BACKGROUND: Intraoperative radiation therapy is often used as an adjuvant treatment for locally advanced tumors. Reconstruction of defects after oncological resection is challenging. We present the largest cohort to date assessing the safety and effectiveness of flap reconstruction in these patients.
METHODS: A retrospective review of patients who underwent intraoperative radiation and simultaneous flap reconstruction for oncological reasons was done. Inclusion criterion was patients 18 years or older who underwent this procedure from January 2010 to January 2020 at our institution.
RESULTS: A total of 231 patients (122 men, 109 women) and 244 flaps were included. Mean age at surgery was 55.5 years (SD: 13.2); mean body mass index was 28.1 (SD 6.5). Patient comorbidities included active smoking (8.2%), diabetes (16.8%), and hypertension (41.4%). Of all patients, 17.7% were on chronic anticoagulation, 94% had neoadjuvant radiation therapy, 3.4% had adjuvant radiation therapy, 80.2% had neoadjuvant chemotherapy, and 27.2% had adjuvant chemotherapy. Mean intraoperative radiation dose was 12.1 Gy (SD 2.3). Median hospital length-of-stay was 7 days (Q1–3: 5–13); median follow-up length was 16.4 months (Q1–3: 4.5–42.2). Primary tumor included colorectal (52.9%), reproductive system (15.6%), and extremity (17.2%). In total, 91.8% of patients had one flap reconstruction and 8.9% had two flaps. Flap types included omental flaps (n = 112), vertical rectus abdominis muscle flaps (n = 61), rotational or advancement flaps (n = 16), pedicled gracilis flaps (n = 8), pedicle gastrocnemius flaps (n = 9), and free flaps (n = 7).
Even though several perioperative complications were reported, 91.4% of reconstructions were successful. Various infectious problems accounted for a total of 60.6% of patients. Complications included abscess (26.6%), wound infection requiring debridement (22.5%), seroma (12.3%), necrosis (12.7%), cellulitis (11.5%), hematoma (7.4%), and full-thickness wound dehiscence (7.8%). Of all patients, 4.3% had intraoperative bleeding that required blood transfusion, 19% had postoperative bleeding, and 9% had thromboembolic events. Of all flaps, 27.2% required unplanned surgical re-intervention and 7.3% required postoperative hyperbaric oxygen therapy. When comparing extremity with abdominal flap reconstructions, extremity reconstructions were associated with higher odds of developing cellulitis (OR 1.4 (1.4-–140.9), P = 0.003). Multiple variables analysis showed that obesity was associated with an increased risk of developing wound infection that required debridement (OR 1.93 (1.02–3.64), P = 0.04).
CONCLUSIONS: Flap reconstruction is safe and effective for coverage of oncological defects in patients receiving intraoperative radiotherapy. Postoperative antibiotics beyond the usual 24-hour period should be considered. Careful selection of patients is critical to achieve the best outcomes possible.