. et al. Clinical outcome of limb-salvage surgery after wide resection of sarcoma and femoral vessel reconstruction. Ann Vasc Surg 2011; 25 (08) 1070-7
    CrossrefPubMedGoogle Scholar
  • 23 Adelani MA. et al. Revascularization after segmental resection of lower extremity soft tissue sarcomas. J Surg Oncol 2007; 95 (06) 455-60
    CrossrefPubMedGoogle Scholar
  • 24 Jones KB. et al. Complete femoral nerve resection with soft tissue sarcoma: functional outcomes. Ann Surg Oncol 2010; 17 (02) 401-6
    CrossrefPubMedGoogle Scholar
  • 25 Fischer S. et al. Local tendon transfer for knee extensor mechanism reconstruction after soft tissue sarcoma resection. J Plast Reconstr Aesthet Surg 2015; 68 (05) 729-35
    CrossrefPubMedGoogle Scholar
  • 26 Lo SJ. et al. A reappraisal of functional reconstruction of extension of the knee following quadriceps resection or loss. J Bone Joint Surg Br 2012; 94 (08) 1016-23
    PubMedGoogle Scholar
  • 27 Tung TH, Chao A, Moore AM. Obturator nerve transfer for femoral nerve reconstruction: anatomic study and clinical application. Plast Reconstr Surg 2012; 130 (05) 1066-74
    CrossrefPubMedGoogle Scholar
  • 28 Penna V. et al. Free tissue transfer in reconstruction following soft tissue sarcoma resection. Microsurgery 2011; 31 (06) 434-40
    CrossrefPubMedGoogle Scholar
  • 29 Engelhardt TO. et al. [Free Gracilis Flap for Anatomic Reconstruction after Limb-sparing Sarcoma Resection]. Handchir Mikrochir Plast Chir 2015; 47 (02) 111-7
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Daigeler A. et al. The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients. Langenbecks Arch Surg 2011; 396 (08) 1271-9
    CrossrefPubMedGoogle Scholar
  • 31 Gurunluoglu R, Rosen MJ. Recipient vessels for microsurgical flaps to the abdomen: A systematic review. Microsurgery. 2017
    PubMedGoogle Scholar
  • 32 Seo BF. et al. Perforators as recipients for free flap reconstruction of the inguinal and perineal region. Microsurgery 2015; 35 (08) 627-33
    CrossrefPubMedGoogle Scholar
  • 33 Davis LA. et al. Limb-sparing surgery with vascular reconstruction for malignant lower extremity soft tissue sarcoma. J Vasc Surg 2017; 65 (01) 151-156
    CrossrefPubMedGoogle Scholar