RU2283041C1 - Method for preventing complications after primary reconstructive-plastic operations in patients with mammary cancer - Google Patents

Abstract

FIELD: medicine, oncosurgery.

SUBSTANCE: one should intraoperationally inject 0.5 ml 1%-patent-blue-VF into thoracodorsal artery by performing direct contrast angiography of the flap of the broadest muscle of back (BMB). Moreover, at suturing a great thoracic muscle and BMB one should not touch contrasted vessels. The innovation enables to visualize muscular branches of the mentioned artery and its branches, control its integrity, prevent the chance for suturing muscular branches of thoracodorsal artery, avoid affected supply of BMB flap; as for applied patient-blue-VF preparation, it is excreted out of the body very quickly and doesn't destroy vascular endothelium.

EFFECT: higher efficiency of prophylaxis.

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Description

The invention relates to medicine, in particular to surgery, and can be used for primary breast plastic surgery (hereinafter referred to as MF) after operations ranging from radical resection to subcutaneous mastectomy for localized and locally advanced forms of breast cancer I (T1N0M0), IIA (T1N1M0 , T2N0M0), IIВ (T2N1M0, T3N0M0), IIIA (T3N1-2M0) stages.

A known method of breast plastic surgery for cancer, including the movement of a graft flap from the latissimus dorsi (HMS) on the chest-back artery to the area of the breast tissue defect (RF patent No. 2110220, publ. 05.20.98, bull. No. 14). The disadvantage of this method, which impedes the achievement of the following therapeutic results, is the inability to visualize the muscle branches of the artery toracodorsalis and control their integrity. This can lead to the flashing of one or several arterial trunks, malnutrition of the SHMS flap and, as a result, muscle necrosis and loss of the endoprosthesis in the combined mammoplasty method using the ShMS and endoprosthesis.

At the same time, a known method for detecting stenosis of the visceral and renal arteries with thrombosed aneurysms of the abdominal aorta by contrast magnetic resonance angiography using a contrast agent Magnevist (RF patent No. 2216273, publ. 20.11.03, bull. No. 32). The known method of contrast magnetic resonance angiography, used to monitor the state of blood flow, is implemented using sophisticated equipment, is operator-dependent and cannot be used for intraoperative imaging of blood vessels.

There is also known a method of medical treatment of oncological diseases of the human body, including angiographic diagnosis of cancer of organs with isolated blood flow, using x-ray control. The control is carried out by introducing a contrast agent urographin (RF patent No. 2163490, publ. 27.02.01, bull. No. 6). The disadvantage of this method is the lack of the ability to directly visualize the vascular system, as well as the inevitability of an additional load on the patient, including radiation.

The invention is aimed at solving the problem of preventing complications after primary reconstructive plastic surgery in patients with breast cancer: ischemia and necrosis of a displaced muscle flap, suppuration of the flap, loss of the endoprosthesis.

Using in clinical practice the proposed method allows to achieve several technical (therapeutic) results:

- visualization of the muscle branches of the artery toracodorsalis and its branches;

- monitoring the integrity of the muscle branches of the artery toracodorsalis and its branches;

- preventing the possibility of flashing one or more arterial trunks;

- prevention of malnutrition of the flap ShMS.

These therapeutic results in the implementation of the invention are achieved due to the fact that, as well as in the known method, simultaneous mammoplasty is performed with the help of ShMS or its combination with an endoprosthesis. A feature of the invention lies in the fact that intraoperative direct contrast arteriography of the muscle trunks of the artery of toracodorsalis is also carried out.

The invention consists in the following.

Currently, to restore a defect in the breast after a radical resection, radical subtotal resection, subcutaneous mastectomy, ShMS, the pectoralis major muscle, endoprosthesis, or combinations thereof are used. The optimal options for simultaneous mammoplasty in patients with breast cancer of the P-SHA stages, both with a nodular form and with multicentric tumor growth of 3.5-5 cm, are subcutaneous mastectomy with simultaneous reconstruction of the ShMS or in combination with an endoprosthesis. The specified method allows to solve oncological and rehabilitation problems. However, the inability to visualize the muscle branches of the artery of toracodorsalis and control their integrity can lead to the flashing of one or more arterial trunks, causing malnutrition of the flap of VMS and, as a result, muscle necrosis and other complications. A similar situation arises when the muscle case is formed in the case of combined mammoplasty with the use of ShMS and endoprosthesis. The occurrence of muscle necrosis can lead to the loss of an endoprosthesis.

These shortcomings can be eliminated by monitoring the state of the vascular bed and created reconstructions. The specified control is possible when using intraoperative contrast angiography prepared for the movement of the flap ShMS.

Currently, several methods of contrast and non-traction angiography are widely used:

- ultrasound,

- spiral computer and electron beam,

- x-ray,

- magnetic resonance.

However, the known methods and the contrast media used for this are intended primarily as diagnostic and preoperative research methods and cannot be used in the intraoperative mode for the following reasons.

1. All of the above methods for monitoring the state of blood flow are implemented using more or less sophisticated equipment and are operator-dependent, which creates additional difficulties in the work of surgeons.

2. The use of electrophysical equipment is associated with an additional load on the patient, including radiation.

3. There is no direct visualization of blood vessels.

At the same time, a preparation intended for intraoperative angiography, prepared to move a muscle transplant, should be a physiologically balanced medium that meets several criteria:

- sufficient intensity and contrast of the color of blood vessels for their immediate visualization;

- biological compatibility with blood without toxic effects;

- rapid absorption into the blood capillaries;

- rapid elimination from the body.

