Gynecologic Oncology 138 (2015) 603–608
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
Vaginal reconstruction with pedicled vertical deep inferior epigastric perforator flap (diep) after pelvic exenteration. A consecutive case series Gwénael Ferron a,⁎, Dimitri Gangloff a, Denis Querleu a,b, Melanie Frigenza a, Juan Jose Torrent a,c, Laetitia Picaud a, Laurence Gladieff d, Martine Delannes e, Eliane Mery f, Berenice Boulet g, Gisele Balague g, Alejandra Martinez a a
Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France Department of Surgical Oncology, Institut Bergonie, 229, cours de l'Argonne, 33000 Bordeaux, France c Departement of Gynecology, Hospital Universitari Germans Trias y Pujol, Carretera de Canyet, 08916 Badalona, Barcelona, Spain d Departement of Medical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France e Departement of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France f Department of Surgical Pathology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France g Department of Radiology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France b
H I G H L I G H T S • Vaginal reconstruction after pelvic exenteration represents an oncologic challenge, and flap reconstruction decreases the risk of postoperative complications. • Total vaginal reconstruction with pedicled DIEP flap allows to fill the pelvis and to reduce donor site complications. • Its reproducibility is high when performed by a trained surgeon, with a low rate of abortion.
a r t i c l e
i n f o
Article history: Received 20 April 2015 Received in revised form 20 June 2015 Accepted 22 June 2015 Available online 27 June 2015 Keywords: Pelvic exenteration Vaginal reconstruction DIEP VRAM
a b s t r a c t Vaginal reconstruction after pelvic exenteration (PE) represents a challenge for the oncologic surgeon. Since the introduction of perforator flaps, using pedicled vertical DIEP (deep inferior epigastric perforator) flap allows to reduce the donor site complication rate. From November 2012 to December 2014, 27 PEs were performed in our institution. 13 patients who underwent PE with vaginal reconstruction and programmed DIEP procedure for gynecologic malignancies were registered. Nine patients underwent PE for recurrent disease and four for primary treatment. Six of the 13 patients have a preoperative fistula. Anterior PE was performed in 10 patients, and total PE in 3 patients. A vertical DIEP flap was performed in 10 patients using one or two medial perforators. The reasons for abortion of vertical DIEP flap procedure were: failure to localizing perforator vessels in two cases, and unavailability of plastic surgeon in one case. A vertical fascia-sparring rectus abdominis myocutaneous flap was then harvested. Median length of surgery was 335 min, and 60 min for DIEP harvesting and vaginal reconstruction. No flap necrosis occurred. One patient in the VRAM (vertical rectus abdominis myocutaneous) group experienced a late incisional hernia and one patient in the DIEP flap group required revision for vaginal stenosis. In our experience, DIEP flap represents our preferred choice of flap for circumferential vaginal reconstruction after PE. To achieve a high reproducibility, the technically demanding pedicled vertical DIEP flap has to be harvested by a trained surgeon, after strict evaluation of the preoperative imaging with identification and localization of perforator vessels. © 2015 Published by Elsevier Inc.
1. Background
⁎ Corresponding author at: Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 avenue Irène Joliot Curie, 31059 Toulouse Cedex 9, France. E-mail address: [email protected] (G. Ferron).
http://dx.doi.org/10.1016/j.ygyno.2015.06.031 0090-8258/© 2015 Published by Elsevier Inc.
Pelvic exenteration (PE) is the most radical surgery performed in gynecologic oncology. Since it was first reported by Brunschwig in 1948, postoperative mortality as well as long-term survival have improved. Postoperative morbidity remains high and new treatment modalities are required to improve patient's postoperative outcome [1,2]. Several
604
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
factors have influenced on improving patient outcome after the procedure. First, better patient selection by using defined clinical predictors, and high quality preoperative image study. Second, improvements in perioperative care, by perioperative parenteral nutrition, better pain management by the use of spinal analgesia, and intensive physiological support. Finally, improvements in surgical technique and experience have also helped to change morbidity and mortality of PE. Operative time and blood loss have diminished due to new surgical instruments such as automatic clips, bowel and skin stapling devices, and coagulating dissectors. The most important advances in surgical technique have been made on the reconstructive part of the procedure, by low colo-rectal anastomosis, continent reservoirs in the urinary diversion, and vaginal and pelvic floor reconstruction by myocutaneous flaps [2]. Currently, the use of myocutaneous flaps, especially VRAM (vertical rectus abdominis myocutaneous) flap is the preferred technique. The recent development of perforator flap, specifically DIEP (deep epigastric inferior perforator) flaps, allows decreasing the donor site complication rate. Since November 2012, we have routinely adopted the use of pedicled vertical DIEP flap for vaginal reconstruction. (See Figs. 1– 5.) The aim of the current study was to analyze the reproducibility and safety of vaginal reconstruction with pedicled vertical DIEP after pelvic exenteration for gynecologic malignancy. 2. Patients and methods Clinical and surgical records from all patients who underwent pelvic exenteration with vaginal reconstruction and programmed DIEP procedure for gynecologic malignancies at the Institut Claudius Regaud Cancer Center from November 2012 to December 2014 were reviewed. The Institutional Review Board from our institution approved the study. All cases were presented and discussed prior to surgery, and approved by the interdisciplinary tumor board from our institution. Preoperative evaluation included in all cases counseling by a stoma educative nurse, a nutritionist, and a psycho-oncologist, to cover all aspects concerning stoma care, sexual function and long-term concerns after surgery. Patients were offered the possibility of meeting other patients who had previously undergone PE. Urostoma placement was decided with the patient, and in most cases it was placed in the umbilicus. Exenterative procedures were classified as total, anterior, or posterior, and sub-classified into type I (supralevator PE), type II (infralevator PE), and type III (extended PE) according to Magrina classification [3]. Whenever possible, a J-omental flap was wrapped over colo-rectal
Fig. 1. Identification of dominant perforator using computerized CT-angiography.
Fig. 2. Hand-held Doppler device for preoperative perforator localizing.
anastomosis, the Miami pouch, or placed to fill the pelvis to enhance healing. All the PE procedures were performed by two senior oncologic surgeons (GF, AM), and the flap harvested by a senior plastic surgeon (DG) trained in perforator flap techniques. All patients were evaluated using an angio-CT to localize perforators prior surgery, in order to choose the side for harvesting. Two types of perforators can be found: musculocutaneous perforators which enter the muscle during its course, and extramuscular branches; which can be paramedian or tendinous according to their location from the muscle. According to previous reports, perforators are located at an average distance from the umbilicus of 4.51 cm, and an average of 1.5 perforators is used to harvest the flap. To choose the best side for harvesting, perforator must be larger than 2 mm diameter and ideally with a short intramuscular course, or be located in a paramedian position [4]. The skin flap was designed vertically, similar to VRAM harvesting. Dissection of perforators was performed as previously described [5–7]. Before and during the
Fig. 3. Pedicled vertical DIEP flap based to two perforators.
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
605
Medical records were examined and patient demographic data, medical comorbidities, pathologic data and prior treatments were recorded. Particular emphasis was made on operative records to detail length of the procedure, surgical technical difficulties, operative times, estimated blood loss (EBL), postoperative early complications (equal or less than 30 days after the procedure) and late complications (more than 30 days after the procedure), and outcome after the procedure. 3. Results
Fig. 4. Absence of parietal abdominal wall defect after vertical DIEP harvesting.
procedure, a hand-held Doppler device was used for perforator dissection. Flap harvesting procedure can be summarized in the following steps: – Perforator dissection: between the muscle and the anterior RAM fascia the perforator is localized using hand-held Doppler device. – Anterior RAM fascia is opened to individualize the perforator. – Skin flap is harvested dissecting it from anterior RAM fascia for muscle and fascia preservation. – Perforator intramuscular or paramuscular is dissected down to the inferior epigastric pedicle. – Ascendant branch of the inferior epigastric artery is sectioned and the deep inferior epigastric artery is completely skeletonized.
