Nghiên cứu sử dụng vạt da nhánh xuyên động mạch thượng vị dưới sâu trong điều tri di chứng phẫu thuật cắt bỏ ung thư vú tt tiếng anh

MINISTRY OF EDUCATION MINISTRY OF DEFENCE MILITARY MEDICAL UNIVERSITY NGUYEN VAN PHUNG STUDY TO USE THE DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP IN TREATMENT OF SEQUELAE OF BREAST CANCER SURGERY Speciality: Surgery Code: 9720104 A thesis for the degree of DOCTOR OF PHILOSOPHY HA NOI - 2019 This study has been finished at Military Medical University Academic Supevisor: Vu Quang Vinh PhD., A/Prof Tran Van Anh PhD., A/Prof Reviewer 1: Reviewer 2: Reviewer 3: This thesis will be defended at Military Medical University at This thesis may be found at: Vietnam National Library Military Medical University Library INTRODUCTION The prevalence of breast cancer has been increased and became the most common cancer in woman According to the World Health Organization, breast cancer accounts for 25% of all cancers in women and there are an estimated of 1.7 million new cases worldwide each year The management of breast cancer requires the coordination of many specialities, not only to prevent or eliminate the tumor but also to deal with the sequelae, the effects psychology and quality of life of patients after treatment Surgery treatment (total masectomy) is considered the key to treat breast cancer However, it will lead to physical disability and may be possible to have lymphatic edema on the side of the surgery in some patients, causing discomfort to the patient because the local deformity of lymphedema cannot be used to cover normal clothing Patients frequently have a feeling of their illness, loss of confidence in the body, reduced fitness, fatigue and psychological decline thereby affecting the quality of life of patients Therefore, breast reconstruction and treatment of lymphedema are important and considered as a stage of treatment for breast cancer Breast reconstruction and treatment of lymphedema will help solve the consequences and compliacations of breast cancer surgery, helping to improve the woman confidence and the quality of life Breast reconstruction can be done by autograft or synthetic materials or by combining both In 1989, Koshima I et al for the first time successfully used deep inferior epigastric artery perforator flaps In 1994, Allen R J described for the first time deep inferior epigastric artery are use in breast reconstruction Because there are many advantages such as relatively large tissue volume, good aesthetics, minimally invase of flap removal, deep inferior epigastric artery perforator flaps are increasingly used in breast reconstruction surgery and is considered as the choice in some breast reconstruction centers around the world Recently, treatment of lymphedema with lymph graft surgery is common in many centers around the world with very positive results Instead of simple lymph nodes flap surgery, the simultaneous implementation of breast reconstruction by abdominal flap with the transfer of petiole ingot lymph nodes has been recently applied in some centers around the world with encouraging initial results Since 1988 breast reconstruction surgery has been performed by latissimus dorsi muscle flap Recently, breast reconstruction surgery has continuously developed with more difficult techniques such as the deep inferior epigastric artery perforator by microsurgery However, there has been no report on the breast reconstruction by simultaneous deep inferior epigastric artery perforator flaps and vascularized groin lymph node flap transfer Because the deep inferior epigastric artery perforator flaps also have many abnormalities in anatomaical variants, blood supply area, identifying the main branch artery of this flap to safely lifting skin flap is still a challenge to plastic surgeons Therefore, the aims of this research are: To investigate the anatomical characteristics of deep inferior epigastric artery perforator in Vietnamese adult To evaluate the effectiveness of deep inferior epigastric artery perforator in treatment of sequelae of breast cancer surgery CHAPTER LITERATURE REVIEWS 1.1 SURGERY FOR BREAST CANCER 1.1.1 Radical mastectomy and extended radical mastectomy 1.1.2 Modified radical mastectomy 1.1.3 Breast conserving surgery 1.1.4 Skin - sparing mastectomy 1.1.5 Nipple and aerola - sparing mastectomy 1.2 BREAST RECONSTRUCTION AFTER BREAST CANCER SURGERY 1.2.1 Indication and contraindication 1.2.1.1 Indicaion 1.2.1.2 Contraindication 1.2.2 Timing of breast reconstruction 1.2.2.1 Immediate breast reconstruction 1.2.2.2 Delayed breast reconstruction 1.2.3 Types of breast reconstruction 1.2.3.1 Reconstruction with prosthetic implants 1.2.3.2 Reconstruction with latissimus dorsi myocutaneous flap 1.2.3.3 Reconstruction with pedicled transverse rectus abdominis myocutaneous flap 1.2.3.4 Reconstruction with free transverse rectus abdominis myocutaneous flap 1.2.3.5 Reconstruction with superficial inferior epigastric artery flap 1.2.3.6 Reconstruction with deep inferior epigastric perforators flap 1.3 LYMPHEDEMA AND BREAST RECONSTRUCTION 1.3.1 Upper extremity lymphedema after surgery for breast cancer 1.3.2 Lymphedema after breast reconstruction 1.3.3 