RU2749127C2 - Method for prevention and treatment of protrusion or extrusion of endoprothesis after breast reconstruction - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to breast surgery. A subcutaneous or skin-preserving mastectomy with a one-stage reconstruction with a silicone endoprosthesis is performed. At the same time, an alloimplant based on the dura mater is placed in the projection of the suture under the integumentary tissues, overlapping the suture with the alloimplant 3 cm from the edges of the wound along the entire length from the inside. When suturing, the alloimplant is fixed with interrupted sutures to the edges of the wound.EFFECT: method makes it possible to strengthen the skin suture for the prevention of its divergence, the occurrence of protrusion or extrusion of the endoprosthesis, as well as for the surgical treatment of the already arisen specified consequences in the absence of purulent-septic complications.1 cl, 7 dwg, 2 ex

Description

The invention relates to medicine, to breast surgery (hereinafter - MF), in particular the treatment of patients with breast cancer (hereinafter - BC) to strengthen the skin suture for the prevention and surgical treatment of protrusion or extrusion of the implant after breast reconstruction.

When performing reconstructive plastic operations using endoprostheses, postoperative complications sometimes occur that require additional surgical intervention, up to removal of the endoprosthesis.

Postoperative complications include skin necrosis, implant rejection, purulent-septic complications (PSS), protrusion, extrusion, gray, hematoma, inconsistency of sutures, capsular contracture. According to various studies, the incidence of complications after reconstructive plastic surgery using an endoprosthesis installed with different approaches, with or without additional shelter, with or without subsequent radiation therapy, varies in the range of 27-75%.

There are also studies that assess the effect of radiation therapy on the development of complications after reconstructive plastic surgery using endoprostheses. So, in one of the works, the frequency of complications after breast reconstruction with silicone endoprostheses with or without subsequent radiation therapy is compared. In patients who underwent breast reconstruction with an endoprosthesis and subsequently received radiation therapy, the overall incidence of complications was noted in 38.9% of cases. The overall incidence of complications in the group of patients who did not receive radiation therapy was lower and was noted in 21.8% of cases (Jagsi R, Momoh AO, Qi J, et al. Impact of Radiotherapy on Complications and Patient-Reported Outcomes After Breast Reconstruction . J Natl Cancer Inst 2018; 110).

The most common complications leading to the loss of the endoprosthesis are protrusion / extrusion due to inconsistency of postoperative sutures.

Currently, there is an active search for new methods for the prevention of postoperative complications associated with the installation of endoprostheses.

There are various ways of additional covering of the endoprosthesis in order to exclude its protrusion or extrusion. Shelter produces the most vulnerable lower slope of the reconstructed breast. Various biological, synthetic materials, as well as autologous tissues are used.

However, there are no optimal methods for preventing the extrusion or protrusion of the endoprosthesis, which arise, in particular, due to the failure of postoperative sutures.

A known method of surgical prevention and treatment of extrusion of a silicone implant during reconstructive operations on the mammary gland (RU 2596090 C1), in which, after removing the endoprosthesis in the lower part of the inner surface of the capsule, a U-shaped incision is made, while maintaining its attachment at the edge of the wound in the form of a strip 1 wide, 5 cm, not reaching the edge of the wound, the capsule is separated over the subcutaneous fat, the endoprosthesis is implanted, the flap of the capsule is turned into the wound above the implant, the free edge of the capsular flap is sutured with a continuous suture to the capsule of the opposite side, going over the edge of the wound by 1.5 cm, suture the subcutaneous fat and skin.

However, with this technique, the volume of the capsule may be insufficient to close the wound, in the case of more pronounced protrusion.

There is a known method of preventing the extrusion of a silicone implant after a skin-preserving mastectomy (RU 2591784 C1), in which, after performing a skin-preserving mastectomy, a silicone implant of the appropriate size and shape is installed in the prepared bed, after which the de-epidermal de-epidermal cell autodermotransplant of the upper is sutured into the prepared bed. the edges of the wound with an overlap of the operating wound by 2 cm.

The disadvantages of this method are the increase in trauma due to the collection of the autodermotransplant from the donor area, the risk of necrosis of the autodermotransplant.

The technical result of the invention is to strengthen the skin suture for the prevention of its divergence, the occurrence of protrusion or extrusion of the endoprosthesis, as well as for the surgical treatment of the already arisen specified consequences in the absence of purulent-septic complications.

The technical result is achieved by the fact that, as in the known method, a subcutaneous or skin-preserving mastectomy is performed with a one-stage reconstruction with a silicone endoprosthesis of the appropriate size and shape.

The peculiarity of the proposed method is that in the projection of the suture under the integumentary tissues, an alloimplant based on the dura mater is installed, overlapping the suture with an alloimplant 3 cm from the edges of the wound along the entire length from the inside, and during suturing, the alloimplant is fixed with 3-4 interrupted sutures to the edges of the wound.