When localizing or dissecting thin perforators was found to be impossible, the vertical DIEP procedure was aborted and a fascia sparing VRAM flap was harvested. For the neovaginal formation, lateral part of the skin paddle was sutured to the remaining vagina or the introitus. To prevent prolapse, flap was sutured to the levator ani fascia. Then, the flap was folded on itself and twisted with a spiral fashioning, the skin surface being placed in the lumen of the neovagina. For the distal anastomosis, the skin paddle was occasionally thinned to avoid tension and bulge.
From November 2012 to January 2015, 27 PEs were performed in our institution. 13 patients underwent a vaginal reconstruction after pelvic exenteration with total vaginectomy for gynecologic malignancies. Demographic and clinical characteristics of all patients are shown in Table 1. The mean age at PE was 55 years (range: 18–79 years). Primary malignancies were cervical or vaginal cancer (n = 9), endometrial cancer (n = 3) and vaginal sarcoma (n = 1). All patients except one have been previously irradiated and 9 of them had also received concomitant chemotherapy. Nine patients underwent PE for recurrent disease and four for primary treatment. Six of the 13 patients had a preoperative fistula. Anterior PE was performed in 10 patients, and total PE in 3 patients. 4 patients had a palliative indication for surgery due to complex symptomatic pelvic fistulas. Anterior PE was performed in 10 patients, and total PE in 3 patients. An infralevator PA was performed in 10 patients, and in the remaining 3 patients a supralevator PE. Uterine conservation was proposed for a 17-yo patient, treated for a second recurrence of vaginal rhabdomyosarcoma. In this patient, an infralevator PE was performed including monobloc resection of bladder and complete colpectomy including the cervix with utero-neovaginal anastomosis. Continent Miami pouch diversion was performed in 10 patients, and trans-colic or trans-ileal Bricker diversion in 3 patients. An omental J flap was routinely created to cover the urinary diversion and to fill the denudated and irradiated pelvis. A vertical DIEP flap was performed in 10 patients based on one (n = 5) or two medial perforators (n = 5). A fascia-sparing VRAM flap was harvested in the remaining 3 patients. The reasons for the abortion of vertical DIEP flap procedure were: failure to localizing perforator in two cases (previous Pfannenstiel incision in one case), and unavailability of plastic surgeon in one case. Median length of surgery was 335 min (range: 217–507), and 60 min (range 44–133) for DIEP harvesting, vaginal reconstruction and abdominal wall closure. Anterior abdominal wall was primarily closed without mesh in all patients. Median estimated intraoperative blood loss was 820 ml (range: 430–2730). R0 resection was achieved in all patients who underwent PE with curative intent, 2 patients required laterally extended endopelvic resection and in 2 patients a complementary vulvectomy. No postoperative flap related complications occurred except for one donor-site abscess. No pedicle twisting, flap loss or vessel thrombosis occurred for both DIEP and VRAM flaps. No incisional hernia was observed in the vertical DIEP group, and one case was observed in the VRAM group. After a median follow-up of 12.6 months (range 7.5–31.5), one patient experienced a flap revision for vaginal stenosis 5 months after PE. 4. Discussion
Fig. 5. Thinned DIEP flap for tension-free perineal anastomosis.
Pelvic exenteration remains the only possible curative intervention in patients with recurrent or persistent pelvic cancer after prior radiation therapy. Since it was first reported, several factors have influenced on improving patient outcome after the procedure. First, better patient selection by using defined clinical predictors, and high quality preoperative image study. Second, improvements in perioperative care and nutrition, better pain management by the use of spinal analgesia, and intensive physiological support. Finally, improvements in surgical technique and experience have also helped to change morbidity and mortality of PE [8]. The surgical technique has substantially evolved, with the
606
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
Table 1 Clinical characteristics of patients. Patient
Age
BMI
Tobacco
Tumor site (recurrence)
Group and type of PE
Urinary reconstruction
Number of perforator
Operative time (min)
Duration DIEP harvesting (min)
1 2 3 4 5 6 7 8 9 10 11 12 13
38 43 67 51 18 47 75 79 71 48 67 54 65
32 21 22 17 19 19 32 20 22 14 17 19 21
No No Yes Yes No Yes No No No Yes No Yes No
Cervix (R) Cervix (R) Cervix Cervix Vagina (R) Cervix Uterus (R) Uterus (R) Uterus (R) Cervix (R) Vagina (R) Cervix (R) Cervix
Ant type II Ant type II Total type II Ant type I Ant type II Ant type I Ant type II Ant type III Ant type II Total type I Ant type III Total type III + LEER + IORT Ant type III
Miami pouch Miami pouch Miami pouch Bricker Miami pouch Miami pouch Miami pouch Bricker Miami pouch Bricker Miami pouch Miami pouch Miami pouch
2 2 2 2 1 1 2 0 1 1 0 1 0
359 311 386 261 428 235 384 279 335 217 281 507 401
65 72 68 44 133 51 88 Failure 55 53 Failure 55 VRAM
BMI: body mass index, (R): recurrence disease, Ant: anterior pelvic exenteration, LEER: laterally extended endopelvic resection, IORT: intraoperative radiation therapy, VRAM: plastic surgeon unavailable (decision to directly performed a VRAM flap).
development of new haemostatic devices, description of laterally extended endopelvic resection and systematization of complex reconstruction techniques of the vagina, perineum, urinary and digestive tract [9,10]. Many reconstructive surgical techniques are actually available to re-establish pelvic functions lost after an exenterative procedure [1,10,11]. Since the introduction of pelvic reconstructive surgery after PE, there has been an improvement in patients QOL [10,12]. In addition, reconstruction procedures contribute to avoid the “empty pelvis syndrome” and therefore result in an additional benefit in reducing the pelvic complication rate. Pelvic filling due to reconstruction reduces early and chronic pelvic complication rate as pelvic abscess or fistulae by improving vascularity and decreasing dead space [13,14]. Benefit of vaginal reconstruction at the time of PE has been described in several reports [15,16]. In addition to pelvic filling and wound healing, vaginal reconstruction using a myocutaneous flap improves the psychosocial benefits and the recovery of body image [17,18]. However, vaginal reconstruction for sexual intercourse is probably not a priority for a majority of patients [19]. Three pedicled flaps are frequently used depending on the defect: the pudendal thigh flap, the vertical rectus abdominis myocutaneous (VRAM) flap, and the gracilis flap. An algorithm approach allows adapting the vaginal reconstruction according to a defect classification [20]. Circumferential vaginal resection and total vaginectomy represent the most common defects after PE. For these cases, the VRAM flap is currently the most frequently used. Harvesting of VRAM flap is technically easy for an oncologic surgeon and highly reliable [11,21]. It utilizes a single incision with no additional scarring especially on the thighs. It does not require vaginal dilatation. The viability of the vascular supply by the inferior epigastric pedicle is good, with a low rate of necrosis and a large arc of rotation. The flap's skin paddle size allows a complete and circumferential vaginal reconstruction, and if required an additional perineal coverage. Main disadvantages of muscle and fascia harvesting are abdominal sequelae: incisional hernias and parietal weakness. The use of meshes for abdominal wall closure has been described by some authors, increasing the rate of flap related complications especially prosthesis infection. Component separation is also effective in allowing closure of VRAM donor sites without excessive fascia tension [22]. In our experience, the use of a mesh was rare due to type abdominal incision technique involving careful fascia sparing. Abdominal incision was performed medially 1 cm along the linea alba. For VRAM harvesting, fascia sparing was laterally as wide as possible, close to the location of perforators. In addition, the creation of stomas frequently required in PE increases the rate of abdominal wall sequelae. To improve pelvic VRAM flap outcomes, some authors have published the use of musclesparring VRAM flap for vaginal reconstruction [21,23]. Due to the fascia defect, no significant reduction of related flap complication was
