Limb Sparing Surgical Resection of Groin Sarcoma. Surgical ... - NCI

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29012cm which is the inferior epigastric artery.This allows a wide arc of rotation when usedas a pedicled flap [23]. This wide arc of rotationallows easy usage of either the right or leftrectus muscle. Adding to the possibility ofharvesting the skin island in a transverse or avertical direction, over its proximal or its distalpart are the main factors behind selection ofthis flap in most patients in the present studyso as to fit most of the previously unplannedskin defects in our patients. We prefer the ipsilateralone except if the ipsilateral inferiorepigastric artery is ligated. The main disadvantageof this flap is abdominal wall weakness soabdominal wall reconstruction by a prolinemesh was mandatory.Tensor fascia lata flap is a myofasciocutaneousflap based on the transverse branch ofthe lateral circumflex femoral artery [21,27,28].We had one case of tensor facia lata flap. A skinisland of 12cm in width and 23cm in lengthwas elevated. The main disadvantage was creationof dog ear and the need to graft the donorsite. Necrosis of distal part has also been reported[27] however; this has been avoided by leavingat least 8cm above the knee joint. Also it isnot suitable for reconstruction of longitudinalgroin defects parallel to the longitudinal axisof the tensor fascia lata flap that is why we hada limited number of patients having this flapreconstruction.The pedicled anteroalteral thigh flap hasbeen used for reconstruction of groin, perinealand gental defects [22]. It can be raised as afasciocutaneous or myocutaneous flap (a portionof vastus lateralis muscle), it is based on thedescending branch of lateral circumflex femoralvessel. The pedicle is long and allows easilymedial rotation. Skin territory of the flap is verywide and large (25 x 18cm). Primary closureof the donor site is possible when the transverseaxis of the defect is less than 8cm [29,30,31]. Wehad one case in the present study having anterolateralthigh flap.Limb Sparing Surgical Resection of Groin SarcomaGracilis myocutaneous flap is a versatileflap for reconstruction of groin, perineal andgental defects [32]. It is based on descendingbranches of medial circumflex femoral artery[24]. Skin availability is limited, that is why weused it in only 3 cases in the present studybecause they had little skin defect. It has noadverse effect on adductor muscle group functiondonor site can be closed primary leavingan acceptable scar in the medial aspect of thethigh.Rectus femoris muscle and myocutaneousflap has been reported in reconstruction of groindefect [26]. It is based on branches from descendingbranch of lateral circumflex femoral.However, it is not widely used because it hassignificant knee weakness and there are otherreliable flap, that is why we did not try to useit in the present study.Sartorius muscle has a segmental bloodsupply (Type IV) [25]. It has a thin muscle belly,which is not suitable to cover large defects afterresection of groin sarcoma [33]. However, weroutinely used it even in the presence of othermuscle flaps to cover femoral vessels unless itis included in the resection. It has been used in57% of our cases.Modified inguinal or abdominoinguinal incisionin the 2 cases shown in the present study,generally healed well without any complicationsand without ischemia to the skin edges. Thishas also been also reported by Karakousis [7].This raises the issue that, appropriate biopsymay avoid the need to remove part of the skinunless involved by the tumor. In such cases,muscle transfer without skin may be enough tocover vascular prosthesis, mesh or exposedvessels. The only situation where ischemia wasexpected to occur with abdominoinguinal incisionwas in a patient who have already had inthe past a transverse incision in the ipsilaterallower abdominal quadrant and therefore thismay result is a narrow strip of skin between theprevious transverse incision and the transverseportion of the abdominoinguinal incision whichmay have deficient blood supply. In order toavoid this complication, the transverse portionof incision was included passing through theprevious transverse incision and then extendsvertically into the groin area.Seroma formation after groin node dissectionis reported to be high. The drain output fromgroin can be as high as 4000ml per 24h in theearly postoperative days and frequently takes2-3 weeks to decrease [3,34]. The daily amountof seroma is markedly lower in the presentseries in comparison with that reported withgroin node dissection and took less time todecrease. The explanation of this finding may
