Outcomes of VAC temporization following the excision of microinvasive sarcomas pending negative formal pathologic margins.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e23559-e23559
Author(s):  
Mitchell Stephen Fourman ◽  
Duncan C. Ramsey ◽  
Erik T. Newman ◽  
Joseph H. Schwab ◽  
Yen-Lin Chen ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Local Recurrence ◽  
False Negative ◽  
Free Flaps ◽  
Soft Tissue Coverage ◽  
Tumor Bed ◽  
Local Recurrences ◽  
Additional Surgery ◽  
Comorbidity Index

e23559 Background: Microinvasive sarcomas can yield a high number of false negative intraoperative pathology margin analyses. Additional oncologic resection after soft tissue coverage is technically challenging and oncologically inaccurate. As a result the rate of local recurrence for these histologies can be 25% or higher. In select patients we have temporized the sarcoma tumor bed with a wound VAC pending final pathologic margins. If positive, the patient can return to the OR for a tumor bed excision. If negative, soft tissue coverage can proceed. Here we evaluate our outcomes using this approach. Methods: We retrospectively studied patients with primary sarcomas managed with a VAC temporizing approach from from 1/1/2003 to 12/1/2019 with a minimum of 2 years of oncologic follow-up. Patients with unplanned ("oopsie") excisions were also included. Our primary outcome was local recurrence. Data is presented as percentages or mean ± standard deviation where appropriate. Results: Sixty-three patients were included (Table). Mean age was 62.3 ± 22.3 (median 67.3) years, 23 (36.5%) were female, and mean age-adjusted charlson comorbidity index was 5.3 ± 1.9. Twenty-four (38.1%) had undergone “oopsie” excisions. R0 margins were achieved in 59 (93.7%) patients, while the other 4 were known R1 resections due to patient tolerance or anatomy. Five local recurrences (7.9%) were diagnosed 3.2 ± 1.5 years after surgery, of which 3 had known positive margins. Free flaps were needed in 17 (27.0%) patients. Metastatic disease was diagnosed in 8 (12.7%) patients, who all died of disease. Mean follow-up was 4.4 ± 2.9 years. Conclusions: VAC temporization results few local recurrences in patients with formally confirmed negative margins. This technique is particularly useful in the treatment of microinvasive disease or in the management of vulnerable hosts who may not be able to tolerate additional surgery in the future.[Table: see text]

scholarly journals Variants of Extended Latissimus Dorsi Musculocutaneous Flap for Large Wounds in Extremities

2020 ◽  
Author(s):  
Jiqiang He ◽  
Liming Qing ◽  
Panfeng Wu ◽  
Zhengbing Zhou ◽  
Fang Yu ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Latissimus Dorsi ◽  
Donor Site ◽  
Free Flaps ◽  
Lower Limbs ◽  
Soft Tissue Coverage ◽  
Skin Defect ◽  
Reliable Methods ◽  
Large Skin

Abstract Background: Extended latissimus dorsi musculocutaneous (LDMC) flap increasing the size of the flap and most used for breast reconstruction. This report will share our experience in designing different extended LDMC flap for large wounds in extremities.Patients and methods: From January 2004 to December 2018, extended LDMC flaps were performed on 72 consecutive patients aged 2 to 68 years (37 men and 35 women). All the wounds were extensive, either in upper or lower limbs, the skin defect ranged from 18 ×10 cm2 to 37 × 21 cm2. Single wing and double wings extended LDMC flaps were designed and harvested based on the wounds.Results: Seventy-two patients included this series, 5 pedicle and 67 free flaps were successfully harvested. The mean flap harvest time was 56.2 min. The donor sites were closed primarily in all patients. The venous compromise was noticed on the first postoperative day in 4 cases. Two flaps were salvaged after emergency re-exploration, another two patient’s flaps were total necrosis. One of the patients was received lower extremity amputation, another patient was repaired by extended LDMC flap on the other side. The wounds healed well, providing reliable soft tissue coverage and good contour in the reconstructed areas. Five patients lost follow-up, the follow-up period ranged from 10 to 56 months (mean, 15.7 months). Patients didn’t occur significant donor site morbidities that influenced their daily activities during follow-up.Conclusion: The single wing and double wings extended latissimus dorsi musculocutaneous flaps are simple and reliable methods for large skin and soft-tissue defects in extremities.