demonstrated. On the other hand, fascia-sparing VRAM flaps resulted in significantly fewer hernias with less dehiscence, abdominal bulge, and evisceration [24]. Other muscular flaps can be used for vaginal reconstruction such as gracilis or inferior gluteal flaps. Main advantage of both flaps is bulky perineal covering for extended PE reducing postoperative pelvic complication rate. They are associated with a higher rate of necrosis of around 13–38%, secondary to its tenuous blood supply, and donor site sequelae with patient discomfort [10]. Since the introduction of perforator flap, our knowledge of flap vascularization has improved. The skin is supplied by perforator vessels, which cross the muscle. Because they don't contribute the flap's supply, harvesting of fascia and muscle is not mandatory. Therefore, perforator flaps provide the surgeon with additional options for reconstruction. For breast reconstruction, the DIEP flap has tended to replace the TRAM flap during the last decade. The main advantage of DIEP flap is focused on decreasing donor site complication. After DIEP flap breast reconstruction, likelihood of developing postoperative donor site dehiscence is correlated to the patient's body mass index and higher visceral fat area [25]. The first article using pedicled DIEP flap for vaginal reconstruction was published in 2006 in the context of surgical management of congenital vaginal agenesis [26]. Because of the length of the epigastric pedicle, DIEP flap for vaginal reconstruction do not require microsurgery for vascular anastomosis, reducing the surgical risk for thrombosis. For vaginal reconstruction after PE, the first series was published by Qiu et al. in 2013 [6,27]. The authors observed a reduced abdominal wall complication rate using DIEP flap. Nineteen percent of patients who underwent vaginal reconstruction with TRAM flap experienced abdominal wall weakness, while no events related to the donor site were registered in the group of patients who received the DIEP flap. DIEP dissection requires a complete skeletonization of the pedicle. The perforator supplying the skin paddle is dissected through the muscle, which is totally spared. In spite of limited surgical damage to the rectus abdominis and oblique muscles, potential side effects could be expected. Dynamic tests for the rectus muscle after DIEP flap have shown favorable results compared to the contralateral side [28]. DIEP flap had no major impact on abdominal muscle strength compared to TRAM flap as shown in a randomized trial [29]. The contribution of new imaging techniques such as MRI- or CTangiography allows to identify the dominant and centrally located abdominal wall perforators, and to plan the flap harvesting [18,30]. Pre-operative imaging is helpful in detecting contra-indications of DIEP or VRAM harvesting, such epigastric or perforator vessels damage after Pfannenstiel incision or previous colostomy [31]. Previous reports show that obesity is not a contraindication for DIEP flaps in breast reconstruction. However, obesity increased the risk of flap necrosis and donor site complications [32]. Per-operative use of handheld ultrasound scan is helpful for perforator dissection especially
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
in obese patients. Technically demanding, DIEP flap harvesting requires specific skills and training. In our experience, DIEP flap was performed using one (50%) or two (50%) perforators. If the perforating vessel cannot be identified easily on an ultrasound scan or has been damaged by a previous abdominal incision, a VRAM flap must be used. Very few series have reported the use of a DIEP flap for perineal reconstruction and, in particular, the use of a vertical skin paddle for vaginal reconstruction. Except in the Qiu series [6], majority of patients included in previous publications were treated for vaginal agenesis. We document in the paper for the first time the feasibility rate of DIEP reconstruction in cancer patients. Procedure abortion was related to failure to detect perforator and unavailability of a plastic surgeon. Thin perforators are described in approximately 1 to 3% of DIEP used for breast reconstruction procedures [33]. The risk of radiation damage of perforators is minimized by their location, close to the umbilicus. To assess the mean time to perform vaginal reconstruction, time for the abdominal wall closure has to be considered in addition to the time to raise the flap and to reconstruct the vagina. Indeed closure of the laparotomy is much longer after VRAM harvesting, especially if a component separation is required. For Qiu [6], DIEP harvesting time was shorter than for the VRAM flap, respectively 63 min vs 105 min with a reduction of the total operating time. In our current report, additional time for DIEP harvesting was constantly less than 90 min compared to a VRAM flap, which generally takes 60 min (author, unpublished data). Operating time decreases drastically with experience. Total duration of surgery was less than 7 h in our series for all procedures, including PE procedure even with laterally extended endopelvic resection, continent pouch construction, omental J flap and, if required, colorectal anastomosis or intra-operative radiation therapy. Partial or total flap loss due to venous congestion or arterial thrombosis has been reported in DIEP free flaps series. For vaginal reconstruction, the use of a pedicled DIEP flap limits this specific related free flap complication. The dissection of the pedicle has to be performed until the required length of the pedicle is obtained. Careful transfer of the flap into the pelvis is mandatory to prevent twisting or tension. Thus, in our experience, a blue dye line is marked along the pedicle during the dissection in order to check it after mobilization and to avoid twisting. Pedicled DIEP flap loss has never been reported for vaginal reconstruction after PE probably due to the small sample size and the population selection with an indication for vaginal reconstruction. As published for VRAM flap, a satisfactory filling of the pelvic dead space is reported with DIEP flap [6]. The flexibility of the skin paddle allows a neovagina formation easier. To avoid tension or bulge during the low anastomosis to the remaining vagina or to the perineum, the skin paddle can be thinned without damage to the blood supply for perineal anastomosis [5]. Vaginal stenosis is uncommonly reported after either flap. Unlike after DIEP flap, muscle atrophy occurred for VRAM flap, associated with, as a consequence, neovagina stiffness. According to Qiu's report [6], the DIEP neovagina seems to be more soft, elastic and expansible two months after surgery than a VRAM flap. 5. Conclusion The most recent modifications of pelvic exenteration reconstructive procedures are in addition to vaginal reconstruction, continent urinary conduit, and colorectal anastomosis both with the goal of improving functional outcome. Vaginal reconstruction plays an extremely important role to improve healing, ease of closure of the perineum and prevention of small bowel fistulae and obstruction. The pedicled vertical DIEP flap can provide a reliable and adequate soft tissue paddle for vaginal reconstruction after PE, and an optimal pelvic filling. The rate of donor site complication decreases compared to VRAM due to complete preservation of rectus abdominis continuity and fascia sparring. The feasibility of the procedure is documented for the first time in this paper, confirming its high reproducibility when performed by a trained surgeon. Our current study represents the largest consecutive
607
case series published about pedicled DIEP flaps for vaginal reconstruction after PE. In our experience, after strict evaluation of the preoperative imaging and a detection of perforators by ultrasound scan, DIEP flap represents our preferred choice of flap for circumferential vaginal reconstruction after PE. Conflict of interest statement The authors declare that there are no conflicts of interest.
