Using Delayed Bilateral Lumbar Artery Perforator Flaps for Salvaging a Large and Complicated Sacral Defect──A Case Report

利用延遲性雙側腰動脈穿通枝皮瓣重建一個大且複雜之薦部缺損──案例報告

李秉侖(Biing-Luen Lee) ； 馬旭(Hsu Ma) ； 石育仲(Yu-Chung Shih)

《臺灣整形外科醫學會雜誌》 25卷1期 (2016/03) Pp. 12-18

摘要

背景：薦骨腫瘤切除及薦椎切除後所產生的大型缺損之重建對於整形外科醫師而言是極具挑戰的，原因是腫瘤的切除及輔助的放射線治療通常會造成缺損周圍軟組織及血管的傷害，以致於無法使用局部皮瓣來做重建。游離皮瓣亦非常困難，因為不易找到適當的受供應血管。目的及目標：利用延遲性雙側腰動脈穿通枝皮瓣重建一個先前因為薦部脊索瘤，經腫瘤及薦椎切除及放射線治療後併發小腸疝氣及壞死，造成薦部大型缺損合併小腸外露的病患。材料及方法：一位51歲女性因先前薦部脊索瘤，經腫瘤及薦椎切除及放射線治療後併發因小腸疝氣及壞疽造成薦部壞死性筋膜炎，經腸段切除，筋膜切開及清創術後被轉至本院。起初表現為薦部15乘15公分大小之缺損合併小腸外露，以及小腸吻合處滲漏造成之腹內膿瘍。我們先使用腹腔引流及積極之傷口換藥治療，待病患之感染控制，營養狀態改善後，使用延遲性雙側腰動脈穿通枝皮瓣來重建其薦部缺損。結果：經18個月的門診追蹤，傷口癒合良好且無併發症產生，且病人能夠正常行走。結論：針對本研究所描述的案例，因放射線治療後無法使用局部皮瓣來重建，以及因為腹部手術後無法使用經骨盆腔直向腹直肌皮瓣來重建的狀況下，我們成功的使用延遲性雙側腰動脈穿通枝皮瓣取代游離皮瓣重建其薦部缺損，術後並未產生併發症且維持病人原先正常的走路功能。

並列摘要

Background: Reconstructing large sacral defects after sacrectomy for sacral tumor ablation remains a challenging task for plastic surgeons. The extent of tumor ablation and the delivery of adjuvant radiation therapy to the sacrum make the use of local tissue flaps unsuitable to cover the wound. Furthermore, free tissue transfers to this area can be challenging because of difficult access to adequate recipient vessels at the wound site. Aim and Objectives: We used delayed bilateral lumbar artery perforator flaps to salvage a sacral defect caused by a sacral chordoma treated with complete resection and sacrectomy followed by radiation therapy, which was complicated with bowel herniation and gangrene after bowel resection. Materials and Methods: A 51-year-old woman with an initial presentation of a 15 × 15 cm sacral defect with bowel exposure and intra-abdominal abscess caused by small bowel anastomosis leakage, which was caused by a sacral chordoma treated with complete resection and sacrectomy followed by radiation therapy and complicated with bowel herniation and gangrene after bowel resection and re-anastomosis. She was initially treated with vigorous wound care with wet dressings and intra-abdominal abscess drainage. After her infection status was controlled and her general condition and nutrition status improved, delayed bilateral lumbar artery perforator flaps were used for salvaging the sacral defect. Results: Stable coverage without complications and normal ambulation of the patient were observed during 18 months of postoperative follow-up. Conclusion: In the present case, we described a large sacral defect after sacrectomy for a sacral chrodoma ablation and adjuvant radiation therapy, which prohibits local tissue transfer, and the use of regional flaps such as a transpelvic vertical rectus abdominis myocutaneous flap were unsuitable because of the previous abdominal operation. Delayed bilateral lumbar artery perforator flaps, another viable alternative to free tissue transfer, provided a simple way of salvaging the defect with acceptable result. (J Taiwan Soc of Plast Surg 2016;25:12～18)

並列關鍵字

bilateral lumbar artery perforator flaps ； sacral defect ； sacrectomy ； radiation therapy