VAC temporization pending final margins after suprafascial myxofibrosarcoma excision to reduce the rate of local recurrence.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 11573-11573
Author(s):  
Mitchell Stephen Fourman ◽  
Duncan C. Ramsey ◽  
Justin Kleiner ◽  
Anser Daud ◽  
Erik T. Newman ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Local Recurrence ◽  
Single Stage ◽  
Cancer Center ◽  
Wound Complications ◽  
P Value ◽  
Adjuvant Radiation ◽  
Soft Tissue Coverage ◽  
Soft Tissue Reconstruction ◽  
Tumor Bed

11573 Background: The microinvasive nature of suprafascial myxofibrosarcoma complicates the accuracy of intraoperative margin assessment, and tumor bed resections after soft tissue reconstruction are unreliable. For the past 3 years we have temporized the excised tumor bed with a wound VAC, delaying soft tissue coverage until final negative margins were achieved. Here, we compare the oncologic/surgical outcomes of suprafascial myxofibrosarcomas managed with VAC temporization (VT) with single-stage excision/reconstruction (SS). Methods: We retrospectively studied suprafascial myxofibrosarcomas managed from 1/1/2000 to 1/1/2019 who received neoadjuvant or adjuvant radiation and had at least 2-years of oncologic follow-up at a tertiary referral cancer center. Our primary outcome was local recurrence. Comparisons were performed using Fisher’s Exact Test or Students t-test. A p-value < 0.05 was considered significant. Results: Fifty-three patients (18 VAC temporized, 35 single stage) were included. While VT patients were older (74.9 ± 10.2 vs. 63.9 ± 13.6, p = 0.003), treatment groups did not significantly differ with respect to comorbidity, tumor volume, stage and grade. VT patients had significantly fewer local recurrences (5.6% vs. 28.6% after SS, p = 0.048) and R1 resections that required an unplanned readmission for tumor bed re-excision (0% vs. 37.1% after SS, p = 0.002). VT required more total surgeries (2.8 ± 0.9 vs. 1.8 ± 0.9 for SS, p = 0.0002). Post-operative infectious and wound complications were equivalent (Table). Conclusions: Our VAC temporization strategy had a significantly lower LR than SS treatment. While high quality multi-institutional validation is required, VT may represent a paradigm shift in the management of myxofibrosarcoma.[Table: see text]

FREE FLAPS FOR SOFT TISSUE COVERAGE IN THE HAND AND FINGERS

Hand Clinics ◽  
1999 ◽  
Vol 15 (4) ◽  
pp. 541-554 ◽  
Author(s):  
Hung-Chi Chen ◽  
Mark T. Buchman ◽  
Fu-Chan Wei
Keyword(s):  
Soft Tissue ◽  
Free Flaps ◽  
Soft Tissue Coverage

Principles of Wound Management and Soft Tissue Repair II

2018 ◽  
Author(s):  
Jonathan S. Friedstat ◽  
Michelle R Coriddi ◽  
Eric G Halvorson ◽  
Joseph J Disa
Keyword(s):  
Soft Tissue ◽  
Tissue Repair ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Wound Management ◽  
Soft Tissue Coverage ◽  
Soft Tissue Repair ◽  
Healing Wound ◽  
Contour Defects ◽  
Tissue Flaps

Wound management and soft-tissue repair can vary depending on the location. The head and neck, chest and back, arm and forearm, hand, abdomen, gluteal area and perineum, thigh, knee, lower leg, and foot all have different local options and preferred free flaps to use for reconstruction. Secondary reconstruction requires a detailed analysis of all aspects of the wound including any scars, soft tissue and/or skin deficits, functional defects, contour defects, complex or composite defects, and/or unstable previous wound coverage. Careful monitoring of both the patient and reconstruction is necessary in the postoperative period to ensure long-term success.   This review contains 2 figures and 17 references. Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps

Principles of Wound Management and Soft Tissue Repair II

2018 ◽  
Author(s):  
Jonathan S. Friedstat ◽  
Michelle R Coriddi ◽  
Eric G Halvorson ◽  
Joseph J Disa
Keyword(s):  
Soft Tissue ◽  
Tissue Repair ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Wound Management ◽  
Soft Tissue Coverage ◽  
Soft Tissue Repair ◽  
Healing Wound ◽  
Contour Defects ◽  
Tissue Flaps

