Presentation is loading. Please wait.

Presentation is loading. Please wait.

Reconstructive Surgery and Cancer Treatment Michael J. Miller, M.D., F.A.C.S. Division of Plastic Surgery Arthur G. James Cancer Center The Ohio State.

Similar presentations


Presentation on theme: "Reconstructive Surgery and Cancer Treatment Michael J. Miller, M.D., F.A.C.S. Division of Plastic Surgery Arthur G. James Cancer Center The Ohio State."— Presentation transcript:

1 Reconstructive Surgery and Cancer Treatment Michael J. Miller, M.D., F.A.C.S. Division of Plastic Surgery Arthur G. James Cancer Center The Ohio State University Michael J. Miller, M.D., F.A.C.S. Division of Plastic Surgery Arthur G. James Cancer Center The Ohio State University

2 The 8th Circle of Dante’s Hell “Who could … give an account of all the blood and wounds I saw … “... nose cut off …” “... only one ear” “... opened his windpipe” Canto XXVIII

3 The 8th Circle of Dante’s Hell “Why are you staring? Why is your sight so fixed … among Those miserable, mutilated shadows?” Canto XXIX.4-6 “Why are you staring? Why is your sight so fixed … among Those miserable, mutilated shadows?” Canto XXIX.4-6

4 Patient’s Choice Cancer Death Living Hell Not much of a choice…

5 Patient’s Choice Cancer Death Living Hell Life/Restoration

6 Cancer Reconstructive Surgery Contributions to Oncology – Surgical treatment of “unresectable” tumors –Prevent complications –Promote “Quality of Life” Contributions to Oncology – Surgical treatment of “unresectable” tumors –Prevent complications –Promote “Quality of Life”

7 Cancer Reconstructive Surgery Unique considerations: – Limited survival – Often more elderly – Other therapies involved Reliability is essential Unique considerations: – Limited survival – Often more elderly – Other therapies involved Reliability is essential Reconstruction must not interfere with cancer treatment. Reconstruction must not interfere with cancer treatment.

8 Multidisciplinary Oncology Team Plastic surgeon must have: –Skills in complex tissue transfer –Understanding of the anatomy and function of the structures to be restored –Understanding of oncology principles –Remember aesthetic principles Plastic surgeon must have: –Skills in complex tissue transfer –Understanding of the anatomy and function of the structures to be restored –Understanding of oncology principles –Remember aesthetic principles

9 The Ohio State University Division of Plastic Surgery Patient care Education – Professional – Patient Research – Clinical investigation – Basic research Patient care Education – Professional – Patient Research – Clinical investigation – Basic research

10 Breast Cancer Estimated 175,000 new cases/year 43,300 deaths Chances of getting breast cancer –By age 30….1 out of 2,525 –By age 40….1 out of 217 –By age 50….1 out of 50 –By age 60….1 out of 24 –By age 70….1 out of 14 –By age 80….1 out of 10 Estimated 175,000 new cases/year 43,300 deaths Chances of getting breast cancer –By age 30….1 out of 2,525 –By age 40….1 out of 217 –By age 50….1 out of 50 –By age 60….1 out of 24 –By age 70….1 out of 14 –By age 80….1 out of 10

11 Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implant alone

12 Transverse Rectus Abdominis Musculocutaneous (TRAM) Flap

13 Transverse Rectus Abdominis Musculocutaneous (TRAM) flap

14 Deep Inferior Epigastric Perforator (DIEP) flap Deep Inferior Epigastric Perforator (DIEP) flap

15 METHODS Database review All DIEP flaps 11/1/96 - 3/30/00 n = 38 flaps All Free TRAM flaps 1/1/99 - 3/30/00 n = 217 flaps Variables affecting flap success studied Database review All DIEP flaps 11/1/96 - 3/30/00 n = 38 flaps All Free TRAM flaps 1/1/99 - 3/30/00 n = 217 flaps Variables affecting flap success studied

16 FAT NECROSIS

17 FLAP LOSS

18 Fat Necrosis in DIEP Flaps Peripheral Across midline of flap Required excision in 44% (4/9) Salvage: –Flap repositioning in 89% (8/9) –Latissimus dorsi flap in 1 case Peripheral Across midline of flap Required 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. 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 Cases by Category Department of Plastic surgery

21 Head and Neck Reconstruction

22 Total Pharyngoesophageal Reconstruction With Free Jejunal Transfer: An 11 Year Experience With 168 Patients Department of Plastic Surgery 2001 ASRM, San Diego, CA

