转移背阔肌肌皮瓣在局部晚期乳腺癌手术.ppt

转移背阔肌肌皮瓣修复术在局部晚期乳腺癌手术中的应用 汕头大学医学院附属肿瘤医院乳腺中心黄文河主任医师huangwenhe2009 Contents 局部晚期乳腺癌定义 局部晚期乳腺癌治疗现状 背阔肌解剖学 背阔肌肌皮瓣修复术手术要点 注意事项及临床体会 什么是局部晚期乳腺癌 局部晚期乳腺癌定义 IIIA T3N1M0除外 IIIB或IIIC期的非炎性乳腺癌 Locallyadvancedbreastcancer LABC ischaracterizedbyvaryingclinicalpresentationssuchaspresenceofalargeprimarytumour 5cm associatedwithorwithoutskinorchest wallinvolvementorwithfixed matted axillarylymphnodesorwithdiseasespreadtotheipsilateralinternalmammaryorsupraclavicularnodesintheabsenceofanyevidenceofdistantmetastases JCancerResTher 2005Jan Mar 1 1 21 30 局部晚期乳腺癌治疗现状 发展中国家局部晚期乳腺癌治疗现状 Locallyadvancedbreastcancer LABC accountsforasizeablenumber 30 60 ofbreastcancercasesandisacommonclinicalscenarioindevelopingcountries TreatmentofLABChasevolvedfromsinglemodalitytreatment consistingofradicalmutilatingsurgeryorhigherdosesofradiotherapyininoperablediseasetomultimodalitymanagementconsistingofsurgery radiationtherapy RT chemotherapywithorwithouthormonaltherapy The5yearoverallsurvivalformastectomygroupwas67 and80 fortheBCTgroup MultidisciplinarytherapyhasnowbecomethestandardforwomenwithLABC 2005 Volume 1 Issue 1 Page 21 30Managementoflocallyadvancedbreastcancer EvolutionandcurrentpracticeAshishRustogi AshwiniBudrukkar KetayunDinshaw RakeshJalaliDepartmentofRadiationOncology TataMemorialHospital Parel Mumbai India Impactofprogressionduringneoadjuvantchemotherapyonsurgicalmanagementofbreastcancer METHODS WereviewedclinicopathologicaldataonpatientswhoreceivedNCTforstageI IIIbreastcancerfrom1994to2007 Chemotherapyregimenswereanthracycline and ortaxane basedasdeterminedbythetreatingmedicaloncologist RESULTS Of1 928patientswhoreceivedNCT 1 762 91 hadapartialorcompleteresponse 107 6 hadstabledisease SD and59 3 progressed PD whilereceivingatleastoneregimen Ofthepatientswithprogressivedisease 40 68 patientsunderwentmastectomy 12 20 underwentBCT and7 12 didnotundergosurgery Inpatientswhounderwentmastectomy onlythree 8 wereBCTcandidatesbeforeprogression Overall diseaseprogressionchangedtheoperativeplanin11 0 5 patients 3developeddistantmetastasis 2developedclinicallymphadenopathy 3requiredmastectomyinsteadofBCT 2becameinoperable and1requiredflapclosure CONCLUSIONS DiseaseprogressionwhilereceivingNCTisinfrequent 3 butearlyidentificationmayallowforchangetoother potentiallybeneficial therapeuticinterventions PatientswithbreastcancerwhoreceiveNCTshouldbeevaluatedfrequentlyforresponsetotherapy Overall progressionduringNCTchangesthesurgicalmanagementinasmallproportionofpatients CaudleASetal AnnSurgOncol 2011Apr 18 4 