Wound management and soft-tissue repair can vary depending on the location. The head and neck, chest and back, arm and forearm, hand, abdomen, gluteal area and perineum, thigh, knee, lower leg, and foot all have different local options and preferred free flaps to use for reconstruction. Secondary reconstruction requires a detailed analysis of all aspects of the wound including any scars, soft tissue and/or skin deficits, functional defects, contour defects, complex or composite defects, and/or unstable previous wound coverage. Careful monitoring of both the patient and reconstruction is necessary in the postoperative period to ensure long-term success.   This review contains 2 figures and 17 references. Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps

scholarly journals Being Prepared for the Next Conflict Part II: Case Analysis of a Military Level 1 Trauma Center

2020 ◽  
Vol 185 (7-8) ◽  
pp. e1235-e1239
Author(s):  
Thomas T Wood ◽  
Haydn J Roberts ◽  
Daniel J Stinner
Keyword(s):  
Soft Tissue ◽  
Lower Extremity ◽  
Trauma Center ◽  
Free Flaps ◽  
Soft Tissue Coverage ◽  
Combat Casualty ◽  
Civilian Trauma ◽  
Low Volume ◽  
Level 1 ◽  
Level 1 Trauma Center

Abstract Introduction Combat-related injuries have declined substantially in recent years as we have transitioned to a low-volume combat casualty flow era. Surgeons must remain actively committed to training for the next engagement to maintain life and limb-saving skills. Soft tissue coverage procedures were imperative to the management of complex lower extremity trauma that occurred during recent conflicts. The purpose of this study was to evaluate advanced soft tissue coverage procedures performed on the lower extremity over the previous decade on military and civilian trauma patients at a Department of Defense Level 1 trauma center to provide data that can be used to guide future training efforts. Materials and Methods The electronic surgical record system was searched for cases that utilized advanced soft tissue coverage (rotational and free flaps) to the lower extremity. The date of treatment, indication, procedure performed, and military/civilian patient designation were recorded. The data was categorized between military and civilian cases, rotational versus free flap, and indication and then charted over time. It was assessed as moving averages over a 12-month period. Statistically distinct periods were then identified. Results From January 2006 to March 2015, 132 advanced soft tissue coverage procedures were performed on the lower extremity (100 military, 32 civilian). Military soft tissue coverage data demonstrated peaks in 2007 and late 2011 to late 2012, averaging 6.5 (3.5–9.6) and 4.5 (3.2–5.8) per quarter, respectively. There were two low periods, from 2008 to mid-2010 and from mid-2012 to the end of the study, averaging 1.1 (0.6–1.6) and 1.8 (1.1–2.6) cases per quarter, respectively. Civilian procedures averaged 0.9 per quarter (0.5–1.2) throughout the study, but notably were equal to the number of military procedures by the last quarter of 2013 at 2.0 (1.2–2.8 civilian, 0.8–3.1 military). Conclusions This data supports prior identified trends in military cases correlating increased number of procedures with increased combat activity related to the conflicts in Iraq and Afghanistan in 2007 and 2011, respectively. The data showed relative stability in the numbers of civilian procedures with a slight uptrend beginning in mid-2012. A comparison after mid-2012 shows military procedures declining and civilian procedures increasing to eventually become equivalent at the end of the data collection. These trends follow previously reported data on tibia fracture fixation procedures and lower extremity amputations for the same time periods. These data demonstrate the importance of the civilian trauma mission for maintaining surgical skills relevant to limb salvage, such as rotational and free flaps, during a low-volume combat casualty flow era.

