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Journal of Plastic, Reconstructive &... Jun 2022The vertical rectus abdominis myocutaneous (VRAM) flap is one of the options for soft-tissue reconstruction in the groin and thigh. The aim of this study is to evaluate...
BACKGROUND
The vertical rectus abdominis myocutaneous (VRAM) flap is one of the options for soft-tissue reconstruction in the groin and thigh. The aim of this study is to evaluate the clinical outcomes, risk factors for complications, and the utility of using mesh to prevent abdominal hernia.
METHODS
A retrospective review of patients who underwent VRAM flap reconstruction to reconstruct proximal thigh and groin defects from 1997 to 2018 was performed. Data regarding patient demographics, surgical characteristics, and postoperative outcomes were collected. Proportional hazard regression analysis was performed to assess the association of the risk of recipient site complications. A systematic review was performed to assess the outcomes and summarize the evidence from published studies.
RESULTS
Fifty-three patients were identified and included in this study. In most of the cases, the procedures were performed after tumor resection (77%) and in the rest of the cases, they were performed for chronic complicated wounds (23%). Twenty-five (47.2%) patients developed complications. Intraoperative and postoperative radiotherapy, chronic kidney disease, history of prior tumor resection, and reconstructions of chronic complicated wounds were associated with an increased risk of recipient site complications. A systematic review identified 9 articles, for a total of 189 reconstructions. The pooled complications and failure rates were 31.2% and 2.1%, respectively. Stratified analysis showed that the rate of abdominal hernia was similar in patients with mesh (16.7%) and in patients with primary closure only (15.1%; p = 0.761).
CONCLUSION
Defects in the groin or proximal thigh can be treated successfully with the VRAM flap. Although wound complications and hernia rates are high, the reconstruction failure rate is low.
Topics: Groin; Hernia, Abdominal; Humans; Myocutaneous Flap; Neoplasms; Postoperative Complications; Plastic Surgery Procedures; Rectus Abdominis; Retrospective Studies; Thigh
PubMed: 35148978
DOI: 10.1016/j.bjps.2022.01.015 -
British Journal of Anaesthesia Dec 2023Fascial plane blocks provide effective analgesia after midline laparotomy; however, the most efficacious technique has not been determined. We conducted a systematic... (Meta-Analysis)
Meta-Analysis Review
Comparative efficacy and safety of non-neuraxial analgesic techniques for midline laparotomy: a systematic review and frequentist network meta-analysis of randomised controlled trials.
BACKGROUND
Fascial plane blocks provide effective analgesia after midline laparotomy; however, the most efficacious technique has not been determined. We conducted a systematic review and network meta-analysis of randomised controlled trials to synthesise the evidence with respect to pain, opioid consumption, and adverse events.
METHODS
We searched Ovid MEDLINE, Embase, Cochrane Central, and Scopus databases for studies comparing commonly used non-neuraxial analgesic techniques for midline laparotomy in adult patients. The co-primary outcomes of the study were 24-h cumulative opioid consumption and 24-h resting pain score, reported as i.v. morphine equivalents and 11-point numerical rating scale, respectively. We performed a frequentist meta-analysis using a random-effects model and a cluster-rank analysis of the co-primary outcomes.
RESULTS
Of 6115 studies screened, 67 eligible studies were included (n=4410). Interventions with the greatest reduction in 24-h cumulative opioid consumption compared with placebo/no intervention were single-injection quadratus lumborum block (sQLB; mean difference [MD] -16.1 mg, 95% confidence interval [CI] -29.9 to -2.3, very low certainty), continuous transversus abdominis plane block (cTAP; MD -14.0 mg, 95% CI -21.6 to -6.4, low certainty), single-injection transversus abdominis plane block (sTAP; MD -13.7 mg, 95% CI -17.4 to -10.0, low certainty), and continuous rectus sheath block (cRSB; MD -13.2 mg, 95% CI -20.3 to -6.1, low certainty). Interventions with the greatest reduction in 24-h resting pain score were cRSB (MD -1.2, 95% CI -1.8 to -0.6, low certainty), cTAP (MD -1.0, 95% CI -1.7 to -0.2, low certainty), and continuous wound infusion (cWI; MD -0.7, 95% CI -1.1 to -0.4, low certainty). Clustered-rank analysis including the co-primary outcomes showed cRSB and cTAP blocks to be the most efficacious interventions.
