Deckung komplexer pararektaler Beckendefekte: Rolle der freien myokutanen Musculus vastus lateralis Lappenplastik

Zusammenfassung

Hintergrund Aufgrund eines fortgeschrittenen Rektumkarzinoms kann eine Eviszeration mit Rektumamputation notwendig werden. Dabei können vor allem bei entsprechenden Voroperationen und neoadjuvanter Radiatio, ausgedehnte sowie tiefgreifende Weichteildefekte entstehen, die eine freie mikrovaskuläre Gewebetransplantation nötig werden lassen. In dieser Fallserie zeigen wir die erfolgreiche Kombination der muskulokutanen M. vastus lateralis-Lappenplastik (MVL) mit direktem Anschluss an die A. glutealis superior.

Material und Methoden Wir untersuchten über einen Zeitraum von 47 Monaten, 11 retrospektiv Fälle von Patienten, bei denen dorsale Beckendefekte nach Eviszeration und Rektumamputation bestanden, die mit lokalen oder regionalen Mitteln nicht zu verschließen waren. Bei all diesen Patienten erfolgte bei ausgedehnten Defekten mit tiefen pararektal Wundhöhlen eine Defektdeckung durch eine freie myokutaner MVL-Lappenplastik mit direkte Gefäßanschluss an die superioren Glutealgefäße.

Ergebnisse Die Defektgröße betrug im Mittel 290,0 cm² (SD: 131,2; Range: 200–600 cm²). Die Defekttiefe betrug im Mittel 10,5 cm. Die Defekte machten somit MVL-Lappenplastiken mit einer mittleren Größe von 336,3 cm² notwendig. Es waren aufgrund von Nachblutungen drei operative Revisionen nötig. Es traten weder arterielle noch venöse Thrombosen sowie kein Lappenverlust auf. Einzig wurde eine Lappenspitzennekrose beobachtet, die sekundär per Direktnaht korrigiert werden konnte. Die Auswertung des Case-Mix ergab einen Wert von im Mittelwert 24,251 (SD: 21,699; Range: 7,036–65,748) Punkten, was die Komplexität der Fälle unterstreicht.

Schlussfolgerungen Unsere Ergebnisse zeigen, dass eine freie mikrovaskuläre MVL-Lappenplastik eine praktikable Therapieoption für pararektale Defekte darstellt, die nicht durch lokoregionale Methoden verschlossen werden können. Die A. glutea superior ist dafür ein sicheres und suffizientes Anschlussgefäß. In Kombination lassen sich auch ausgedehnte Defekte erfolgreich verschließen.

Abstract

Background In the event of an advanced rectal carcinoma, an evisceration with rectal amputation may become necessary. The resulting defects, due to their extent, depth, or local tissue damage from previous surgeries and radiation, can in many cases only be closed through free microvascular tissue transfer. In this case series, we demonstrate the successful combination of a musculocutaneous musculus vastus lateralis flap (MVL) with a direct connection to the superior gluteal artery.

Materials and Methods Over a 47-month period, we retrospectively examined 11 cases of patients with dorsal pelvic defects after evisceration and rectal amputation that could not be closed using local or regional means. In cases of extensive defects with deep pararectal wound cavities, all these patients underwent defect coverage through a free myocutaneous MVL flap with a direct vascular anastomosis to the superior gluteal vessels.

Results The mean defect size was 290.0 cm² (SD: 131.2; range: 200–600 cm²). The mean defect depth was 10.5 cm, necessitating MVL flap reconstruction with an average size of 336.3 cm². Three operative revisions were required due to postoperative bleeding. There were no arterial or venous thromboses, and no flap loss occurred. Only one necrosis of a distal flap tip was observed, which could be corrected secondarily by direct suturing. The case-mix evaluation yielded an average value of 24.251 (SD: 21.699; range: 7.036–65.748) points, emphasizing the complexity of the cases.

Conclusions Our results indicate that a free microvascular MVL flap is a viable therapeutic option for pararectal defects that cannot be closed by local or regional methods. The superior gluteal artery proves to be a safe and sufficient vascular connection. In combination, even extensive defects can be successfully closed.

Schlüsselwörter

myokutanen Musculus vastus lateralis-Lappenplastik - pararektale Defekte - Eviszeration

Keywords

MVL - Arteria glutea superior - superior gluteal artery - pararectal defects - evisceration - microvascular flap - musculus vastus lateralis myocutaneous flap

Publikationsverlauf

Eingereicht: 28. Januar 2024

Angenommen: 27. Februar 2024

Artikel online veröffentlicht:
22. April 2024

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