The invention is illustrated by a detailed description, tables, examples and illustrations, which depict:

Fig. 1 - photographic illustration of patient N. before surgery: a) in lateral and b) direct projections.

FIG. 2 - Installation of a TMO-based alloimplant.

FIG. 3 - photo illustration: suturing with fixation with several separate interrupted sutures of the dura mater to the edges of the wound (the arrow indicates the movement of the needle).

FIG. 4 - photo illustration of patient N .: view of the postoperative wound.

FIG. 5 - photo illustration of patient L .: a) preoperative marking; b) a subcutaneous mastectomy on the right was performed with a one-stage reconstruction with a silicone endoprosthesis Mentor 330cc.

FIG. 6 - photographic illustration of the operation: in the projection of the postoperative suture under the integumentary tissues, an alloimplant of the dura mater with dimensions of 12x7 cm is installed.

FIG. 7 - photo illustration of patient L .: view of the postoperative wound.

The method is carried out as follows in various cases.

In order to prevent protrusion or extrusion, this method is used at the surgical stage of treatment of patients with breast cancer with a one-stage reconstruction with an endoprosthesis after subcutaneous or skin-preserving mastectomy (Fig. 5), as well as with delayed and two-stage reconstruction. In this case, in the supine position of the patient under general anesthesia, a subcutaneous or skin-preserving mastectomy with a one-stage reconstruction with a silicone endoprosthesis is performed, or the second stage of a delayed or one-stage reconstruction, according to generally accepted methods.

Further, in the projection of the postoperative suture under the integumentary tissue, an alloimplant of the dura mater is placed (Fig. 6). The size of the alloimplant used depends on the size of the wound. Throughout the inside, the seam is covered with an alloimplant 3 cm from the edges of the wound. To avoid displacement from the projection of the suture, the alloimplant is fixed with 3-4 interrupted sutures to the edges of the wound. Then the postoperative wound is sutured layer by layer with a continuous suture, at the end - an intradermal cosmetic suture (Fig. 7).

For the purpose of surgical treatment of protrusion or extrusion, this method is used in the absence of infection.

In this case, in the position of the patient lying on his back under general or local anesthesia, excision of the edges of the wound is performed with the aim of better subsequent healing. An alloimplant of the dura mater is installed under the integumentary tissues in the projection of the suture, overlapping the suture with the alloimplant along the entire length from the inside, 3 cm from the edges of the wound (Fig. 2). The size of the alloimplant used depends on the size of the wound. In order to avoid its displacement from the projection of the suture, during suturing, the alloimplant is fixed with 3-4 interrupted sutures to the edges of the wound (Fig. 3). The wound is sutured with separate interrupted sutures.

The proposed method was used both for prophylaxis immediately during the installation of the endoprosthesis at the surgical stage of treatment of patients with breast cancer, and for the treatment of surgical complications that have already arisen, if there was no associated infection.

Clinical example No. 1.

Patient N., 42 years old. Clinical diagnosis: Cancer of the left breast IIIB stage. ypT0N0M0, luminal type A. Complex treatment in 2018-2019. (NAPHT + OP. + LT). In the process of HT. Condition after delayed reconstruction of the left breast from 01/17/2020. Post-traumatic violation of the integrity of the integumentary tissues of the left formed breast.

Complaints: divergence of the seams of the postoperative wound, gaping of the implant in the wound (Fig. 1 a, b).

Medical history: Considers herself ill since February 2018, when she independently discovered a formation in the left mammary gland. In May 2018, I independently applied to the Moscow Oncological Research Institute. P. A. Herzen. Comprehensively examined, diagnosed with cancer of the left breast, according to the morphological study of the biopsy specimen of the tumor node of the left breast - invasive trabecular cancer, probably lobular G-2. According to immunohistochemical studies: ER = 7 points, PR = 8 points, Her2 / neu - negative expression, Ki67 in 5% of tumor cells, E-cadgerin - negative expression. The treatment tactics were discussed at the council on 06/21/18. At the first stage of complex treatment, it was decided to carry out NAPHT according to the 4AC + 4T scheme. From June to December, 8k NAPHT were implemented with a positive effect in the form of a decrease in edema and a decrease in a tumor node. The patient was re-discussed at the consultation on January 19, 2018, it was recommended that surgical treatment be carried out at the second stage of complex treatment. 01/18/2019 a radical left mastectomy was performed with a one-stage reconstruction with a Mentor 450 tissue expander.