CONCLUSIONS
Based on current evidence, continuous rectus sheath block and continuous transversus abdominis plane block were the most efficacious non-neuraxial techniques at reducing 24-h cumulative opioid consumption and 24-h resting pain scores after midline laparotomy (low certainty). Future studies should compare techniques for upper vs lower midline laparotomy and other non-midline abdominal incisions.
CLINICAL TRIAL REGISTRATION
PROSPERO Registration Number: CRD42021269044.
Topics: Adult; Humans; Analgesics, Opioid; Laparotomy; Network Meta-Analysis; Morphine; Pain; Pain, Postoperative
PubMed: 37770254
DOI: 10.1016/j.bja.2023.08.024 -
Journal of Plastic Surgery and Hand... Apr 2021Vulvoperineal defects resulting from surgical treatment of (pre)malignancies may result in reconstructive challenges. The vertical rectus abdominis muscle flap and, more...
Vulvoperineal defects resulting from surgical treatment of (pre)malignancies may result in reconstructive challenges. The vertical rectus abdominis muscle flap and, more recently, the fasciocutaneous lotus petal flap are often used for reconstruction in this area. The goal of this review is to compare the postoperative complications of application of these flaps. A comprehensive literature search of the PubMed, MEDLINE and Cochrane Library databases was performed until 6 June 2020. Search terms included the lotus petal flap, vertical rectus abdominis muscle flap and the vulvoperineal area. Articles were independently screened by two researchers according to the PRISMA-guidelines. A total of 1074 citations were retrieved and reviewed, of which 55 were included for full text analysis. Following lotus petal flap reconstructions, the complication rate varied from 0.0% to 69.9%, with more complications concerning the recipient site compared with the donor site complications (26.0% versus 4.5%). Following vertical rectus abdominis muscle flap reconstructions the complication rate varied between 0.0% and 85.7% with almost twice the number of recipient site complications compared to donor site complications (37.1% versus 17.8%). Overall, the lotus petal flap has lower complication rates at both the donor and the recipient site compared with the vertical rectus abdominis muscle flap. When both options seem viable, the lotus petal flap procedure may be preferred on the basis of the reported lower complication rates. APE: abdominoperineal excision; ELAPE: extra levator abdominoperineal excision; LP flap: lotus petal flap; NIH: National Institute of Health; NR: not reported; RCT: randomized controlled trial; VRAM flap: vertical rectus abdominis myocutaneous flap.
Topics: Female; Humans; Myocutaneous Flap; Perineum; Postoperative Complications; Rectus Abdominis; Surgical Flaps; Vulva
PubMed: 33054472
DOI: 10.1080/2000656X.2020.1828902 -
Surgical Endoscopy Oct 2021A subcutaneous endoscopic onlay repair for ventral hernia with an anterior plication of diastasis recti (DR) has been published under different names in different... (Review)
Review
BACKGROUND
A subcutaneous endoscopic onlay repair for ventral hernia with an anterior plication of diastasis recti (DR) has been published under different names in different countries. The aim of this systematic review is to assess the safety and feasibility of different named techniques with the same surgical concept.
METHODS
The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score system was used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study designs, risk of bias, publication bias, heterogeneity, and statistical analysis.
