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Bowel obstruction following deep circumflex iliac artery free flap harvesting
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British Journal of Oral and Maxillofacial Surgery 47 (2009) 645–647
Short communication
Bowel obstruction following deep circumflex iliac artery free flap harvesting Neil C.-W. Tan a,∗ , Peter A. Brennan b , Asha Senapati c , Roberto Puxeddu a a b c
Department of Otolaryngology, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom Department of Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom Department of General Surgery, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom
Accepted 28 December 2008 Available online 26 February 2009
Abstract The deep circumflex iliac artery flap (DCIA) has been well described as an autograft flap used in head and neck reconstructions, particularly for large maxillary and mandibular defects. Complications, particularly at the donor site, have been well documented. Although it is considered a minor complication, herniation should not be underestimated as it can potentially lead to bowel obstruction, necessitating an emergency operation. We report a case of acute obstruction of the small bowel secondary to herniation at the donor site after harvesting a DCIA free flap for a maxillary defect, a complication that to our knowledge has been reported only once. We review the pathogenesis and possible ways to reduce the likelihood of developing this serious complication. © 2009 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons. Keywords: Deep circumflex iliac artery (DCIA) flap; Reconstruction; Hernia; Bowel obstruction
Introduction
Case report
The ilium is an excellent source of vascularised bone that can be used to reconstruct the maxilla and the mandible. The deep circumflex iliac artery (DCIA) flap has been well described and is commonly used.1,2 Donor site morbidity has often been reported, mostly with minor complications, which include pain, haematoma, seroma, herniation, nerve damage, and arterial injury.3,4 We report a case of acute obstruction of the small bowel secondary to herniation at a DCIA donor site, and review the pathogenesis, management, and options for prophylaxis.
A 59-year-old man with squamous cell carcinoma (SCC) of the maxilla had a left maxillectomy, orbital exenteration, and neck dissection then reconstruction with a composite DCIA free flap. The donor site defect was repaired with polypropylene (Prolene) mesh and closed with 2/0 polypropylene non-absorbable suture (Prolene). No breach of the peritoneum was seen during harvesting of the flap. One month later he presented as an emergency with abdominal pain, nausea, and vomiting. Clinical examination showed abdominal distension. Plain radiographs showed dilated loops of bowel, and an abdominal computed tomogram (CT) showed a large hernia at the DCIA donor site. The small bowel was dilated within the hernia, which extended above and below the margins of the iliac defect. A diagnosis of obstruction of the small bowel was made and he had an emergency laparotomy. The cause of the obstruction
∗ Corresponding author at: Department of Otorhinolaryngology Head and Neck Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, PO6 3LY, United Kingdom. Tel.: +44 7855 269071. E-mail address: [email protected] (N.C.-W. Tan).
0266-4356/$ – see front matter © 2009 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
doi:10.1016/j.bjoms.2008.12.015
646
N.C.-W. Tan et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 645–647
Discussion
Fig. 1. Abdominal wall defect with hernial content reduced and sac removed.
Fig. 2. Complete closure of the defect with biological mesh fixed by a double line of 0 polypropylene non-absorbable suture (Prolene).
was an adhesional endoperitoneal band medial to the neck of the hernia. This was divided and the small bowel was still viable. The hernial sac was resected (Fig. 1) and the defect closed with biological mesh (Permacol® , Tissue Science Laboratories, Hampshire, UK) and closed with double line 0 polypropylene non-absorbable suture (Prolene) (Fig. 2). He made an uneventful recovery and his intestinal function returned to normal. The hernia had not recurred 12 months later.
Table 1 Reported rates of herniation after harvest of a deep circumflex iliac artery free flap. First author
Reference no.
No. of patients
Technique
No. (%) with herniation
Boyd Kantelhardt Lyons Iqbal Iqbal Halsnad
5 6 7 9 9 10
60 103 26 37 18 4
Mesh Mesh Mesh Mesh Protack Plate
2 (3) 3 (3) 3 (12) 4 (11) 0 0
Herniation through a DCIA donor site is a recognised complication that has been reported (Table 1).5–7 Herniation at a donor site occurs for a number of reasons that include patient-related factors such as age, gender, obesity, constipation, diabetes, and tobacco consumption; and perioperative factors such as inadequate analgesia, vomiting, and postoperative pneumonia. To obtain a suitable graft, 5–15 cm of the internal oblique muscle is transferred as well as underlying bone, which leaves a considerable bone and soft tissue defect through which herniation can occur. The material of choice for primary repair at the donor DCIA site is usually polypropylene, which is a nonabsorbable woven sheet that can be cut to the desired shape and size. It is flexible, easily sutured into place, and inexpensive. The disadvantages include an increased rate of infectious complications, postoperative and chronic pain.8 A number of alterations have been described to anchor mesh to underlying bone including titanium tacks (ProTackTM , US Surgical) as reported by Iqbal (Table 1).9 Alternatively a titanium plaque can be used as proposed by Halsnad et al.10 in which three-dimensional CT modelling is used to prefabricate a plate that covers the defect. Porcine collagen mesh (Permacol® ) is a biological material, comprised of acellular porcine collagen and elastin that is non-allergenic to the human body. The graft remains within the tissues with cellular and microvascular ingrowth. In our case the anterior edge of the Prolene mesh repair had failed. We used double lined Prolene with biological mesh successfully in the secondary repair. Herniation through the DCIA donor site is uncommon, and bowel obstruction is even less so. Meticulous care is essential when repairing the abdominal wall at the time of DCIA harvest to reduce the likelihood of these potentially fatal complications.