Risk of recurrence when cutting into intramucosal (pT1a) cancer from the cutting-plane side during gastric endoscopic submucosal dissection

Endoscopy ◽  
2020 ◽  
Vol 52 (10) ◽  
pp. 833-838
Author(s):  
Hiroko Nakahira ◽  
Takashi Kanesaka ◽  
Noriya Uedo ◽  
Masayasu Ohmori ◽  
Hiroyoshi Iwagami ◽  
...  
Keyword(s):  
Local Recurrence ◽  
Endoscopic Submucosal Dissection ◽  
Cutting Plane ◽  
Risk Of Recurrence ◽  
Gastric Cancers ◽  
Submucosal Dissection ◽  
Additional Surgery ◽  
Risk Factors For Recurrence ◽  
Surveillance Endoscopy

Background During endoscopic submucosal dissection (ESD), procedural difficulty and poor visibility of the cutting plane sometimes cause the operator to cut into the lesion from the cutting-plane side, making the vertical margin positive (VM1) or unclear (VMX). In the present study, we evaluated the risk of recurrence of gastric cancer with VM1 /VMX after ESD. Methods In total, 1723 consecutive gastric cancers treated by ESD at Osaka International Cancer Institute from July 2012 to December 2017 were included in this retrospective cohort study. Among them, 231 submucosal or more deeply invasive gastric cancers were excluded because nontechnical factors may contribute to VM1 /VMX in such lesions. To quantify the risk of cutting into cancer from the cutting-plane side during ESD, the proportion of lesions with VM1 /VMX among the pT1a gastric cancers treated by ESD was calculated. The proportion of recurrence among these cases was calculated after exclusion of lesions with positive lymphovascular invasion or a positive horizontal margin in order to eliminate the obvious risk factors for recurrence. Results Among 1492 pT1a gastric cancers treated by ESD, 28 lesions (1.9 %; 95 % confidence interval [CI] 1.3 % – 2.7 %) histologically showed VM1 /VMX. No local recurrence (0.0 %; 95 %CI 0.0 % – 12.2 %) occurred among 23 cases. The median follow-up period was 41 months (range 10 – 84 months). Conclusions No local recurrence was detected in pT1a gastric cancers after VM1 /VMX resection by ESD. Surveillance endoscopy could be adopted for such cases without additional surgery.

scholarly journals The Pedicled Latissimus Dorsi Flap Provides Effective Coverage for Large and Complex Soft Tissue Injuries Around the Elbow

Hand ◽  
2017 ◽  
Vol 13 (5) ◽  
pp. 586-592 ◽  
Author(s):  
Jacques H. Hacquebord ◽  
Douglas P. Hanel ◽  
Jeffrey B. Friedrich
Keyword(s):  
Soft Tissue ◽  
Latissimus Dorsi ◽  
Soft Tissue Injuries ◽  
Soft Tissue Defect ◽  
Latissimus Dorsi Flap ◽  
Soft Tissue Coverage ◽  
Effective Coverage ◽  
Latissimus Flap ◽  
Proximal Forearm

Background: The pedicled latissimus flap has been shown to provide effective coverage of wounds around the elbow with an average size of 100 to 147 cm2 but with complication rates of 20% to 57%. We believe the pedicled latissimus dorsi flap is an effective and safe technique that provides reliable and durable coverage of considerably larger soft tissue defects around the elbow and proximal forearm. Methods: A retrospective review was performed including all patients from Harborview Medical Center between 1998 and 2012 who underwent coverage with pedicled latissimus dorsi flap for defects around the elbow. Demographic information, injury mechanism, soft tissue defect size, complications (minor vs major), and time to surgery were collected. The size of the soft tissue defect, complications, and successful soft tissue coverage were the primary outcome measures. Results: A total of 18 patients were identified with variable mechanisms of injury. Average defect size around the elbow was 422 cm2. Three patients had partial necrosis of the distal most aspect of the flap, which was treated conservatively. One patient required a secondary fasciocutaneous flap, and another required conversion to a free latissimus flap secondary to venous congestion. Two were lost to follow-up after discharge from the hospital. In all, 88% (14 of 16) of the patients had documented (>3-month follow-up) successful soft tissue coverage with single-stage pedicled latissimus dorsi flap. Conclusions: The pedicled latissimus dorsi flap is a reliable option for large and complex soft tissue injuries around the elbow significantly larger than previous reports. However, coverage of the proximal forearm remains challenging.