RESULTS
The systematic literature search found 2548 articles, 317 of which were duplicates and excluded from analysis. The titles and abstracts from the remaining 2231 articles were assessed. After careful evaluation, 2125 articles were determined to be unrelated to our study and subsequently excluded. The full text of the remaining 106 articles was thoroughly assessed. Case reports, editorials, letters to the editor, and general reviews were then excluded. A total of 13 articles were ultimately included for this review, describing a similar subcutaneous endoscopic approach for repair of concomitant ventral hernias and rectus diastasis defined under nine different named techniques on 716 patients. The number of patients in those studies varied from 10 to 201. The mean operative time varied from 68.5 to 195 min. The most common complication was seroma, followed by pain requiring intervention, hematoma, and surgical site infection.
CONCLUSIONS
There are a few technique variations described in different studies, but with no significant differences in outcomes. We, therefore, propose to unify these procedures under one term, ENDoscopic Onlay Repair (ENDOR). This technique has shown to be effective and safe, with seroma being the most common complication.
Topics: Diastasis, Muscle; Endoscopy; Hernia, Ventral; Herniorrhaphy; Humans; Rectus Abdominis; Surgical Mesh
PubMed: 34031740
DOI: 10.1007/s00464-021-08560-5 -
Paediatric Anaesthesia Apr 2016The role of rectus sheath blocks (RSB) and transversus abdominis plane (TAP) blocks in pediatric surgery has not been well established. (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The role of rectus sheath blocks (RSB) and transversus abdominis plane (TAP) blocks in pediatric surgery has not been well established.
OBJECTIVE
We aimed to determine if RSB and TAP blocks decrease postoperative pain and improve recovery in children.
DATA SOURCES
Duplicate searching of MEDLINE, EMBASE, Cochrane, Web of Science, and trial registries databases by two reviewers.
STUDY SELECTION
Included were randomized trials in children on RSB or TAP block in abdominal operations, excluding inguinal procedures.
DATA EXTRACTION
Independent duplicate data extraction and quality assessment using a standardized form.
RESULTS
Ten trials met inclusion criteria (n = 599), RSB in five and TAP block in five. A linear mixed effects model on patient level data from three trials showed nerve blocks lowered morphine requirements 6-8 h after surgery, -0.03 mg · kg(-1) (95% CI -0.05, -0.002). Pooled analysis of summary data showed nerve blocks lowered 0-10 scale pain scores immediately after the operation, -0.7 (95% CI -1.3, -0.1); lowered 4-16 scale pain scores, -2.0 (95% CI -2.3, -1.7); and delayed the time to first rescue analgesia, 17 min (95% CI 1.3, 33). Quality assessment showed some studies at moderate to high risk of bias.
CONCLUSION
Abdominal wall blocks reduce pain and opiate use in children. We advise cautious interpretation of the results given the heterogeneity of studies.
Topics: Abdominal Wall; Humans; Nerve Block; Randomized Controlled Trials as Topic; Rectus Abdominis
PubMed: 26846889
DOI: 10.1111/pan.12855 -
Journal of Plastic Surgery and Hand... Aug 2021Rectus diastasis is characterized by widening and laxity of the linea alba, causing the abdominal content to bulge. Rectus diastasis is treated either conservatively... (Review)
Review
Rectus diastasis is characterized by widening and laxity of the linea alba, causing the abdominal content to bulge. Rectus diastasis is treated either conservatively with physiotherapy, or surgically, surgical treatment showing especially convincing results. The primary aim of this study was to describe surgical techniques used to correct abdominal rectus diastasis. Secondary, we wished to assess postoperative complications in relation to the various techniques. A systematic scoping review was conducted and reported according to the PRISMA-ScR statement. PubMed, Embase, and Cochrane Library were searched systematically. Studies were included if they described a surgical technique used to repair abdominal rectus diastasis, with or without concomitant ventral hernia. Secondary outcomes were recurrence rate and other complications. A total of 61 studies were included: 46 used an open approach and 15 used a laparoscopic approach for repair of the abdominal rectus diastasis. All the included studies used some sort of plication, but various technical modifications were used. The most common surgical technique was classic low abdominoplasty. The plication was done as either a single or a double layer, most commonly with permanent sutures. There were overall low recurrence rates and other complication rates after both the open and the laparoscopic techniques. We identified many techniques for repair of abdominal rectus diastasis. Recurrence rate and other complication rates were in general low. However, there is a lack of high-level evidence and it is not possible to recommend one method over another. Thus, further randomized controlled trials are needed in this area.
