6 Cancer Reconstructive Surgery Contributions to OncologySurgical treatment of “unresectable” tumorsPrevent complicationsPromote “Quality of Life”
7 Cancer Reconstructive Surgery Unique considerations:Limited survivalOften more elderlyOther therapies involvedReliability is essentialReconstruction must not interferewith cancer treatment.
8 Multidisciplinary Oncology Team Plastic surgeon must have:Skills in complex tissue transferUnderstanding of the anatomy and function of the structures to be restoredUnderstanding of oncology principlesRemember aesthetic principles
9 The Ohio State University Division of Plastic Surgery Patient careEducationProfessionalPatientResearchClinical investigationBasic research
10 Breast Cancer Estimated 175,000 new cases/year 43,300 deaths Chances of getting breast cancerBy age 30….1 out of 2,525By age 40….1 out of 217By age 50….1 out of 50By age 60….1 out of 24By age 70….1 out of 14By age 80….1 out of 10
12 Transverse Rectus Abdominis Musculocutaneous (TRAM) FlapFor instance, to restore the breast mound following mastectomy, patients often undergo a Tummy Tuck procedure, where viable, functional tissue is taken from one portion of the body (the donor site) and transferred to the breast mound.In essence, we are robbing Peter to pay Paul.
18 Fat Necrosis in DIEP Flaps PeripheralAcross midline of flapRequired excision in 44% (4/9)Salvage:Flap repositioning in 89% (8/9)Latissimus dorsi flap in 1 case
19 SUMMARY DIEP flaps were associated with higher FN and PFL loss rate. The number of perforators harvested with the flap did not predict FN or PFL.Appropriate for selected patients...May not be suitable for reconstructions that need tissue across flap midline.
20 Department of Plastic surgery Cases by Category
25 Postoperative Diet* Diet history available in 148 patients
26 Primary Means of Communication Speech data available on 40% of patients
27 Summary FJT is a reliable technique PO diet within 2 weeks FJT loss (3.4%)FJT vessel thrombosis (6.9%)FJT adapted to most defectsPO diet within 2 weeksLiquids (78%) solids (40%)
28 Esophageal Cancer Rising incidence Highly lethal disorder Most present with advanced diseaseTreatmentSurgeryCurability vs. ResectabilityExtent of resectionChoice and position of replacementAdjuvant Therapies-
29 Esophageal Cancer Cervical Esophagus Intrathoracic Esophagus Intra-abdominal esophagus(Gastro-esophageal Junction)
30 Conduit Options Stomach Pedicled Left Colon Greater curvature tube Right ColonReversed gastric tubePedicledJejunal SegmentNon-reversed gastric tubeFreeJejunal Segment
31 Conduit Options Stomach Pedicled Left Colon Greater curvature tube Right ColonReversed gastric tubePedicledJejunal SegmentNon-reversed gastric tubeFreeJejunal Segment
32 Total Esophageal Reconstruction Pedicled stomach (Gastric pull-up)Complication rates %Cervical leak rate: 11% at MDACC (Putnam et. al., Ann Thor Surg 1994)Mortality rates 5 – 31%Pedicled colon (Colon Interposition)Complication rates 15 to 42%Mortality rates 3 – 29%
33 Conduit Options Stomach Pedicled Left Colon Greater curvature tube Right ColonReversed gastric tubePedicledJejunal SegmentNon-reversed gastric tubeFreeJejunal Segment
34 PurposeEvaluate the use of an isolated, pedicled segment of proximal jejunum with distal microvascular augmentation (i.e., “supercharged”) as an alternative for total esophageal reconstruction in cancer patients.
41 Results No operative patient deaths No flap failures Complications n Post-op pneumonia 3Fistulae 2Wound infection 2Vocal cord paralysis 2Rt. colon necrosis (Ogilvie’s) 1Post op. cardiac arrest 1
42 Results ICU length of stay 5 days (range 3-7) Hospital length of stay 19 days (range 11 – 29)Follow-up – 24 monthsOral intake“Regular” diet 82% (9/11)Liquid diet (+ tube supplements) 18% (2/11)Late stricture 18% (2/11)
43 Esophagectomy Gastric or Colon Interposition Op Mort 10% 3%Anast Leak 12% 5% 0.001ReoperationBleeding 7% 1% 0.03Anast Leak 4% 0.05% 0.01ICU Days 5.1 days 2.3 days 0.005In the first place, morbidity and mortality has dropped dramatically with time. If done in an experienced center morbidity and mortality can be quite low. Mortality in the 90s is around 3% as compared to 10% in the 80s. Similarly, leak rates and reoperation rates as well as days in the ICU have dropped dramatically.Swisher et al., Am J Surg, 1995
44 ConclusionsPedicled segments of jejunum with vascular augmentation (“supercharged”) effectively restore total esophageal defects in selected patients.Key technical points:Planning the location of the segmentPassage through the chestRecipient vesselsMultidisciplinary planning and cooperation is essential for success.Plastic surgery has an important and expanding role in multidisciplinary cancer care.
55 Anterior view of molding chamber (left) and latex Cap40 mmCentralBase66 mmAnterior view of molding chamber (left) and latexmodel of bone segment (right).Assembled implant.Three implant segments.40 mmHollow space66 mmSuture cuffView from open face in x-z plane.