Analysis of five-year survival rate in patients with proximal femoral tumours after total hip replacement

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 19508-19508
Author(s):  
S. A. Saravanan ◽  
V. Sokolovski ◽  
V. Voloshin ◽  
M. Aliev ◽  
V. Zybikov ◽  
...  
Keyword(s):  
Overall Survival ◽  
Survival Rate ◽  
Soft Tissue ◽  
Local Recurrence ◽  
Total Hip Replacement ◽  
Hip Replacement ◽  
Pathological Fracture ◽  
Overall Survival Rate ◽  
Total Hip

19508 Background: To analyse the five-year survival rate in patients with proximal femoral tumours after total hip replacement. Methods: Between the period of 1994–2003, 50 patients were operated (Total Hip Replacement) for proximal femoral tumours at the Department of General Oncology (Bone & Soft tissue tuomurs), N. N. Blokhin Cancer Research Institute & Moscow Regional Clinical Research Institute, Moscow, Russian Federation. The histological diagnoses included 14 - metastases, 10 - osteosarcoma, 8 - chondrosarcoma, 4 - Ewing’s sarcoma, 4 - Giant cell tumor, 3 - malignant fibrous histiocytoma, 2 paraosteal and 2 periosteal osteosarcoma, and 1 each from primary neuroectodermal tumor, myeloid disease, and aneurysmal bone cyst. The follow-up ranged from 1–9 years (mean follow-up 5 years). 21 patients (45.7%) had pathological fracture. The cause of the pathological fracture was metastasis in 12 patients (26%). 28 patients (60.8%), had soft tissue invasion. All the survival analyses were done using Kaplan-Meier survivorship analysis method. Functional outcome was estimated using Enneking’s evaluation criteria. Results: The overall survival rate of patients was 66.7% at 5 years. 2 patients had local recurrence.12 patients had metastases after surgery. In that 11 patients were died. There was no evidence of disease in 32 patients. In 3 patients, we performed disarticulation of the hip joint because of the local recurrence. The overall survival rate of limb was 92.7% at 5 years. The overall survival rate of prostheses was 84.2% at 5 years. At the latest follow up, functional outcome was excellent in 15 (30%) patients, good in 27 (54%) patients, fair in 5 (10%) patients, poor in 3 (6%) patients. Conclusions: Though the extent of the muscle and bone resection is large, there is no doubt that endoprosthetic replacement of the proximal femur provides a good functional and oncological outcome when compared with the various other reconstructive surgeries. No significant financial relationships to disclose.

scholarly journals Reverse Radial Forearm Flap to Provide Arterial Inflow to a Toe Transfer

Hand ◽  
2016 ◽  
Vol 12 (2) ◽  
pp. 154-161 ◽  
Author(s):  
Joohak Kim ◽  
Alfred P. Yoon ◽  
Neil F. Jones
Keyword(s):  
Soft Tissue ◽  
Case Reports ◽  
Radial Forearm Flap ◽  
Soft Tissue Coverage ◽  
Forearm Flap ◽  
Arterial Inflow ◽  
Radial Forearm ◽  
Age Range ◽  
Toe Transfer

Background: Toe-to-thumb transfer has become the gold standard for thumb reconstruction, but in badly mutilated hands, additional soft tissue coverage may be required or a suitable recipient artery may not be available. There are only 3 case reports describing the successful use of a reverse radial forearm flap for coverage of a soft tissue defect around the thumb as well as providing arterial inflow for a toe transfer, performed either simultaneously or secondarily. Methods: A single surgeon’s experience of all toe-to-hand transfers performed in conjunction with a reverse radial forearm flap between 1995 and 2014 was reviewed, including patient demographics, type of toe transfer and vascular pedicle, whether immediate or secondary, follow-up, and complications. Results: Eight toe-to-hand transfers were performed in 7 patients—3 children (age range, 3-15 years) and 4 adults (age range, 19-39 years). Three patients underwent primary toe-to-thumb transfer simultaneously with a reverse radial forearm flap, and 5 patients underwent secondary toe-to-hand transfer between 4 months and 2½ years after an initial reverse radial forearm flap. All toe transfers survived completely. Average follow-up was 5.1 years. All patients were satisfied with the function and appearance of their reconstructed thumb. Conclusion: The reverse radial forearm flap is a very reliable procedure as a “Sister” or “Siamese” flap to provide immediate arterial inflow to a simultaneous toe-to-thumb transfer, or to provide primary soft tissue coverage on the radial aspect of the hand and subsequently provide a recipient arterial inflow for a secondary toe transfer.

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