Topics: Abdominal Wall; Abdominoplasty; Hernia, Ventral; Humans; Rectus Abdominis; Sutures
PubMed: 33502282
DOI: 10.1080/2000656X.2021.1873794 -
Annals of Plastic Surgery May 2016Although several studies have found obesity to increase the risk of postoperative morbidity in autologous breast reconstruction, there remains some controversy over the... (Comparative Study)
Comparative Study Meta-Analysis Review
Effects of Obesity on Postoperative Complications After Breast Reconstruction Using Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous, Deep Inferior Epigastric Perforator, and Superficial Inferior Epigastric Artery Flap: A Systematic Review and Meta-analysis.
BACKGROUND
Although several studies have found obesity to increase the risk of postoperative morbidity in autologous breast reconstruction, there remains some controversy over the influence of obesity for muscle-conserving abdominal flaps, including muscle-sparing transverse rectus abdominis myocutaneous (msTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps. This review evaluates the effects of obesity on complications in breast reconstruction using muscle-conserving abdominal flaps and compares them to those for conventional free transverse rectus abdominis myocutaneous (TRAM) flaps.
METHODS
A literature search was conducted using MEDLINE, Ovid, and Cochrane databases for studies reporting complication rates for obese and nonobese patients undergoing breast reconstruction using msTRAM, DIEP, and SIEA flaps and conventional free TRAM flaps. The pooled relative risks (RRs) of the obesity for flap-related and donor complications were estimated in the muscle-conserving flaps by meta-analytic methodology and the pooled complication rates in obese patients were compared between muscle-conserving flaps and conventional TRAM flaps. Here, only those studies following the World Health Organization definition of obesity (body mass index ≥ 30 kg/m) were included.
RESULTS
A total of 17 articles were analyzed. Eight studies were used to compute the obesity-related risks of flap-related and donor complications for msTRAM, DIEP, and SIEA flaps. Obesity increased the risk of total flap loss [RR, 1.68; 95% confidence interval (CI), 0.85-3.33], partial flap loss (RR, 2.26; 95% CI, 1.01-5.02), abdominal bulge or hernia (RR, 1.72; 95% CI, 1.00-2.95), and overall abdominal complications (RR, 1.53; 95% CI, 1.10-2.14). The results of a pooled analysis with 15 studies are consistent with those of the meta-analysis. In comparison to free TRAM flaps, muscle-conserving abdominal flaps showed a lower pooled incidence of flap loss, fat necrosis, and abdominal bulge or hernia in obese patients.
CONCLUSIONS
This review suggests that obesity increases the risk of both flap-related and donor-site complications in breast reconstruction using msTRAM, DIEP, and SIEA flaps. In comparison to conventional TRAM flaps, however, muscle-conserving abdominal flaps may have an advantage in reducing the morbidity in obese patients.
Topics: Epigastric Arteries; Female; Free Tissue Flaps; Humans; Mammaplasty; Myocutaneous Flap; Obesity; Postoperative Complications; Rectus Abdominis; Risk Factors; Surgical Flaps
PubMed: 25536199
DOI: 10.1097/SAP.0000000000000400 -
Cancers Feb 2021Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative... (Review)
Review
BACKGROUND
Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers).
METHODS
We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE.
RESULTS
Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43-0.71; < 0.01/Group B: OR 0.54, CI 0.17-1.68; = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35-0.68; < 0.001/Group B: OR 0.38, 95% CI 0.12-1.17; < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39-4.35; < 0.01) and major (OR 1.67, 95% CI 0.90-3.08; = 0.1) perineal complications in Group C.