References 1. Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF. The internal oblique-iliac crest free flap in composite defects of the oral cavity involving bone, skin, and mucosa. Laryngoscope 1991;101:257–70. 2. Brown JS. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect. Head Neck 1996;18:412–21. 3. Puxeddu R, Ledda GP, Siotto P, et al. Free-flap iliac crest in mandibular reconstruction following segmental mandibulectomy for squamous cell carcinoma of the oral cavity. Eur Arch Otorhinolaryngol 2004;261:202–7. 4. Urken ML, Weinberg H, Vickery C, Aviv JE, Buchbinder D, Lawson W, et al. The combined sensate radical forearm and iliac crest free flaps for reconstruction of significant glossectomy–mandibulectomy defects. Laryngoscope 1992;102:543–58. 5. Boyd JB, Rosen I, Rotstein L, Freeman J, Gullane P, Manktelow R, et al. The iliac crest and the radial forearm flap in vascularized oromandibular reconstruction. Am J Surg 1990;159:301–8.
N.C.-W. Tan et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 645–647 6. Kantelhardt T, Stock W, Stützle H, Deiler S. Results at the donor site after free microvascular iliac crest transplantation. Eur J Plastic Surg 1999;22:366–9. 7. Lyons AJ, James R, Collyer R. Free vascularised iliac crest graft: an audit of 26 consecutive cases. Br J Oral Maxillofac Surg 2005;43:210–4. 8. Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg 2003;237:129–35.
647
9. Iqbal M, Lloyd CJ, Paley MD, Penfold CN. Repair of the deep circumflex iliac artery free flap donor site with Protack (titanium spiral tacks) and Prolene (polypropylene) mesh. Br J Oral Maxillofac Surg 2007;45:596–7. 10. Halsnad SM, Dhariwal DK, Bocca AP, Evans PL, Hodder SC. Titanium plate reconstruction of the osseous defect after harvest of a composite free flap using the deep circumflex iliac artery. Br J Oral Maxillofac Surg 2004;42:254–6.
British Journal of Oral and Maxillofacial Surgery 47 (2009) 645–647
Short communication
Bowel obstruction following deep circumflex iliac artery free flap harvesting Neil C.-W. Tan a,∗ , Peter A. Brennan b , Asha Senapati c , Roberto Puxeddu a a b c
Department of Otolaryngology, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom Department of Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom Department of General Surgery, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom
Accepted 28 December 2008 Available online 26 February 2009
Abstract The deep circumflex iliac artery flap (DCIA) has been well described as an autograft flap used in head and neck reconstructions, particularly for large maxillary and mandibular defects. Complications, particularly at the donor site, have been well documented. Although it is considered a minor complication, herniation should not be underestimated as it can potentially lead to bowel obstruction, necessitating an emergency operation. We report a case of acute obstruction of the small bowel secondary to herniation at the donor site after harvesting a DCIA free flap for a maxillary defect, a complication that to our knowledge has been reported only once. We review the pathogenesis and possible ways to reduce the likelihood of developing this serious complication. © 2009 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons. Keywords: Deep circumflex iliac artery (DCIA) flap; Reconstruction; Hernia; Bowel obstruction
Introduction
Case report
The ilium is an excellent source of vascularised bone that can be used to reconstruct the maxilla and the mandible. The deep circumflex iliac artery (DCIA) flap has been well described and is commonly used.1,2 Donor site morbidity has often been reported, mostly with minor complications, which include pain, haematoma, seroma, herniation, nerve damage, and arterial injury.3,4 We report a case of acute obstruction of the small bowel secondary to herniation at a DCIA donor site, and review the pathogenesis, management, and options for prophylaxis.
A 59-year-old man with squamous cell carcinoma (SCC) of the maxilla had a left maxillectomy, orbital exenteration, and neck dissection then reconstruction with a composite DCIA free flap. The donor site defect was repaired with polypropylene (Prolene) mesh and closed with 2/0 polypropylene non-absorbable suture (Prolene). No breach of the peritoneum was seen during harvesting of the flap. One month later he presented as an emergency with abdominal pain, nausea, and vomiting. Clinical examination showed abdominal distension. Plain radiographs showed dilated loops of bowel, and an abdominal computed tomogram (CT) showed a large hernia at the DCIA donor site. The small bowel was dilated within the hernia, which extended above and below the margins of the iliac defect. A diagnosis of obstruction of the small bowel was made and he had an emergency laparotomy. The cause of the obstruction
∗ Corresponding author at: Department of Otorhinolaryngology Head and Neck Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, PO6 3LY, United Kingdom. Tel.: +44 7855 269071. E-mail address: [email protected] (N.C.-W. Tan).
