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Flap Reconstruction after Sacrectomy: Evaluation of Reconstructive Techniques and the Use of Acellular Dermal Matrix
Marco Maricevich, MD, Renata Maricevich, MD, Steven Moran, MD, Samir Mardini, MD.
Mayo Clinic, Rochester, MN, USA.
PURPOSE: Sacral tumors remain a real challenge for the reconstructive surgeon. The loss of posterior abdominal domain during sacrectomy can predispose patients to the development of parasacral herniation and possible bowel obstruction, adhesion, and perforation. Recently we have employed the use of acellular dermal matrix (ADM) in an attempt to restore abdominal domain and prevent complications. Here we present a retrospective comparative study examining the outcomes with ADM and without.
METHODS: The medical records of all patients who had partial or total sacrectomy flap reconstruction at our institution in between January of 1998 and June of 2011 were reviewed. Pedicled rectus abdominis muscle (RAM), gluteal, thigh, free and combination of flaps were performed. Prior to flap insetting, ADM was sewn to the remaining pelvic periosteal rim or the retro pubic remnants. Bony fixation was obtained with suture anchors. Postoperative complications were divided in three groups: flap, pelvic and abdominal wall. Statistical analysis was performed with the JMP 9 software, using Fisher’s exact test, Pearson chi-square test, and logistic regression models (univariate/multivariate) to test for factors associated with complication outcomes.
RESULTS: Seventy-seven patients were included in our study. Fifty patients were male and 27 female, with a mean age of 50.7 years (range 12-78). The length of follow up ranged from 14 days to 9.5 years (mean 25.5 months). ADM was used for pelvic floor reconstruction in 13 patients. Flap complications occurred in 30 patients (41.1%), and consisted of partial flap loss (n=4), total flap loss (n=2), skin dehiscence (n=18), seroma (n=3), hematoma in (n=1), non-healing wound (n=7), and wound infection (n=8). Pelvic complications inherent to the oncological procedure and extirpation of the tumor from the pelvis occurred in 27 patients (37%), and consisted of parasacral hernia (n=1), pelvic abscess (n=13), bowel obstruction (n=1), bowel perforation (n=2), enterocutaneous fistula (n=2), CSF leak (n=2), pelvic hematoma (n=5), and hardware failure (n=5). Abdominal wall complications associated with pedicled RAM flaps occurred in 10 patients (25%). The use ADM was an independent protective factor (p 0.001) for pelvic complications in our data analysis, 0 versus 45% incidence. No significant impact was observed in flap complications when using ADM (p 0.68), 46.1 versus 40% incidence. When comparing the ADM and No ADM groups, the group with ADM reconstruction was less exposed to chemotherapy and preoperative radiotherapy. Demographics and other risk factors were all comparable, including wound defect volume (cm3) distribution (p 0.27). Regarding flap distribution, the ADM group had more gluteal flaps and less pedicled RAM and thigh flaps when compared with the No ADM group (p < 0.001). Chemotherapy, radiotherapy, and type of flap were not statistically significant protective/predictor factors for pelvic complications after univariate and multivariate logistic regression analysis.
CONCLUSIONS: Since flap complication incidence is not increased with the use of ADM and there is a statistically significant protective factor for pelvic complications, we recommend the use of ADM for reconstruction of the posterior abdominal domain following flap sacrectomy reconstruction.
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