References [1] A. Schneider, C. Köhler, E. Erdemoglu, Current developments for pelvic exenteration in gynecologic oncology, Curr. Opin. Obstet. Gynecol. 21 (1) (Feb 2009) 4–9. [2] H.O. Smith, M.C. Genesen, C.D. Runowicz, G.L. Goldberg, The rectus abdominis myocutaneous flap: modifications, complications, and sexual function, Cancer 83 (3) (Aug 1 1998) 510–520. [3] J.F. Magrina, C.R. Stanhope, A.L. Weaver, Pelvic exenterations: supralevator, infralevator, and with vulvectomy, Gynecol. Oncol. 64 (1997) 130–135. [4] J.E. Ireton, C. Lakhiani, M. Saint-Cyr, Vascular anatomy of the deep inferior epigastric artery perforator flap: a systematic review, Plast. Reconstr. Surg. 134 (5) (Nov 2014) 810e–821e. [5] B.R. Fang, H. Ameet, X.F. Li, Q. Lu, X.C. Wang, A. Zeng, Q. Qiao, Pedicled thinned deep inferior epigastric artery perforator flap for perineal reconstruction: a preliminary report, J. Plast. Reconstr. Aesthet. Surg. 64 (12) (Dec 2011) 1627–1634. [6] S.S. Qiu, M. Jurado, B. Hontanilla, Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration, Plast. Reconstr. Surg. 132 (6) (Dec 2013) 1020e–1027e. [7] Z. Ang, Q. Qun, Y. Peirong, L.Z. Fei, Z. Lin, L.W. Wei, Z.H. Lin, F.B. Rong, Refined DIEP flap technique for vaginal reconstruction, Urology 74 (1) (Jul 2009) 197–201. [8] A. Martínez, T. Filleron, L. Vitse, D. Querleu, E. Mery, G. Balague, M. Delannes, M. Soulie, C. Pomel, G. Ferron, Laparoscopic pelvic exenteration for gynaecological malignancy: is there any advantage? Gynecol. Oncol. 120 (3) (Mar 2011) 374–379. [9] R.E. Horch, W. Hohenberger, A. Eweida, U. Kneser, K. Weber, A. Arkudas, S. Merkel, J. Göhl, J.P. Beier, A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration, Int. J. Color. Dis. 29 (7) (Jul 2014) 813–823. [10] J.M. Fowler, Incorporating pelvic/vaginal reconstruction into radical pelvic surgery, Gynecol. Oncol. 115 (1) (Oct 2009) 154–163. [11] G. Ferron, C. Pomel, A. Martinez, F. Narducci, E. Lambaudie, F. Marchal, P. Rouanet, D. Querleu, Pelvic exenteration: current state and perspectives, Gynecol. Obstet. Fertil. 40 (1) (Jan 2012) 43–47. [12] J.M. Young, T. Badgery-Parker, L.M. Masya, M. King, C. Koh, A.C. Lynch, A.G. Heriot, M.J. Solomon, Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy, Br. J. Surg. 101 (3) (Feb 2014) 277–287. [13] Y.A. Rezk, K.E. Hurley, J. Carter, F. Dao, B.H. Bochner, J.J. Aubey, A. Caceres, M.H. Einstein, N.R. Abu-Rustum, R.R. Barakat, V. Makker, D.S. Chi, A prospective study of quality of life in patients undergoing pelvic exenteration: interim results, Gynecol. Oncol. 128 (2) (Feb 2013) 191–197. [14] B. Miller, M. Morris, D.M. Gershenson, C.L. Levenback, T.W. Burke, Intestinal fistulae formation following pelvic exenteration: a review of the University of Texas M. D. Anderson Cancer Center experience, 1957–1990, Gynecol. Oncol. 56 (2) (Feb 1995) 207–210. [15] S. Hawighorst-Knapstein, G. Schönefussrs, S.O. Hoffmann, P.G. Knapstein, Pelvic exenteration: effects of surgery on quality of life and body image—a prospective longitudinal study, Gynecol. Oncol. 66 (3) (Sep 1997) 495–500. [16] R. Mirhashemi, H.E. Averette, N. Lambrou, M.A. Penalver, L. Mendez, G. Ghurani, E. Salom, Vaginal reconstruction at the time of pelvic exenteration: a surgical and psychosexual analysis of techniques, Gynecol. Oncol. 87 (1) (Oct 2002) 39–45. [17] F.A. Holman, I.S. Martijnse, M.J. Traa, D. Boll, G.A. Nieuwenhuijzen, I.H. de Hingh, H.J. Rutten, Dynamic article: vaginal and perineal reconstruction using rectus abdominis myocutaneous flap in surgery for locally advanced rectum carcinoma and locally recurrent rectum carcinoma, Dis. Colon Rectum 56 (2) (Feb 2013) 175–185. [18] J.R. Scott, D. Liu, D.W. Mathes, Patient-reported outcomes and sexual function in vaginal reconstruction: a 17-year review, survey, and review of the literature, Ann. Plast. Surg. 64 (3) (Mar 2010) 311–314. [19] U.S. Løve, P. Sjøgren, P. Rasmussen, S. Laurberg, H.K. Christensen, Sexual dysfunction after colpectomy and vaginal reconstruction with a vertical rectus abdominis myocutaneous flap, Dis. Colon Rectum 56 (2) (Feb 2013) 186–190. [20] A.L. Pusic, B.J. Mehrara, Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction, J. Surg. Oncol. 94 (6) (Nov 1 2006) 515–521. [21] J.L. Berger, S.N. Westin, B. Fellman, V. Rallapali, M. Frumovitz, P.T. Ramirez, A.K. Sood, P.T. Soliman, Modified vertical rectus abdominis myocutaneous flap vaginal reconstruction: an analysis of surgical outcomes, Gynecol. Oncol. 125 (1) (Apr 2012) 252–255. [22] D.P. Baumann, C.E. Butler, Component separation improves outcomes in VRAM flap donor sites with excessive fascial tension, Plast. Reconstr. Surg. 126 (5) (Nov 2010) 1573–1580. [23] L. Weiwei, L. Zhifei, Z. Ang, Z. Lin, L. Dan, Q. Qun, Vaginal reconstruction with the muscle-sparing vertical rectus abdominis myocutaneous flap, J. Plast. Reconstr. Aesthet. Surg. 62 (3) (Mar 2009) 335–340. [24] C.A. Campbell, C.E. Butler, Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects, Plast. Reconstr. Surg. 128 (2) (Aug 2011) 447–458.
608
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
[25] B. Levi, J. Rinkinen, K.M. Kidwell, M. Benedict, I.C. Stein, J. Lisiecki, B. Enchakalody, S.C. Wang, J.H. Kozlow, A.O. Momoh, Morphomic analysis for preoperative donor site risk assessment in patients undergoing abdominal perforator flap breast reconstruction: a proof of concept study, J. Reconstr. Microsurg. 30 (9) (Nov 2014) 635–640. [26] X. Wang, Q. Qiao, A. Burd, Z. Liu, R. Zhao, K. Song, R. Feng, A. Zeng, Y. Zhao, A new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report, Plast. Reconstr. Surg. 119 (6) (May 2007) 1785–1790. [27] R. Ruiz-de-Erenchun, J. Murillo, A. Bazán, M. Jurado, E. García-Tutor, Vaginal reconstruction using a modified rectus abdominis musculocutaneous flap in pelvic cancer surgery, Ann. Plast. Surg. 51 (5) (Nov 2003) 455–459. [28] C. Kässmann, A. Peek, F. Luxenhofer, O. Scheufler, K. Exner, Myosonographic evaluation of rectus abdominis muscle function after DIEP flap breast reconstruction, Handchir. Mikrochir. Plast. Chir. 34 (6) (Nov 2002) 386–394. [29] C.M. Futter, E. Weiler-Mithoff, S. Hagen, K. Van de Sijpe, P.L. Coorevits, J.C. Litherland, M.H. Webster, M. Hamdi, P.N. Blondeel, Do pre-operative abdominal exercises prevent post-operative donor site complications for women undergoing DIEP flap
[30]
[31]
[32]
[33]
breast reconstruction? A two-centre, prospective randomised controlled trial, Br. J. Plast. Surg. 56 (7) (Oct 2003) 674–683. A. Gravvanis, D. Tsoutsos, G. Papanikolaou, A. Diab, P. Lambropoulou, D. Karakitsos, Refining perforator selection for deep inferior epigastric perforator flap: the impact of the dominant venous perforator, Microsurgery 34 (3) (Mar 2014) 169–176. A.L. Mahajan, A. Zeltzer, K.E. Claes, K. Van Landuyt, M. Hamdi, Are Pfannenstiel scars a boon or a curse for DIEP flap breast reconstructions? Plast. Reconstr. Surg. 129 (4) (Apr 2012) 797–805. K.T. Lee, G.H. Mun, Effects of obesity on postoperative complications after breast reconstruction using free muscle-sparing transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, and superficial inferior epigastric artery flap: a systematic review and meta-analysis, Ann. Plast. Surg. (Dec 19 2014) http://dx. doi.org/10.1097/SAP.0000000000000400 (Epub ahead of print). P.N. Blondeel, One hundred free DIEP flap breast reconstructions: a personal experience, Br. J. Plast. Surg. 52 (2) (Mar 1999) 104–111.