Histological examination of the operating material from 05.02.2019. In the breast tissue in the central zone, among the pronounced proliferation of dense connective tissue, there are complexes of tumor cells with moderately pronounced dystrophic changes. Therapeutic pathomorphosis of the 3rd degree. In the surrounding breast tissue, lymphoid infiltration of the stroma, deposits of calcifications and cholesterol crystals, proliferation of duct epithelium without atypia. There is no tumor growth in the medial, lateral, upper, lower, cutaneous, fascial margins of resection. The nipple is intact. In one investigated sentinel lymph node and in one lymph node taken separately in No. 1, in 9 investigated lymph nodes of the axillary-subscapularis tissue there were no cancer metastases, histiocytosis of the sinuses, lipomatosis. The council # 1611 of 02/06/2019 recommended radiation therapy and hormone therapy. From March 14, 2019 until April 8, 2019 conducted radiation therapy to the formed left mammary gland and regional zones SOD 40 Gy. The patient is currently undergoing hormone therapy. 01/17/2020 The tissue expander was replaced with a Mentor 370cc CPG 312 silicone endoprosthesis. after the fall, the patient noted the discrepancy of the postoperative sutures, the gaping of the silicone implant in the wound. Local status: at the site of the left formed breast in the area of the postoperative scar, laterally there was a divergence of the sutures, 2 cm long, the gaping of the implant in the wound cavity, serous discharge from the wound. In the right mammary gland, pathological formations are not determined. The lymph nodes available to palpation are not changed. Clinical and laboratory data within the reference values. Body temperature is normal.

Taking into account the absence of signs of purulent-septic complications, the patient was offered surgical treatment of the endoprosthesis extrusion in this way.

In the position of the patient lying on his back under local anesthesia, excision of the wound edges was performed with the aim of better subsequent healing. The wound was washed with amikacin solution. The alloimplant of the dura mater of 10x7 cm was placed under the integumentary tissues in the projection of the suture, overlapping the suture with the alloimplant along the entire length from the inside, 3 cm from the edges of the wound (Fig. 2). The wound was sutured with separate interrupted sutures. When suturing a postoperative wound, the alloimplant was fixed with 4 interrupted sutures to the edges of the wound to avoid displacement from the projection of the suture (Fig. 3). Postoperative wound view (Fig. 4). The patient was followed up for 7 months, no complications were noted.

Clinical example No. 2.

Patient L., 40 years old. Clinical diagnosis: Cancer of the left breast IIB stage, cT1c (m) N1 (sn) M0G2, pT2N1M0G2. luminal type B, HER2 / neu- negative . Condition after complex treatment in 2019 In the process of hormone therapy.

Complaints at admission: the presence of education in the right mammary gland.

Medical history: Considers himself ill since April 2019, when a nodular formation in the right mammary gland was revealed during an examination at the place of residence. For further examination and development of treatment tactics, I turned to the polyclinic of the Moscow Oncological Research Institute. P.A. Herzen. The patient was comprehensively examined, trepanbiopsy of the formation was performed, and cancer of the right breast was diagnosed. The treatment tactics were discussed at the council; at the first stage, surgical treatment was recommended. On examination, the skin of the mammary glands is of a physiological color, edema is not observed. In the right mammary gland in the lower-outer quadrant, a tumor formation about 2 cm in diameter is palpable. In the left mammary gland, the nodules are not palpable. The nipple-areola complexes are not changed, there is no discharge from the nipples. The lymph nodes available to palpation are not changed.

On 05/07/2019, a subcutaneous mastectomy on the right was performed with a one-stage reconstruction with a silicone endoprosthesis Mentor 330cc according to conventional techniques (Fig. 5 a, b).

In order to prevent protrusion or extrusion of the endoprosthesis, the skin was strengthened in this way. In the projection of the postoperative suture under the integumentary tissue, an alloimplant of the dura mater with dimensions of 12x7 cm is installed (Fig. 6). Throughout the inside, the suture was blocked with an alloimplant 3 cm from the edges of the wound. To avoid displacement from the projection of the suture, the alloimplant was fixed with 3 interrupted sutures to the edges of the wound. Layer-by-layer suturing of the postoperative wound with a continuous suture, at the end - an intradermal cosmetic suture (Fig. 7).

The patient was treated according to the recommendations. The period of observation of the patient after the end of the complex treatment to the present time was 9 months, no complications were noted.

Thus, the use of the proposed method in clinical practice makes it possible to: reduce the number of complications such as protrusion or extrusion of the endoprosthesis after subcutaneous or skin-preserving mastectomy with one-stage reconstruction with a silicone endoprosthesis, or after a delayed or two-stage reconstruction, and also to avoid removal of the endoprosthesis after the occurrence of these complications, due to the possibilities of their surgical treatment.

Claims (1)

A method for the prevention and treatment of protrusion or extrusion of an endoprosthesis after breast reconstruction, including performing a subcutaneous or skin-preserving mastectomy with one-stage reconstruction with a silicone endoprosthesis, characterized in that an alloimplant based on the dura mater is placed in the projection of the suture under the integumentary tissues, overlapping the suture with an alloimplant 3 cm from the edges of the wound along the entire length from the inside, and during suturing, the alloimplant is fixed with 3-4 interrupted sutures to the edges of the wound.

Images