0266-4356/$ – see front matter © 2009 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
doi:10.1016/j.bjoms.2008.12.015
646
N.C.-W. Tan et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 645–647
Discussion
Fig. 1. Abdominal wall defect with hernial content reduced and sac removed.
Fig. 2. Complete closure of the defect with biological mesh fixed by a double line of 0 polypropylene non-absorbable suture (Prolene).
was an adhesional endoperitoneal band medial to the neck of the hernia. This was divided and the small bowel was still viable. The hernial sac was resected (Fig. 1) and the defect closed with biological mesh (Permacol® , Tissue Science Laboratories, Hampshire, UK) and closed with double line 0 polypropylene non-absorbable suture (Prolene) (Fig. 2). He made an uneventful recovery and his intestinal function returned to normal. The hernia had not recurred 12 months later.
Table 1 Reported rates of herniation after harvest of a deep circumflex iliac artery free flap. First author
Reference no.
No. of patients
Technique
No. (%) with herniation
Boyd Kantelhardt Lyons Iqbal Iqbal Halsnad
5 6 7 9 9 10
60 103 26 37 18 4
Mesh Mesh Mesh Mesh Protack Plate
2 (3) 3 (3) 3 (12) 4 (11) 0 0
Herniation through a DCIA donor site is a recognised complication that has been reported (Table 1).5–7 Herniation at a donor site occurs for a number of reasons that include patient-related factors such as age, gender, obesity, constipation, diabetes, and tobacco consumption; and perioperative factors such as inadequate analgesia, vomiting, and postoperative pneumonia. To obtain a suitable graft, 5–15 cm of the internal oblique muscle is transferred as well as underlying bone, which leaves a considerable bone and soft tissue defect through which herniation can occur. The material of choice for primary repair at the donor DCIA site is usually polypropylene, which is a nonabsorbable woven sheet that can be cut to the desired shape and size. It is flexible, easily sutured into place, and inexpensive. The disadvantages include an increased rate of infectious complications, postoperative and chronic pain.8 A number of alterations have been described to anchor mesh to underlying bone including titanium tacks (ProTackTM , US Surgical) as reported by Iqbal (Table 1).9 Alternatively a titanium plaque can be used as proposed by Halsnad et al.10 in which three-dimensional CT modelling is used to prefabricate a plate that covers the defect. Porcine collagen mesh (Permacol® ) is a biological material, comprised of acellular porcine collagen and elastin that is non-allergenic to the human body. The graft remains within the tissues with cellular and microvascular ingrowth. In our case the anterior edge of the Prolene mesh repair had failed. We used double lined Prolene with biological mesh successfully in the secondary repair. Herniation through the DCIA donor site is uncommon, and bowel obstruction is even less so. Meticulous care is essential when repairing the abdominal wall at the time of DCIA harvest to reduce the likelihood of these potentially fatal complications.
References 1. Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF. The internal oblique-iliac crest free flap in composite defects of the oral cavity involving bone, skin, and mucosa. Laryngoscope 1991;101:257–70. 2. Brown JS. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect. Head Neck 1996;18:412–21. 3. Puxeddu R, Ledda GP, Siotto P, et al. Free-flap iliac crest in mandibular reconstruction following segmental mandibulectomy for squamous cell carcinoma of the oral cavity. Eur Arch Otorhinolaryngol 2004;261:202–7. 4. Urken ML, Weinberg H, Vickery C, Aviv JE, Buchbinder D, Lawson W, et al. The combined sensate radical forearm and iliac crest free flaps for reconstruction of significant glossectomy–mandibulectomy defects. Laryngoscope 1992;102:543–58. 5. Boyd JB, Rosen I, Rotstein L, Freeman J, Gullane P, Manktelow R, et al. The iliac crest and the radial forearm flap in vascularized oromandibular reconstruction. Am J Surg 1990;159:301–8.
N.C.-W. Tan et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 645–647 6. Kantelhardt T, Stock W, Stützle H, Deiler S. Results at the donor site after free microvascular iliac crest transplantation. Eur J Plastic Surg 1999;22:366–9. 7. Lyons AJ, James R, Collyer R. Free vascularised iliac crest graft: an audit of 26 consecutive cases. Br J Oral Maxillofac Surg 2005;43:210–4. 8. Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg 2003;237:129–35.
647
9. Iqbal M, Lloyd CJ, Paley MD, Penfold CN. Repair of the deep circumflex iliac artery free flap donor site with Protack (titanium spiral tacks) and Prolene (polypropylene) mesh. Br J Oral Maxillofac Surg 2007;45:596–7. 10. Halsnad SM, Dhariwal DK, Bocca AP, Evans PL, Hodder SC. Titanium plate reconstruction of the osseous defect after harvest of a composite free flap using the deep circumflex iliac artery. Br J Oral Maxillofac Surg 2004;42:254–6.