Magdy El-Sherbiny 291be related to the retroperitoneal exposure thatmay enhance absorption of the resulting seroma.This encouraged us to remove the drains asearly as possible to minimize the incidence ofdeep infection. The drains were removed beforethe end of 2 weeks postoperatively in all caseswith no resulting lymphatic fistula or collection.The rate of perioperative morbidity must beevaluated in the light of the goals of limb salvagefor soft tissue sarcoma. Hematoma, deep woundinfection, skin necrosis, local flap sloughingand lymphatic fistulas are the major causes ofa complicated postoperative course. The use ofprosthetic material as proline mesh or prostheticvascular graft is considered a possible risk factorfor the development of deep wound infection[5,35]. Wound morbidity rate of 34.7% has beenreported. Deep wound infection and exposureof the proline mesh near the lower part of theabdominal wall was seen in one case in thepresent series (7%). This patient received preoperativeradiotherapy which is considered arisk factor. Cautious interpretation, however, ismandatory to minimize the risk of wound complications.Aseptic procedural standards, thecorrect placement of suction drains, prophylacticadministration of antibiotics, Careful hemostasisand use of suitable local muscle or musculocutaneousflaps to completely cover deep structuresare behind the low rate of complications in thepresent study.Chronic lymphedema is most likely causedby extensive resection of lymphatic tissue andextensive fibrosis due to postoperative radiotherapy[3]. Lymphedema may have a vascularcomponent due to loss of venous patency aftervenous replacement. On long term follow-up,only 35% of our cases developed chroniclymphedema. It is low in comparison with otherauthors [2,16]. This may be explained by developmentof collaterals across myocutaneous flapsused in 71.4% of patients. For most patients,the edema occasionally decreases with physiotherapy.Removal of the pubic bone and its rami doesnot appear to have any long term effects inambulation [36] however, reconstruction of theresulting defect is mandatory to prevent thedevelopment of inguinal heria. In one case inaddition of resection pubic bone, part of theacetabulum was included with the resection.This was reconstructed by a double layer ofdacron graft and proline mesh. This has notbeen reported however, this may be consideredas, on follow-up, this patient did not have anyhip pain, stiffness or migration of the head offemur. According to the MSTS function score,all our patients have achieved a high functionalscore ranging from 92% to 97%.The use of adjuvant radiation therapy inpatients with limb sparing surgery for extremitySTS has been widely accepted [37,38,39]. Weapply postoperative radiotherapy for extremitysoft tissue sarcoma in our institute. Intraoperativeradiotherapy improves local tumor control[40]. However; this type of therapy is not availablein our institute. We had no delay in startingradiotherapy in the present study as we had nowound problems in nearly all cases. The onlyone case who had wound breakdown had receivedradiation therapy before salvage surgery.Concerning patient survival and local tumorcontrol, this study had shown that a stagedependentlong-term survival and local tumorcontrol could be achieved. The 2 year survivalrate and local tumor control in those selectivehigh-risk group of STS patients, the minimalfollow-up period, was 92.8% and 85.7% respectively.We cannot compare our results with otherreported series [2,41,42] because we need a largernumber of patients and a longer follow-up period.Conclusion: Patients having groin sarcomawith some sort of improper management maystill have a chance of successful limb sparingsurgical resection with a curative intent. Properpreoperative reevaluation of extension of thetumor and vascular involvement, wide retroperitonealexposure to maximize tumor resectionwith negative margins, vascular replacement ifiliofemoral vessels are involved and availabilityof local myocutaneous flaps minimizes theproblems of wound healing and subsequentinfection. All those factors enable a safe limbsparingresection with stage-dependent oncologiclong-term outcome and good limb functionalresults.Acknowledgment: I would like to thank DrKarim salam for his support during vascularreconstruction in this series. Also, I would liketo thank Dr. Mohamed Rifat and Dr. Wael Samywho allowed us to include one case done bythem in this series.
Page 2: 282A high percentage of patients ha
Page 6 and 7: 286flap without skin was used in 2
Page 8 and 9: 288Limb Sparing Surgical Resection
Page 12 and 13: 292REFERENCES1- Brooks AD, Bowne WB

Limb Sparing Surgical Resection of Groin Sarcoma. Surgical ... - NCI

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