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
Vaginal reconstruction with pedicled vertical deep inferior epigastric perforator flap (diep) after pelvic exenteration. A consecutive case series Gwénael Ferron a,⁎, Dimitri Gangloff a, Denis Querleu a,b, Melanie Frigenza a, Juan Jose Torrent a,c, Laetitia Picaud a, Laurence Gladieff d, Martine Delannes e, Eliane Mery f, Berenice Boulet g, Gisele Balague g, Alejandra Martinez a a
Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France Department of Surgical Oncology, Institut Bergonie, 229, cours de l'Argonne, 33000 Bordeaux, France c Departement of Gynecology, Hospital Universitari Germans Trias y Pujol, Carretera de Canyet, 08916 Badalona, Barcelona, Spain d Departement of Medical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France e Departement of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France f Department of Surgical Pathology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France g Department of Radiology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 av Joliot Curie, 31000 Toulouse Cedex 09, France b
H I G H L I G H T S • Vaginal reconstruction after pelvic exenteration represents an oncologic challenge, and flap reconstruction decreases the risk of postoperative complications. • Total vaginal reconstruction with pedicled DIEP flap allows to fill the pelvis and to reduce donor site complications. • Its reproducibility is high when performed by a trained surgeon, with a low rate of abortion.
a r t i c l e
i n f o
Article history: Received 20 April 2015 Received in revised form 20 June 2015 Accepted 22 June 2015 Available online 27 June 2015 Keywords: Pelvic exenteration Vaginal reconstruction DIEP VRAM
a b s t r a c t Vaginal reconstruction after pelvic exenteration (PE) represents a challenge for the oncologic surgeon. Since the introduction of perforator flaps, using pedicled vertical DIEP (deep inferior epigastric perforator) flap allows to reduce the donor site complication rate. From November 2012 to December 2014, 27 PEs were performed in our institution. 13 patients who underwent PE with vaginal reconstruction and programmed DIEP procedure for gynecologic malignancies were registered. Nine patients underwent PE for recurrent disease and four for primary treatment. Six of the 13 patients have a preoperative fistula. Anterior PE was performed in 10 patients, and total PE in 3 patients. A vertical DIEP flap was performed in 10 patients using one or two medial perforators. The reasons for abortion of vertical DIEP flap procedure were: failure to localizing perforator vessels in two cases, and unavailability of plastic surgeon in one case. A vertical fascia-sparring rectus abdominis myocutaneous flap was then harvested. Median length of surgery was 335 min, and 60 min for DIEP harvesting and vaginal reconstruction. No flap necrosis occurred. One patient in the VRAM (vertical rectus abdominis myocutaneous) group experienced a late incisional hernia and one patient in the DIEP flap group required revision for vaginal stenosis. In our experience, DIEP flap represents our preferred choice of flap for circumferential vaginal reconstruction after PE. To achieve a high reproducibility, the technically demanding pedicled vertical DIEP flap has to be harvested by a trained surgeon, after strict evaluation of the preoperative imaging with identification and localization of perforator vessels. © 2015 Published by Elsevier Inc.
1. Background
⁎ Corresponding author at: Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, 1 avenue Irène Joliot Curie, 31059 Toulouse Cedex 9, France. E-mail address: [email protected] (G. Ferron).
http://dx.doi.org/10.1016/j.ygyno.2015.06.031 0090-8258/© 2015 Published by Elsevier Inc.
Pelvic exenteration (PE) is the most radical surgery performed in gynecologic oncology. Since it was first reported by Brunschwig in 1948, postoperative mortality as well as long-term survival have improved. Postoperative morbidity remains high and new treatment modalities are required to improve patient's postoperative outcome [1,2]. Several
604
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
factors have influenced on improving patient outcome after the procedure. First, better patient selection by using defined clinical predictors, and high quality preoperative image study. Second, improvements in perioperative care, by perioperative parenteral nutrition, better pain management by the use of spinal analgesia, and intensive physiological support. Finally, improvements in surgical technique and experience have also helped to change morbidity and mortality of PE. Operative time and blood loss have diminished due to new surgical instruments such as automatic clips, bowel and skin stapling devices, and coagulating dissectors. The most important advances in surgical technique have been made on the reconstructive part of the procedure, by low colo-rectal anastomosis, continent reservoirs in the urinary diversion, and vaginal and pelvic floor reconstruction by myocutaneous flaps [2]. Currently, the use of myocutaneous flaps, especially VRAM (vertical rectus abdominis myocutaneous) flap is the preferred technique. The recent development of perforator flap, specifically DIEP (deep epigastric inferior perforator) flaps, allows decreasing the donor site complication rate. Since November 2012, we have routinely adopted the use of pedicled vertical DIEP flap for vaginal reconstruction. (See Figs. 1– 5.) The aim of the current study was to analyze the reproducibility and safety of vaginal reconstruction with pedicled vertical DIEP after pelvic exenteration for gynecologic malignancy. 2. Patients and methods Clinical and surgical records from all patients who underwent pelvic exenteration with vaginal reconstruction and programmed DIEP procedure for gynecologic malignancies at the Institut Claudius Regaud Cancer Center from November 2012 to December 2014 were reviewed. The Institutional Review Board from our institution approved the study. All cases were presented and discussed prior to surgery, and approved by the interdisciplinary tumor board from our institution. Preoperative evaluation included in all cases counseling by a stoma educative nurse, a nutritionist, and a psycho-oncologist, to cover all aspects concerning stoma care, sexual function and long-term concerns after surgery. Patients were offered the possibility of meeting other patients who had previously undergone PE. Urostoma placement was decided with the patient, and in most cases it was placed in the umbilicus. Exenterative procedures were classified as total, anterior, or posterior, and sub-classified into type I (supralevator PE), type II (infralevator PE), and type III (extended PE) according to Magrina classification [3]. Whenever possible, a J-omental flap was wrapped over colo-rectal
Fig. 1. Identification of dominant perforator using computerized CT-angiography.
Fig. 2. Hand-held Doppler device for preoperative perforator localizing.
anastomosis, the Miami pouch, or placed to fill the pelvis to enhance healing. All the PE procedures were performed by two senior oncologic surgeons (GF, AM), and the flap harvested by a senior plastic surgeon (DG) trained in perforator flap techniques. All patients were evaluated using an angio-CT to localize perforators prior surgery, in order to choose the side for harvesting. Two types of perforators can be found: musculocutaneous perforators which enter the muscle during its course, and extramuscular branches; which can be paramedian or tendinous according to their location from the muscle. According to previous reports, perforators are located at an average distance from the umbilicus of 4.51 cm, and an average of 1.5 perforators is used to harvest the flap. To choose the best side for harvesting, perforator must be larger than 2 mm diameter and ideally with a short intramuscular course, or be located in a paramedian position [4]. The skin flap was designed vertically, similar to VRAM harvesting. Dissection of perforators was performed as previously described [5–7]. Before and during the
Fig. 3. Pedicled vertical DIEP flap based to two perforators.
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
605
Medical records were examined and patient demographic data, medical comorbidities, pathologic data and prior treatments were recorded. Particular emphasis was made on operative records to detail length of the procedure, surgical technical difficulties, operative times, estimated blood loss (EBL), postoperative early complications (equal or less than 30 days after the procedure) and late complications (more than 30 days after the procedure), and outcome after the procedure. 3. Results
Fig. 4. Absence of parietal abdominal wall defect after vertical DIEP harvesting.
procedure, a hand-held Doppler device was used for perforator dissection. Flap harvesting procedure can be summarized in the following steps: – Perforator dissection: between the muscle and the anterior RAM fascia the perforator is localized using hand-held Doppler device. – Anterior RAM fascia is opened to individualize the perforator. – Skin flap is harvested dissecting it from anterior RAM fascia for muscle and fascia preservation. – Perforator intramuscular or paramuscular is dissected down to the inferior epigastric pedicle. – Ascendant branch of the inferior epigastric artery is sectioned and the deep inferior epigastric artery is completely skeletonized.
