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Reconstructive Surgery and Cancer Treatment

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Presentation on theme: "Reconstructive Surgery and Cancer Treatment"— 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 1 1

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

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

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”

7 Cancer Reconstructive Surgery
Unique considerations: Limited survival Often more elderly Other therapies involved Reliability is essential 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

9 The Ohio State University Division of Plastic Surgery
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

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

12 Transverse Rectus Abdominis Musculocutaneous
(TRAM) Flap For 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.

13 Transverse Rectus Abdominis Musculocutaneous (TRAM) flap

14 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

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

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

21 Head and Neck Reconstruction 1990 - 2000

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

23 FJT Transfer FJT Harvest Proximal anastomosis: 1 or 2 layer
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 PO diet within 2 weeks
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 -

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

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

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

33 Conduit Options Stomach Pedicled Left Colon Greater curvature tube
Right Colon Reversed gastric tube Pedicled Jejunal Segment Non-reversed gastric tube 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
Roux (FR) Jejunal interposition Kramarenko (USSR) Vascular augmentation in cadavers CLINICAL REPORTS n Position vessel Longmire (USA) 1947 21 Subcut. IMA/IMV Androsov (USSR) 1956 11 Hirabayashi (JPN) 1993 14 Inoue (JPN) 1994 1 Retrostrn? TA/CV Huang (CHINA) 1999 27 Subcut./Retrostrn. Cerv. a./EJ Heitmiller (USA) 2000 Retrostrn.

36 Surgery 22:94, 1947.

37 “Supercharged” Jejunum
Roux (FR) Jejunal interposition Kramarenko (USSR) Vascular augmentation in cadavers CLINICAL REPORTS n Position vessel Longmire (USA) 1947 21 Subcut. IMA/IMV Androsov (USSR) 1956 11 Hirabayashi (JPN) 1993 14 Inoue (JPN) 1994 1 Retrostrn? TA/CV Huang (CHINA) 1999 27 Subcut./Retrostrn. Cerv. a./EJ Heitmiller (USA) 2000 Retrostrn.

38 Patients and Methods March 2000 – November 2001
11 patients (8 male, 3 female) Mean age 51.9 yrs (Range 37-71)

39 Patients and Methods

40

41 Results No operative patient deaths No flap failures Complications n
Post-op pneumonia 3 Fistulae 2 Wound infection 2 Vocal cord paralysis 2 Rt. colon necrosis (Ogilvie’s) 1 Post 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 months Oral 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% 0.001 Reoperation Bleeding 7% 1% 0.03 Anast Leak 4% 0.05% 0.01 ICU Days 5.1 days 2.3 days 0.005 In 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 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.

45 Head and Neck Reconstruction 1990 - 2000

46 Mandible Reconstruction May, 1988 - October 1996
Total Head and Neck Hemimandible 31 % (102/332) (n=964) Lateral/Posterior 37 % (123/332) 332 Anterior 32 % (107/332)

47 Mandible Reconstruction Tumor Histology
37 42 251

48 Mandible Reconstruction Adjuvant Radiotherapy
78% of patients exposed to therapeutic radiation 5 73 107 140

49 Mandible Reconstruction Patient Characteristics
85% (282/332) immediate reconstruction 99% (227/332) with soft tissue resection Preoperative dentition (unknown in 26) Full 28% (87/306) Partial 42% (128/306) Edentulous 30% (91/306)

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

51 Reconstructive Surgery Concepts
Tissue Replacement New Tissue Restoration Transfer Modify Simple geometric Whole tissue + Biomaterial Microvascular 6 6

52 Reconstructive Surgery Concepts
Tissue Replacement New Tissue Restoration Transfer Modify Simple geometric Whole tissue + Biomaterial Microvascular Tissue engineering 6 6

53

54

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

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

57

58

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

60

61

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

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

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

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

66 Bioengineers Bioscientists Clinician Scientists Tissue Engineering Techniques Industry products FDA Clinicians Clinical Practice

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

68 Thank You!


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