Effect of breast reconstruction on preexisting lymphedema 1.3.4 Combining autologous breast reconstruction and vascularized lymph node transfer 1.4 DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP 1.4.1 Definition of perforator, perforator flap and classification of perforator 1.4.1.1 Definition of perforator, perforator flap 1.4.1.2 Classification of perforator 1.4.2 Vascular anatomy, nerve anatomy of deep inferior epigastric perforator flap 1.4.2.1 Arterial system 1.4.2.2 Nerve innervation 1.4.3.1 Arterial perfusion 1.4.3.2 Venous drainage 1.4.4 Methods for the examination of deep inferor epigastric artery perforator 1.4.4.1 Doppler sonography 1.4.4.2 Fluorescent angiography 1.4.4.3 Multidetector computed monography 1.4.5 Deep inferor epigastric artery perforator flap: Anatomical study and clinical application in breast reconstruction 1.4.5.1 Anatomical study The first study on anatomical characteristics of transverse rectus abdominal muscle was conducted by Scheflan M et al in 1983, after which it was further clarified with Hartramf C R's research Following, some other authors have had more detailed anatomical studies on deep inferior epigastric artery such as Boyd J B et al 1984, Moon H K et al 1988, Tuominen H P in 1992 In 1993, Itoh Y and Arai K revealed that the deep epigastric artery separated into two internal and external branches, and most of the transverse branches originated from the outer branch In 2004 Munhoz A M also showed in his study that the branch from the outer branch of the lower epigastric artery should be choosen to shorten the time of internal surgery In 2006, Holm C et al suggested that there should be a change in the perfusion of the transverse arterial branch deep of Harmanpf Thus, the anatomical studies not yet have uniformity in the perfusion partition of the flap, the division of branches of the deep epigastric artery and its perforators distribution In Vietnam, there are several authors describing the epigastric arterial system but have not described in detail the characteristics of the transverse branches Therefore, in this topic, we will study the characteristics anatomy, perfusion of deep epigastric perforators 1.4.5.2 Clinical application of deep inferior epigastric artery perforator in breast reconstruction In 1989, Koshima I et al for the first time used the deep inferior epigastric artery perforator flaps to cover the oropharyngeal defect By 1992, Allen R J et al described the application of a deep inferior epigastric artery perforator in breast reconstruction In 1994, Bloodel P N et al performed the DIEP flap with two vascular prongs in breast reconstruction with good results In 2004, Guerra A B et al reported using 280 strips of DIEP to reconstruct breast and both sides with a success rate of 98.2% Also, in this year Gill P S and CS reported the results of 758 flap DIEP in breast reconstruction within 10 years with a success rate of up to 97% In Vietnam, DIEP has been used in breast reconstruction since 2007 and there have been some publications about the result of this flap However, the number of ties used in these publications is quite modest but also shows encouraging results, with a success rate of 80% 1.4.5.3 Using deep inferior epigastric artery perforator in combination with inguinal vascularized groin lymph node flap transfer to reconstruct breast and treat lymphedema simultaneously The combination of breast reconstruction and treatment of upper limb edema after breast cancer surgery by inguinal vascularized groin lymph node flap transfer is first described by Saaristo AM et al in 2012 with promising results on patients In 2013, Dancey A et al reported 18 cases of using DIEP in combination with inguinal vascularized groin lymph node flap transfer with the rate of improvement of lymphatic edema symptoms being 100% of cases Another study of 2015 by Nguyen A T et al showed similar benefits in patients using combination of DIEP with groin lymph node flap transfer to reconstruct breast and treat lymphedema simultaneously In 2016, De Brucker B B et al reported 25 cases with a symptom improvement rate of 21/25 cases In 2017 Akita S and et al reported 27 patients with lymphatic edema after breast cancer surgery treated with inguinal lymph graft, of which 13 patients had breast reconstruction combined with DIEP flap The author found that in the group using DIEP flap combined groin lymph node flap transfer, lymphatic function improved compared to patients with groin lymph node flap transfer only Chang E I and CS in a 2018 report also showed the reliability and effectiveness of simultaneous use of DIEP and inguinal lymph graft At the same time, the author also provided the role of inguinal lymph nodes examination by means of preoperative diagnostic imaging, especially MDCT In Vietnam so far, there have been no reports of combining the use of DIEP flap and inguinal lymph node grafting in breast reconstruction and simultaneous treatment of lymphedema CHAPTER OBJECTS AND METHODS 2.1 OBJECTS 2.1.1 Anatomical study 2.1.1.1 Anatomical cadaver study Anatomical characteristics of the deep epigastric arteries in the abdomen were studied on 20 fresh cadavers of adult Vietnamese who