When localizing or dissecting thin perforators was found to be impossible, the vertical DIEP procedure was aborted and a fascia sparing VRAM flap was harvested. For the neovaginal formation, lateral part of the skin paddle was sutured to the remaining vagina or the introitus. To prevent prolapse, flap was sutured to the levator ani fascia. Then, the flap was folded on itself and twisted with a spiral fashioning, the skin surface being placed in the lumen of the neovagina. For the distal anastomosis, the skin paddle was occasionally thinned to avoid tension and bulge.
From November 2012 to January 2015, 27 PEs were performed in our institution. 13 patients underwent a vaginal reconstruction after pelvic exenteration with total vaginectomy for gynecologic malignancies. Demographic and clinical characteristics of all patients are shown in Table 1. The mean age at PE was 55 years (range: 18–79 years). Primary malignancies were cervical or vaginal cancer (n = 9), endometrial cancer (n = 3) and vaginal sarcoma (n = 1). All patients except one have been previously irradiated and 9 of them had also received concomitant chemotherapy. Nine patients underwent PE for recurrent disease and four for primary treatment. Six of the 13 patients had a preoperative fistula. Anterior PE was performed in 10 patients, and total PE in 3 patients. 4 patients had a palliative indication for surgery due to complex symptomatic pelvic fistulas. Anterior PE was performed in 10 patients, and total PE in 3 patients. An infralevator PA was performed in 10 patients, and in the remaining 3 patients a supralevator PE. Uterine conservation was proposed for a 17-yo patient, treated for a second recurrence of vaginal rhabdomyosarcoma. In this patient, an infralevator PE was performed including monobloc resection of bladder and complete colpectomy including the cervix with utero-neovaginal anastomosis. Continent Miami pouch diversion was performed in 10 patients, and trans-colic or trans-ileal Bricker diversion in 3 patients. An omental J flap was routinely created to cover the urinary diversion and to fill the denudated and irradiated pelvis. A vertical DIEP flap was performed in 10 patients based on one (n = 5) or two medial perforators (n = 5). A fascia-sparing VRAM flap was harvested in the remaining 3 patients. The reasons for the abortion of vertical DIEP flap procedure were: failure to localizing perforator in two cases (previous Pfannenstiel incision in one case), and unavailability of plastic surgeon in one case. Median length of surgery was 335 min (range: 217–507), and 60 min (range 44–133) for DIEP harvesting, vaginal reconstruction and abdominal wall closure. Anterior abdominal wall was primarily closed without mesh in all patients. Median estimated intraoperative blood loss was 820 ml (range: 430–2730). R0 resection was achieved in all patients who underwent PE with curative intent, 2 patients required laterally extended endopelvic resection and in 2 patients a complementary vulvectomy. No postoperative flap related complications occurred except for one donor-site abscess. No pedicle twisting, flap loss or vessel thrombosis occurred for both DIEP and VRAM flaps. No incisional hernia was observed in the vertical DIEP group, and one case was observed in the VRAM group. After a median follow-up of 12.6 months (range 7.5–31.5), one patient experienced a flap revision for vaginal stenosis 5 months after PE. 4. Discussion
Fig. 5. Thinned DIEP flap for tension-free perineal anastomosis.
Pelvic exenteration remains the only possible curative intervention in patients with recurrent or persistent pelvic cancer after prior radiation therapy. Since it was first reported, several factors have influenced on improving patient outcome after the procedure. First, better patient selection by using defined clinical predictors, and high quality preoperative image study. Second, improvements in perioperative care and nutrition, better pain management by the use of spinal analgesia, and intensive physiological support. Finally, improvements in surgical technique and experience have also helped to change morbidity and mortality of PE [8]. The surgical technique has substantially evolved, with the
606
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
Table 1 Clinical characteristics of patients. Patient
Age
BMI
Tobacco
Tumor site (recurrence)
Group and type of PE
Urinary reconstruction
Number of perforator
Operative time (min)
Duration DIEP harvesting (min)
1 2 3 4 5 6 7 8 9 10 11 12 13
38 43 67 51 18 47 75 79 71 48 67 54 65
32 21 22 17 19 19 32 20 22 14 17 19 21
No No Yes Yes No Yes No No No Yes No Yes No
Cervix (R) Cervix (R) Cervix Cervix Vagina (R) Cervix Uterus (R) Uterus (R) Uterus (R) Cervix (R) Vagina (R) Cervix (R) Cervix
Ant type II Ant type II Total type II Ant type I Ant type II Ant type I Ant type II Ant type III Ant type II Total type I Ant type III Total type III + LEER + IORT Ant type III
Miami pouch Miami pouch Miami pouch Bricker Miami pouch Miami pouch Miami pouch Bricker Miami pouch Bricker Miami pouch Miami pouch Miami pouch
2 2 2 2 1 1 2 0 1 1 0 1 0
359 311 386 261 428 235 384 279 335 217 281 507 401
65 72 68 44 133 51 88 Failure 55 53 Failure 55 VRAM
BMI: body mass index, (R): recurrence disease, Ant: anterior pelvic exenteration, LEER: laterally extended endopelvic resection, IORT: intraoperative radiation therapy, VRAM: plastic surgeon unavailable (decision to directly performed a VRAM flap).
development of new haemostatic devices, description of laterally extended endopelvic resection and systematization of complex reconstruction techniques of the vagina, perineum, urinary and digestive tract [9,10]. Many reconstructive surgical techniques are actually available to re-establish pelvic functions lost after an exenterative procedure [1,10,11]. Since the introduction of pelvic reconstructive surgery after PE, there has been an improvement in patients QOL [10,12]. In addition, reconstruction procedures contribute to avoid the “empty pelvis syndrome” and therefore result in an additional benefit in reducing the pelvic complication rate. Pelvic filling due to reconstruction reduces early and chronic pelvic complication rate as pelvic abscess or fistulae by improving vascularity and decreasing dead space [13,14]. Benefit of vaginal reconstruction at the time of PE has been described in several reports [15,16]. In addition to pelvic filling and wound healing, vaginal reconstruction using a myocutaneous flap improves the psychosocial benefits and the recovery of body image [17,18]. However, vaginal reconstruction for sexual intercourse is probably not a priority for a majority of patients [19]. Three pedicled flaps are frequently used depending on the defect: the pudendal thigh flap, the vertical rectus abdominis myocutaneous (VRAM) flap, and the gracilis flap. An algorithm approach allows adapting the vaginal reconstruction according to a defect classification [20]. Circumferential vaginal resection and total vaginectomy represent the most common defects after PE. For these cases, the VRAM flap is currently the most frequently used. Harvesting of VRAM flap is technically easy for an oncologic surgeon and highly reliable [11,21]. It utilizes a single incision with no additional scarring especially on the thighs. It does not require vaginal dilatation. The viability of the vascular supply by the inferior epigastric pedicle is good, with a low rate of necrosis and a large arc of rotation. The flap's skin paddle size allows a complete and circumferential vaginal reconstruction, and if required an additional perineal coverage. Main disadvantages of muscle and fascia harvesting are abdominal sequelae: incisional hernias and parietal weakness. The use of meshes for abdominal wall closure has been described by some authors, increasing the rate of flap related complications especially prosthesis infection. Component separation is also effective in allowing closure of VRAM donor sites without excessive fascia tension [22]. In our experience, the use of a mesh was rare due to type abdominal incision technique involving careful fascia sparing. Abdominal incision was performed medially 1 cm along the linea alba. For VRAM harvesting, fascia sparing was laterally as wide as possible, close to the location of perforators. In addition, the creation of stomas frequently required in PE increases the rate of abdominal wall sequelae. To improve pelvic VRAM flap outcomes, some authors have published the use of musclesparring VRAM flap for vaginal reconstruction [21,23]. Due to the fascia defect, no significant reduction of related flap complication was