932 8 转移背阔肌肌皮瓣修复术适应症及禁忌症 适应症 乳房切除术后皮肤缺损乳腺癌根治术后自体组织乳房重建保乳术后局部畸形放疗后胸壁溃疡 禁忌症开胸术后背阔肌被切断胸背血管受损者上胸壁大面积皮肤缺损者 背阔肌的解剖学基础 背阔肌解剖学 位于肩胛骨下方 三角形发于T7 T12 腰骶椎和最下面3 4根肋骨 止于肱骨结节间沟供血来源于胸背动脉和内乳动脉及肋间动脉的穿支神经支配为胸背神经功能 使肱骨内旋 上臂的内收和外展 背阔肌肌皮瓣的应用 历史 Baudet 1976 首先进行了游离移植的报道 以后临床广泛应用 成为最常用的游离皮瓣之一皮瓣特点 血管分布恒定 蒂部管径在1 5 2 0mm 血管蒂长 6 8cm易于剥离和切取供区范围大 6 8cmX12 15cm供区不遗留明显的功能障碍皮瓣血运丰富可形成单纯的肌瓣可用于进行肌肉功能的重建应用范围 带蒂移植 胸部 上肢的组织缺损 屈肘功能重建 乳房再造等游离移植 头 面 颈 四肢 躯干等部位均可应用 转移背阔肌肌皮瓣修复术手术要点 1 术前先描画出手术切口全麻下 先仰卧位 行乳腺癌改良根治或根治术乳房切口彻底止血后用湿大纱布覆盖并用无菌手术膜隔离 2 再取侧卧位 在背阔肌表面按预先设计的梭形切口逐层切开沿背阔肌前缘切取背阔肌并向后方延续 注意保护前锯肌及大圆肌注意保护血管蒂把肌皮瓣经皮下隧道轻送到乳房创面 3 再改为仰卧位 将转移的肌皮瓣缝合固定于前胸壁切口并关闭皮肤切口切口轻度加压包扎引流管负压吸引 手术技巧及注意事项 1 体位 1 先仰卧位 2 侧卧位 3 最后仰卧位 2 保护胸背血管蒂 胸背血管 胸外侧血管 3 防止肌皮瓣血管蒂扭转 4 防止肌皮瓣坏死 背阔肌肌皮瓣 皮瓣在背阔肌肌性部分之上 5 慎防误切大圆肌及前锯肌 前锯肌 误切上述二肌肉会引起肩关节内收功能障碍 我院乳腺中心开展转移背阔肌肌皮瓣修复术病例资料 临床体会 体会1 严格掌握适应症防止并发症发生 Indicationsandcomplicationsoflatissimusdorsimyocutaneousflapsinoncologicbreastsurgery METHODSTheuseofthelatissimusdorsimyocutaneousflap LDMF inreconstructivebreastsurgeryiswelldocumented Fewreportsexistofitsuseinoncologicbreastsurgery ThisseriesdescribesindicationsandcomplicationsoftheLDMFinlocallyadvancedcancer Therecordsof83patientswereanalysedRESULTSTheindicationwastocoverdefectscausedbyresectionoflocallyadvancedbreastcancer 67cases recurrentbreastcancer 13cases radiationdamage 2cases andsurgicalcomplications 1case Themeanageofthepatientswas50 2years 52 werepostmenopausal Theflapshadmeandiametersof32by14cm Thedonorsitewasskingrafted Clearmarginswereachievedin83 AttheLDMFinsertionsite woundinfectionrequireddrainagein1case flapnecrosisrequiredreinterventionin7cases In2casesasecondskingraftwasdonefortheLDMFdonorsite CONCLUSIONSTheuseoftheLDMFmadewideresectionoflocallyadvancedlesionsandradionecrosispossible majorcomplicationswererare LDMFhasitsplaceinthearmamentariumofthesurgeonwhoregularlyseeslocallyadvancedbreastcancer WorldJSurg 2002Sep 26 9 1088 93 Epub2002Jun21 体会2 术后开始辅助放射治疗的时间选择 UseoftheextendedV Ylatissimusdorsimyocutaneousflapforchestwallreconstructioninlocallyadvancedbreastcancer TheextendedV YlatissimusdorsimyocutaneousflapdescribedbyMicaliandCarramaschiprovidesaninnovativemethodofclosinglargeanteriorchestdefectsafterresectionofbreastcancer ThetechniqueprovidesrobustchestwallcoveragethatisabletowithstandimmediatepostoperativeradiotherapyTwelvepatientswhounderwentresectionoflocallyadvancedbreastcancerhadimmediatechestwallreconstructionwiththeextendedV Ylatissimusdorsimusculocutaneousflap TheVtoYdesignoftheflap scutaneousislandallowedprimaryclosureofchestwoundanddonordefect Therewer