23 FJT Transfer FJT Harvest –laparotomy: 162* –endoscopic surgery: 7* Proximal anastomosis: 1 or 2 layer Revascularize: end-to-side to IJ & EC Distal anastomosis: 1 layer Monitor flap FJT Harvest –laparotomy: 162* –endoscopic surgery: 7* Proximal anastomosis: 1 or 2 layer Revascularize: end-to-side to IJ & EC Distal anastomosis: 1 layer Monitor flap * Attempted: 7; Successful: 6

24 Complications Overall rate: 40%

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 – FJT loss (3.4%) – FJT vessel thrombosis (6.9%) – FJT adapted to most defects PO diet within 2 weeks –Liquids (78%)solids (40%) FJT is a reliable technique – FJT loss (3.4%) – FJT vessel thrombosis (6.9%) – FJT adapted to most defects PO diet within 2 weeks –Liquids (78%)solids (40%)

28 Esophageal Cancer Rising incidence Highly lethal disorder Most present with advanced disease Treatment –Surgery Curability vs. Resectability Extent of resection Choice and position of replacement –Adjuvant Therapies Rising incidence Highly lethal disorder Most present with advanced disease Treatment –Surgery Curability vs. Resectability Extent of resection Choice and position of replacement –Adjuvant Therapies

29 Esophageal Cancer Cervical Esophagus Intrathoracic Esophagus Intra-abdominal esophagus (Gastro-esophageal Junction)

30 Conduit Options Stomach Greater curvature tube Reversed gastric tube Non-reversed gastric tube Pedicled Left Colon Pedicled Right Colon Pedicled Jejunal Segment Free Jejunal Segment

31 Conduit Options Stomach Greater curvature tube Reversed gastric tube Non-reversed gastric tube Pedicled Left Colon Pedicled Right Colon Pedicled Jejunal Segment Free Jejunal 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% 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 Greater curvature tube Reversed gastric tube Non-reversed gastric tube Pedicled Left Colon Pedicled Right Colon Pedicled Jejunal Segment Free Jejunal Segment

34 Purpose Evaluate 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.

35 “Supercharged” Jejunum CLINICAL REPORTS nPositionvessel Longmire (USA) Subcut. IMA/IM V Androsov (USSR) Subcut. IMA/IM V Hirabayashi (JPN) Subcut. IMA/IM V Inoue (JPN) Retrostrn? TA/CV Huang (CHINA) Subcut./Retros trn. Cerv. a./EJ Heitmiller (USA) Retrostrn. IMA/IM V Roux (FR) 1907Jejunal interposition Kramarenko (USSR) 1921Vascular augmentation in cadavers

36 Surgery 22:94, 1947.

37 “Supercharged” Jejunum CLINICAL REPORTS nPositionvessel Longmire (USA) Subcut. IMA/IM V Androsov (USSR) Subcut. IMA/IM V Hirabayashi (JPN) Subcut. IMA/IM V Inoue (JPN) Retrostrn? TA/CV Huang (CHINA) Subcut./Retros trn. Cerv. a./EJ Heitmiller (USA) Retrostrn. IMA/IM V Roux (FR) 1907Jejunal interposition Kramarenko (USSR) 1921Vascular augmentation in cadavers

38 Patients and Methods March 2000 – November patients (8 male, 3 female) Mean age 51.9 yrs (Range ) March 2000 – November patients (8 male, 3 female) Mean age 51.9 yrs (Range )

39 Patients and Methods

40

41 Results No operative patient deaths No flap failures Complicationsn –Post-op pneumonia3 –Fistulae2 –Wound infection2 –Vocal cord paralysis2 –Rt. colon necrosis (Ogilvie’s)1 –Post op. cardiac arrest1 No operative patient deaths No flap failures Complicationsn –Post-op pneumonia3 –Fistulae2 –Wound infection2 –Vocal cord paralysis2 –Rt. colon necrosis (Ogilvie’s)1 –Post op. cardiac arrest1

42 Results ICU length of stay 5 days (range 3-7) Hospital length of stay 19 days (range 11 – 29) Follow-up 5 – 24 months Oral intake –“Regular” diet82% (9/11) –Liquid diet (+ tube supplements)18% (2/11) Late stricture 18% (2/11) ICU length of stay 5 days (range 3-7) Hospital length of stay 19 days (range 11 – 29) Follow-up 5 – 24 months Oral intake –“Regular” diet82% (9/11) –Liquid diet (+ tube supplements)18% (2/11) Late stricture 18% (2/11)