demonstrated. On the other hand, fascia-sparing VRAM flaps resulted in significantly fewer hernias with less dehiscence, abdominal bulge, and evisceration [24]. Other muscular flaps can be used for vaginal reconstruction such as gracilis or inferior gluteal flaps. Main advantage of both flaps is bulky perineal covering for extended PE reducing postoperative pelvic complication rate. They are associated with a higher rate of necrosis of around 13–38%, secondary to its tenuous blood supply, and donor site sequelae with patient discomfort [10]. Since the introduction of perforator flap, our knowledge of flap vascularization has improved. The skin is supplied by perforator vessels, which cross the muscle. Because they don't contribute the flap's supply, harvesting of fascia and muscle is not mandatory. Therefore, perforator flaps provide the surgeon with additional options for reconstruction. For breast reconstruction, the DIEP flap has tended to replace the TRAM flap during the last decade. The main advantage of DIEP flap is focused on decreasing donor site complication. After DIEP flap breast reconstruction, likelihood of developing postoperative donor site dehiscence is correlated to the patient's body mass index and higher visceral fat area [25]. The first article using pedicled DIEP flap for vaginal reconstruction was published in 2006 in the context of surgical management of congenital vaginal agenesis [26]. Because of the length of the epigastric pedicle, DIEP flap for vaginal reconstruction do not require microsurgery for vascular anastomosis, reducing the surgical risk for thrombosis. For vaginal reconstruction after PE, the first series was published by Qiu et al. in 2013 [6,27]. The authors observed a reduced abdominal wall complication rate using DIEP flap. Nineteen percent of patients who underwent vaginal reconstruction with TRAM flap experienced abdominal wall weakness, while no events related to the donor site were registered in the group of patients who received the DIEP flap. DIEP dissection requires a complete skeletonization of the pedicle. The perforator supplying the skin paddle is dissected through the muscle, which is totally spared. In spite of limited surgical damage to the rectus abdominis and oblique muscles, potential side effects could be expected. Dynamic tests for the rectus muscle after DIEP flap have shown favorable results compared to the contralateral side [28]. DIEP flap had no major impact on abdominal muscle strength compared to TRAM flap as shown in a randomized trial [29]. The contribution of new imaging techniques such as MRI- or CTangiography allows to identify the dominant and centrally located abdominal wall perforators, and to plan the flap harvesting [18,30]. Pre-operative imaging is helpful in detecting contra-indications of DIEP or VRAM harvesting, such epigastric or perforator vessels damage after Pfannenstiel incision or previous colostomy [31]. Previous reports show that obesity is not a contraindication for DIEP flaps in breast reconstruction. However, obesity increased the risk of flap necrosis and donor site complications [32]. Per-operative use of handheld ultrasound scan is helpful for perforator dissection especially
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
in obese patients. Technically demanding, DIEP flap harvesting requires specific skills and training. In our experience, DIEP flap was performed using one (50%) or two (50%) perforators. If the perforating vessel cannot be identified easily on an ultrasound scan or has been damaged by a previous abdominal incision, a VRAM flap must be used. Very few series have reported the use of a DIEP flap for perineal reconstruction and, in particular, the use of a vertical skin paddle for vaginal reconstruction. Except in the Qiu series [6], majority of patients included in previous publications were treated for vaginal agenesis. We document in the paper for the first time the feasibility rate of DIEP reconstruction in cancer patients. Procedure abortion was related to failure to detect perforator and unavailability of a plastic surgeon. Thin perforators are described in approximately 1 to 3% of DIEP used for breast reconstruction procedures [33]. The risk of radiation damage of perforators is minimized by their location, close to the umbilicus. To assess the mean time to perform vaginal reconstruction, time for the abdominal wall closure has to be considered in addition to the time to raise the flap and to reconstruct the vagina. Indeed closure of the laparotomy is much longer after VRAM harvesting, especially if a component separation is required. For Qiu [6], DIEP harvesting time was shorter than for the VRAM flap, respectively 63 min vs 105 min with a reduction of the total operating time. In our current report, additional time for DIEP harvesting was constantly less than 90 min compared to a VRAM flap, which generally takes 60 min (author, unpublished data). Operating time decreases drastically with experience. Total duration of surgery was less than 7 h in our series for all procedures, including PE procedure even with laterally extended endopelvic resection, continent pouch construction, omental J flap and, if required, colorectal anastomosis or intra-operative radiation therapy. Partial or total flap loss due to venous congestion or arterial thrombosis has been reported in DIEP free flaps series. For vaginal reconstruction, the use of a pedicled DIEP flap limits this specific related free flap complication. The dissection of the pedicle has to be performed until the required length of the pedicle is obtained. Careful transfer of the flap into the pelvis is mandatory to prevent twisting or tension. Thus, in our experience, a blue dye line is marked along the pedicle during the dissection in order to check it after mobilization and to avoid twisting. Pedicled DIEP flap loss has never been reported for vaginal reconstruction after PE probably due to the small sample size and the population selection with an indication for vaginal reconstruction. As published for VRAM flap, a satisfactory filling of the pelvic dead space is reported with DIEP flap [6]. The flexibility of the skin paddle allows a neovagina formation easier. To avoid tension or bulge during the low anastomosis to the remaining vagina or to the perineum, the skin paddle can be thinned without damage to the blood supply for perineal anastomosis [5]. Vaginal stenosis is uncommonly reported after either flap. Unlike after DIEP flap, muscle atrophy occurred for VRAM flap, associated with, as a consequence, neovagina stiffness. According to Qiu's report [6], the DIEP neovagina seems to be more soft, elastic and expansible two months after surgery than a VRAM flap. 5. Conclusion The most recent modifications of pelvic exenteration reconstructive procedures are in addition to vaginal reconstruction, continent urinary conduit, and colorectal anastomosis both with the goal of improving functional outcome. Vaginal reconstruction plays an extremely important role to improve healing, ease of closure of the perineum and prevention of small bowel fistulae and obstruction. The pedicled vertical DIEP flap can provide a reliable and adequate soft tissue paddle for vaginal reconstruction after PE, and an optimal pelvic filling. The rate of donor site complication decreases compared to VRAM due to complete preservation of rectus abdominis continuity and fascia sparring. The feasibility of the procedure is documented for the first time in this paper, confirming its high reproducibility when performed by a trained surgeon. Our current study represents the largest consecutive
607
case series published about pedicled DIEP flaps for vaginal reconstruction after PE. In our experience, after strict evaluation of the preoperative imaging and a detection of perforators by ultrasound scan, DIEP flap represents our preferred choice of flap for circumferential vaginal reconstruction after PE. Conflict of interest statement The authors declare that there are no conflicts of interest.