CONCLUSION
Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.
PubMed: 33578769
DOI: 10.3390/cancers13040721 -
Journal of Plastic, Reconstructive &... Apr 2023Nutritional status may be impaired in patients with head and neck cancer undergoing surgical treatment, often necessitating gastrostomy tube (G-tube) placement.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Nutritional status may be impaired in patients with head and neck cancer undergoing surgical treatment, often necessitating gastrostomy tube (G-tube) placement. Identifying which patients will require a G-tube remains a challenge. This study identifies predictors of G-tube requirement in patients undergoing tumor resection and reconstruction with pedicled or free flaps.
METHODS
Systematic review of the PubMed, Cochrane, and Scopus databases was performed of English language articles, discussing risk factors of perioperative G-tube placement among patients >18 years. Data on patient, tumor, and treatment factors, as well as need for G-tube, were collected. Univariable meta-analysis was conducted to identify predictors for G-tube placement.
RESULTS
Eleven studies (1,112 patients) met inclusion criteria. Overall pooled prevalence of postoperative G-tube placement was 25%. Patients with advanced cancer stage IV/recurrence were more likely to require a G-tube (OR 2.81 [CI 1.03-7.69]; p<0.05), as were those who had undergone preoperative radiation (OR 3.55 [CI 2.03-6.20], p<0.05). Reconstruction with a radial forearm free flap was associated with a lower need for G-tube versus rectus abdominis (OR 0.25 [CI 0.08-0.83], p=0.02) and latissimus dorsi flap (OR 0.21 [CI 0.04-1.09], p=0.06). There was no difference in G-tube placement between those receiving pedicled flaps versus free flaps (OR 1.54 [CI 0.38-6.20], p=0.54).
CONCLUSIONS
Among patients with head and neck cancer undergoing resection with immediate pedicled or free flap reconstruction, advanced tumor stage and history of prior radiation therapy are associated with increased likelihood of G-tube placement. More randomized controlled trials are needed to develop a decision-making algorithm.
Topics: Humans; Gastrostomy; Plastic Surgery Procedures; Free Tissue Flaps; Head and Neck Neoplasms; Risk Factors; Retrospective Studies; Postoperative Complications
PubMed: 36780787
DOI: 10.1016/j.bjps.2022.08.040 -
Plastic Surgery (Oakville, Ont.) 2015Even with patent deep inferior epigastric vein anastomoses, venous congestion can occur during free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior... (Review)
Review
Intraoperative venous congestion in free transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator flaps during breast reconstruction: A systematic review.
BACKGROUND
Even with patent deep inferior epigastric vein anastomoses, venous congestion can occur during free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flap surgery and lead to flap compromise if not recognized and managed.
OBJECTIVES
To identify the incidence of intraoperative venous congestion and describe the best available prevention and treatment methods.
METHODS
Systematic electronic searches of the PubMed database including Medline were performed to identify studies published until 2014. The following keywords were used: "DIEP" or "free TRAM" and "venous insufficiency" or "venous congestion". Supplemental searches were conducted to identify referenced studies. Statistical analysis using the χ(2) test was performed.
RESULTS
Nine studies representing 4747 free abdominal flaps cases were included and demonstrated an overall incidence of intraoperative venous congestion of 2.8%. The incidence in DIEP flaps (3.3%) was significantly higher than that in the free TRAM flaps (1.0%). All nine articles reported using the superficial inferior epigastric vein to treat venous insufficiency.
CONCLUSION
The risk for developing intraoperative venous congestion following free abdominal flap breast reconstruction is influenced by inadequate perforator selection and persistent dominance in the superficial venous system. The solution is establishing another venous draining route using the superficial inferior epigastric vein.
PubMed: 26665142
DOI: No ID Found