In the literature there is no information about the direct introduction into the arterial vessel of a drug that meets the above requirements. At the same time, in medical practice from the beginning of the 20th century it is known that patent-blue-VF (isomer - lymphazurin) is widely used for direct and indirect lymphography. The specified contrast drug is intended to visualize the lymphatic system, draining the injection region, has lymphotropic properties, is excreted unchanged in the urine for 24 hours in humans, without exerting toxic effects. The inventors have developed and successfully tested in clinical practice a method for visualizing muscle branches by introducing patent-blue-VF (isomer - lymphazurin) into the arterial vessel.

The method is as follows.

Perform a radical resection of the breast (in a volume of 1/4 to hemimammectomy) or subtotal resection, in which 50% to 90% of the gland tissue with the tumor is removed with excision of the skin over it or subcutaneous mastectomy in a single block with fiber and axillary, subscapular lymph nodes , subclavian areas with the preservation of most of the skin of the breast, both pectoral muscles, submammary folds, nipple-areolar complex. After performing a radical resection of the breast or a subcutaneous mastectomy, the patient is laid on his side, the initial skin incision in the breast is extended in the axillary region in the transverse direction to the posterior axillary line and the SCM is separated subcutaneously to the paravertebral line, this muscle is isolated and the tendon is intersected at the site of its attachment to the humerus . Then, in the position of the patient on the back, the latissimus muscle is moved on the neurovascular leg to the area of tissue deficiency of the operated gland, recreating the mammary gland. After mobilization of part or all of the muscle, it is connected with the surrounding tissues only by the neurovascular feeding leg (a, v, n. Thoracodorsalis).

Then direct contrast arteriography of the ShMS flap is performed. A vascular clip is placed on the toracodorsalis artery at the site of its branch from the subscapularis artery. 0.5 ml of a 1% solution of a patent-blue-VF preparation prepared ex tempore is injected into the toracodorsalis artery below the clip in the direction of the CMS using a sterile insulin syringe. Instantaneous staining of the entire arterial vasculature of the muscle flap prepared for plastic surgery in dark blue is noted. A “muscle bed” is formed for the endoprosthesis between the pectoralis major muscle and the ShMS by stitching these muscles with interrupted sutures using suture material Dexon or Vicryl without affecting the contrasted vessels. If necessary, a silicone endoprosthesis of the desired volume, shape is pre-selected, it is placed in the formed muscle "bed".

The wound is drained by two tubular drains, one of which is introduced into the endoprosthesis bed (followed by active suction from the drains). The patent-blue-VF drug used for arteriography is excreted within 2-5 minutes, the color intensity of the vascular network of the ShMS flap by the end of the formation of the muscle pocket is sharply reduced. Subcutaneous tissue is sutured as the last step, an intracutaneous continuous suture is applied to the skin wound. Skin sutures are removed on the 14-16th day after surgery.

Clinical example.

Patient O., 40 years old, medical history PA-981, was in the General Oncology Department of Moscow P.A. Herzen from March 1 to March 11, 2005

Clinical diagnosis: Cancer of the right breast IIIA (T2N2M0) stage. Tumor localization - upper quadrants.

On March 4, 2005, an operation was performed - a subcutaneous mastectomy of the right breast with direct contrast arteriography of a ShMS flap, primary ShMS primary mammoplasty and a silicone endoprosthesis. Under endotracheal anesthesia, a skin incision was made in the upper outer quadrant. Removed 98% of breast tissue with axillary-subclavian-subscapular lymphadenectomy. The skin, nipple-areolar complex, submammary fold saved. During an urgent cytological examination, no neoplasm cells were found in scrapings from the edges of the wound. Then, in a lateral position, the patient extended the initial skin incision in the mammary gland in the axillary region to the posterior axillary line, subcutaneously separated the CMC to the paravertebral line, this muscle was isolated in a sharp way, cutting off its dorsal end at the attachment point, and the tendon was intersected at the site of its attachment to the humerus . Then the patient is laid on his back. Direct contrast arteriography of the flap prepared for plasty of the ShMS is performed by introducing into a. toracodorsalis 0.5 ml of a 1% solution of patent-blue-VF. A muscle ″ bed ″ is formed for the endoprosthesis between the pectoralis major muscle and the ShMS by stitching these muscles with provisional sutures using dexon or vicryl suture without affecting the contrasted arterial vessels of the ShMS flap. A silicone endoprosthesis is inserted into the prepared muscle "bed" and the sutures are tightened. The wound is drained by two tubular drains. The skin over the formed MF is sutured with absorbable material (vicryl). Bandage. The postoperative course is smooth.

An excellent cosmetic result was obtained. According to the ultrasound dopplerography of the ShMS flap performed on the 10th day after the operation, there was no violation of the blood supply to the flap.

Thus, the claimed method has significant advantages compared with known methods of the same purpose and meets the criteria of patentability.

Claims (1)

A method for the prevention of complications after primary reconstructive plastic surgery in patients with breast cancer by simultaneous mammoplasty using the latissimus dorsi muscle or its combination with an endoprosthesis, characterized in that 0.5 ml of 1% patent-blue-VF is intraoperatively injected into the artery, direct contrast angiography of the latissimus dorsi flap, and when stapling the pectoralis major muscle and latissimus dorsi muscle, the contrasted vessels are not affected.