References [1] A. Schneider, C. Köhler, E. Erdemoglu, Current developments for pelvic exenteration in gynecologic oncology, Curr. Opin. Obstet. Gynecol. 21 (1) (Feb 2009) 4–9. [2] H.O. Smith, M.C. Genesen, C.D. Runowicz, G.L. Goldberg, The rectus abdominis myocutaneous flap: modifications, complications, and sexual function, Cancer 83 (3) (Aug 1 1998) 510–520. [3] J.F. Magrina, C.R. Stanhope, A.L. Weaver, Pelvic exenterations: supralevator, infralevator, and with vulvectomy, Gynecol. Oncol. 64 (1997) 130–135. [4] J.E. Ireton, C. Lakhiani, M. Saint-Cyr, Vascular anatomy of the deep inferior epigastric artery perforator flap: a systematic review, Plast. Reconstr. Surg. 134 (5) (Nov 2014) 810e–821e. [5] B.R. Fang, H. Ameet, X.F. Li, Q. Lu, X.C. Wang, A. Zeng, Q. Qiao, Pedicled thinned deep inferior epigastric artery perforator flap for perineal reconstruction: a preliminary report, J. Plast. Reconstr. Aesthet. Surg. 64 (12) (Dec 2011) 1627–1634. [6] S.S. Qiu, M. Jurado, B. Hontanilla, Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration, Plast. Reconstr. Surg. 132 (6) (Dec 2013) 1020e–1027e. [7] Z. Ang, Q. Qun, Y. Peirong, L.Z. Fei, Z. Lin, L.W. Wei, Z.H. Lin, F.B. Rong, Refined DIEP flap technique for vaginal reconstruction, Urology 74 (1) (Jul 2009) 197–201. [8] A. Martínez, T. Filleron, L. Vitse, D. Querleu, E. Mery, G. Balague, M. Delannes, M. Soulie, C. Pomel, G. Ferron, Laparoscopic pelvic exenteration for gynaecological malignancy: is there any advantage? Gynecol. Oncol. 120 (3) (Mar 2011) 374–379. [9] R.E. Horch, W. Hohenberger, A. Eweida, U. Kneser, K. Weber, A. Arkudas, S. Merkel, J. Göhl, J.P. Beier, A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration, Int. J. Color. Dis. 29 (7) (Jul 2014) 813–823. [10] J.M. Fowler, Incorporating pelvic/vaginal reconstruction into radical pelvic surgery, Gynecol. Oncol. 115 (1) (Oct 2009) 154–163. [11] G. Ferron, C. Pomel, A. Martinez, F. Narducci, E. Lambaudie, F. Marchal, P. Rouanet, D. Querleu, Pelvic exenteration: current state and perspectives, Gynecol. Obstet. Fertil. 40 (1) (Jan 2012) 43–47. [12] J.M. Young, T. Badgery-Parker, L.M. Masya, M. King, C. Koh, A.C. Lynch, A.G. Heriot, M.J. Solomon, Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy, Br. J. Surg. 101 (3) (Feb 2014) 277–287. [13] Y.A. Rezk, K.E. Hurley, J. Carter, F. Dao, B.H. Bochner, J.J. Aubey, A. Caceres, M.H. Einstein, N.R. Abu-Rustum, R.R. Barakat, V. Makker, D.S. Chi, A prospective study of quality of life in patients undergoing pelvic exenteration: interim results, Gynecol. Oncol. 128 (2) (Feb 2013) 191–197. [14] B. Miller, M. Morris, D.M. Gershenson, C.L. Levenback, T.W. Burke, Intestinal fistulae formation following pelvic exenteration: a review of the University of Texas M. D. Anderson Cancer Center experience, 1957–1990, Gynecol. Oncol. 56 (2) (Feb 1995) 207–210. [15] S. Hawighorst-Knapstein, G. Schönefussrs, S.O. Hoffmann, P.G. Knapstein, Pelvic exenteration: effects of surgery on quality of life and body image—a prospective longitudinal study, Gynecol. Oncol. 66 (3) (Sep 1997) 495–500. [16] R. Mirhashemi, H.E. Averette, N. Lambrou, M.A. Penalver, L. Mendez, G. Ghurani, E. Salom, Vaginal reconstruction at the time of pelvic exenteration: a surgical and psychosexual analysis of techniques, Gynecol. Oncol. 87 (1) (Oct 2002) 39–45. [17] F.A. Holman, I.S. Martijnse, M.J. Traa, D. Boll, G.A. Nieuwenhuijzen, I.H. de Hingh, H.J. Rutten, Dynamic article: vaginal and perineal reconstruction using rectus abdominis myocutaneous flap in surgery for locally advanced rectum carcinoma and locally recurrent rectum carcinoma, Dis. Colon Rectum 56 (2) (Feb 2013) 175–185. [18] J.R. Scott, D. Liu, D.W. Mathes, Patient-reported outcomes and sexual function in vaginal reconstruction: a 17-year review, survey, and review of the literature, Ann. Plast. Surg. 64 (3) (Mar 2010) 311–314. [19] U.S. Løve, P. Sjøgren, P. Rasmussen, S. Laurberg, H.K. Christensen, Sexual dysfunction after colpectomy and vaginal reconstruction with a vertical rectus abdominis myocutaneous flap, Dis. Colon Rectum 56 (2) (Feb 2013) 186–190. [20] A.L. Pusic, B.J. Mehrara, Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction, J. Surg. Oncol. 94 (6) (Nov 1 2006) 515–521. [21] J.L. Berger, S.N. Westin, B. Fellman, V. Rallapali, M. Frumovitz, P.T. Ramirez, A.K. Sood, P.T. Soliman, Modified vertical rectus abdominis myocutaneous flap vaginal reconstruction: an analysis of surgical outcomes, Gynecol. Oncol. 125 (1) (Apr 2012) 252–255. [22] D.P. Baumann, C.E. Butler, Component separation improves outcomes in VRAM flap donor sites with excessive fascial tension, Plast. Reconstr. Surg. 126 (5) (Nov 2010) 1573–1580. [23] L. Weiwei, L. Zhifei, Z. Ang, Z. Lin, L. Dan, Q. Qun, Vaginal reconstruction with the muscle-sparing vertical rectus abdominis myocutaneous flap, J. Plast. Reconstr. Aesthet. Surg. 62 (3) (Mar 2009) 335–340. [24] C.A. Campbell, C.E. Butler, Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects, Plast. Reconstr. Surg. 128 (2) (Aug 2011) 447–458.
608
G. Ferron et al. / Gynecologic Oncology 138 (2015) 603–608
[25] B. Levi, J. Rinkinen, K.M. Kidwell, M. Benedict, I.C. Stein, J. Lisiecki, B. Enchakalody, S.C. Wang, J.H. Kozlow, A.O. Momoh, Morphomic analysis for preoperative donor site risk assessment in patients undergoing abdominal perforator flap breast reconstruction: a proof of concept study, J. Reconstr. Microsurg. 30 (9) (Nov 2014) 635–640. [26] X. Wang, Q. Qiao, A. Burd, Z. Liu, R. Zhao, K. Song, R. Feng, A. Zeng, Y. Zhao, A new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report, Plast. Reconstr. Surg. 119 (6) (May 2007) 1785–1790. [27] R. Ruiz-de-Erenchun, J. Murillo, A. Bazán, M. Jurado, E. García-Tutor, Vaginal reconstruction using a modified rectus abdominis musculocutaneous flap in pelvic cancer surgery, Ann. Plast. Surg. 51 (5) (Nov 2003) 455–459. [28] C. Kässmann, A. Peek, F. Luxenhofer, O. Scheufler, K. Exner, Myosonographic evaluation of rectus abdominis muscle function after DIEP flap breast reconstruction, Handchir. Mikrochir. Plast. Chir. 34 (6) (Nov 2002) 386–394. [29] C.M. Futter, E. Weiler-Mithoff, S. Hagen, K. Van de Sijpe, P.L. Coorevits, J.C. Litherland, M.H. Webster, M. Hamdi, P.N. Blondeel, Do pre-operative abdominal exercises prevent post-operative donor site complications for women undergoing DIEP flap
[30]
[31]
[32]
[33]
breast reconstruction? A two-centre, prospective randomised controlled trial, Br. J. Plast. Surg. 56 (7) (Oct 2003) 674–683. A. Gravvanis, D. Tsoutsos, G. Papanikolaou, A. Diab, P. Lambropoulou, D. Karakitsos, Refining perforator selection for deep inferior epigastric perforator flap: the impact of the dominant venous perforator, Microsurgery 34 (3) (Mar 2014) 169–176. A.L. Mahajan, A. Zeltzer, K.E. Claes, K. Van Landuyt, M. Hamdi, Are Pfannenstiel scars a boon or a curse for DIEP flap breast reconstructions? Plast. Reconstr. Surg. 129 (4) (Apr 2012) 797–805. K.T. Lee, G.H. Mun, Effects of obesity on postoperative complications after breast reconstruction using free muscle-sparing transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, and superficial inferior epigastric artery flap: a systematic review and meta-analysis, Ann. Plast. Surg. (Dec 19 2014) http://dx. doi.org/10.1097/SAP.0000000000000400 (Epub ahead of print). P.N. Blondeel, One hundred free DIEP flap breast reconstructions: a personal experience, Br. J. Plast. Surg. 52 (2) (Mar 1999) 104–111.