43 Esophagectomy Gastric or Colon Interposition p Op Mort10%3% Anast Leak12%5%0.001 Reoperation Bleeding 7%1%0.03 Anast Leak 4%0.05%0.01 ICU Days5.1 days2.3 days p Op Mort10%3% Anast Leak12%5%0.001 Reoperation Bleeding 7%1%0.03 Anast Leak 4%0.05%0.01 ICU Days5.1 days2.3 days0.005 Swisher et al., Am J Surg, 1995

44 Conclusions Pedicled segments of jejunum with vascular augmentation (“supercharged”) effectively restore total esophageal defects in selected patients. Key technical points: –Planning the location of the segment –Passage through the chest –Recipient vessels Multidisciplinary planning and cooperation is essential for success. Plastic surgery has an important and expanding role in multidisciplinary cancer care. Pedicled segments of jejunum with vascular augmentation (“supercharged”) effectively restore total esophageal defects in selected patients. Key technical points: –Planning the location of the segment –Passage through the chest –Recipient vessels Multidisciplinary planning and cooperation is essential for success. Plastic surgery has an important and expanding role in multidisciplinary cancer care.

45 Head and Neck Reconstruction

46 Mandible Reconstruction May, October 1996 Hemimandible 31 % (102/332) Lateral/Posterior 37 % (123/332) Anterior 32 % (107/332) 332 (n=964) Total Head and Neck

47 Mandible Reconstruction Tumor Histology

48 Mandible Reconstruction Adjuvant Radiotherapy % of patients exposed to therapeutic radiation

49 Mandible Reconstruction Patient Characteristics 85% (282/332) immediate reconstruction 99% (227/332) with soft tissue resection Preoperative dentition (unknown in 26) –Full28% (87/306) –Partial42% (128/306) –Edentulous30% (91/306) 85% (282/332) immediate reconstruction 99% (227/332) with soft tissue resection Preoperative dentition (unknown in 26) –Full28% (87/306) –Partial42% (128/306) –Edentulous30% (91/306)

50 Reconstructive Options Bone (186) Soft tissue only (146) Fibula 141 (bone only: 31) DC IA 27 (bone only: 11) Scapula 14 Radius 4 RAFF 57 RFFF 43 PMMF 26 LDFF 6 Lat. thigh 2 Scapula 1

51 New Tissue Transfer Restoration Modify Simple geometric Microvascular Whole tissue Tissue Replacement Reconstructive Surgery Concepts Biomaterial +

52 New Tissue Transfer Restoration Modify Simple geometric Microvascular Whole tissue Tissue Replacement Reconstructive Surgery Concepts Biomaterial + Tissue engineering

53

54

55 Suture cuff 66 mm 40 mm View from open face in x-z plane. Hollow space Cap Central Base Three implant segments. Assembled implant. 66 mm 40 mm Anterior view of molding chamber (left) and latex model of bone segment (right).

56 Individual Patient Simulations 3-D surface scanComputer-generated Surface Model (A) unloaded Dynamic modeling (B) deformed by gravity

57

58

59 Digital Breast Simulation Patient Surface Imaging Biomechanical Tissue Imaging MRI MRI CT CT Ultrasound Ultrasound Virtual Reality Breast Simulator Software Development

60

61

62 Clinical Application time Perfect! Tissue characterisitcs volume / shape bone quality

63 Task Ahead…. time Perfect! Tissue characterisitcs improved quality shorter time

64 Task Ahead…. time Perfect! Tissue characterisitcs improved quality shorter time Progress – measured in clinical parameters

65 Head and Neck Breast Microsurgical Reconstruction in the 21 st Century Microsurgical Reconstruction in the 21 st Century

66 Clinical Practice Clinicians Industry products BioengineersBioscientistsClinician Scientists Tissue Engineering Techniques FDA

67 Gaspar Tagliacozzi ( ) “We restore, repair, and make whole those parts... which nature has given but which fortune has taken away.” Reconstructive Surgery and Cancer Treatment

68 Thank You!


Download ppt "Reconstructive Surgery and Cancer Treatment Michael J. Miller, M.D., F.A.C.S. Division of Plastic Surgery Arthur G. James Cancer Center The Ohio State."

Similar presentations


Ads by Google