are preserved cold - 300 C at the Anatomy Department of Ho Chi Minh University of Medicine and Pharmacy - Selection criteria: Vietnamese fresh cadavers ≥ 18 years old, preserved in cold, non-injury in the lower abdomen or andominal middle incision without injury of low abdominal quarant - Exclusion criteria: previous surgery at the abdominal wall or any disease that change anatomical structure of the vascular system provided for the lower abdominal wall 2.1.1.2 Anatomical study of patients - Multiple detector computed tomography (MDCT) before surgery to examine the anatomical characteristics of deep epigastric vascular bundles and perforators - Fluorescence intra-arterial injection to evaluate blood supply of flaps 2.1.2 Clinical research 30 female patients with breast reconstruction surgery by deep inferior epigastric artery perforator flap after breast cancer surgery were studied at Binh Dan Hospital, City Hospital of Medicine and Pharmacy University, Ho Chi Minh City and National Burn Hospital from November 2011 to September 2016 2.1.2.1 Selection criteria - Patients who undergo breast cancer surgery with or without lymphadenopathy complication desired to reconstruct breast by autologous graft - There is an excess of skin and fat in the low abdomen 2.1.2.2 Exclusion criteria - There is not excess of skin and fat in the low abdomen - Previous surgery with abdominal skin flap, deep inferior epigastric artery perforator flap or abdominal reconstruction surgery - Infectious condiditon of the abdominal wall - Patients with lesions, scars in the abdominal area, in which can not find the branch of deep epigastric artery to perform DIEP flap - Patients have lower lymphatic edema, intact bilateral inguinal lymph nodes (for breast reconstruction combined with inguinal lymph graft) 2.2 MEANS AND MATERIAL 2.2.1 Means and materials for anatomical study 2.2.2 Means and materials for clinical research 2.3 METHODS 2.3.1 Anatomical characteristics study of the deep epigastric artery perforators 2.3.1.1 Objectives 2.3.1.2 Methods Descriptive cross-sectional study 2.3.1.3 Steps - Investigating the characteristics of deep epigastric vascular bundles and perforators + Classical dissection on cadavers: Fix the body in the supine position The skin flap is designed as rhombic shape with the lower part of the incision on the pubic bone as in clinical practice Draw 1/2 circles which the center is umbilicus with radius of cm, cm, cm, cm This circle is below the umbilical cord to determine the distribution of the perforators One-third middle inguinal incision was made to explore the deep epigastric arteries No 20 catherter is inserted in the vein, fixed and injected with Barisulphat contrast dye mixed with blue Methylene into the vein (10 ml green Methylene / 100 ml Barrisulphat) Observe the drug infiltration of skin flap The cadaver is cold preserved for 24 hours After 24 hours, the flap was dissected from outside to inside to evaluate the characteristics of deep epithelial vascular bundles and perforators such as: original, number, diameter, length, position, distribution + Blood vessels was examined before surgery by multiple detector computed tomography (MDCT) (n = 19 with Toshib's MDCT 128 Aquilon, carried out after injecting 1.5 ml / kg of Ultravist contrast material 300 with ml / sec speed into peripheral veins Position, origin, pathway and anatomical changes of transverse branches, deep epigastric artery, deep epigastric vein was studied in over 19 patients - Evaluate the blood supply of perforator for flap and vascular networks 12  Good: Soft edema, relieve pain, reduce the circumference of the hand, the side of the legs will not match  Medium: Soft limbs relieve pain, the circumference of the hands remains unchanged, the legs on the sides not match  Poor: Hands fit better or / and match the right leg for lymph nodes 2.3.3 Statistical analyses Statistical analyses were performed with Stata 13.0 CHAPTER STUDY RESULT 3.1 STUDY RESULT OF ANATOMY 3.1.1 Characteristics of deep epigastric arteries vessels and perforators 3.1.1.1 Classical dissection on cadavers: - Characteristics of deep epigastric arteries: Results of all DIEA are derived from external pelvic arteries They located behind rectus abdominis 77.5% or inside this muscle 22.5% The average diameter of DIEA is 2.2 ± 0.2 mm DIEA with main branch is 52.5%, main branches are 42.5% and branches are 5% Table 3.4 Characteristics of deep inferior epigastric artery perforators Characteristics Right Left Common Dominant (n=88) (n=89) (n=177) (n=40) Dimension ± SD (mm) - Diameter 0,8 ± 0,2 0,7 ± 0,2 0,7 ± 0,2 1,0 ± 0,1 - Length 45,6 ± 11,6 45,9 ± 12,0 45,8 ± 11,8 44,3 ± 13,8 Starting point - From lateral branch 12 (13,6%) 21 (23,6%) 33 (18,6%) (12,5%) - From medial branch 13 (14,8%) 25 (28,1%) 38 (21,5%) 11 (27,5%) - From arterial trunk 63 (71,6%) 43 (48,3%) 106 (59,9%) 24 (60%) 13 Direction - Straight 41 (46,6%) 31 (34,8%) 72 (40,7%) 24 (60%) - Oblique 47 (54,4%) 57 (64,0%) 104 (58,8%) 16 (40%) - Paramuscular (0%) (1,1%) (0,6%) (0%) Distance ± SD (mm) - To ombilic 37,9 ± 18,2 30,8 ± 15,4 34,4 ± 17,2 29,3 ± 13,2 - To x-axis 25,2 ± 16,4 22,5 ± 15,1 23,8 ± 15,8 16,2 ± 7,1 - To y-axis 25,9 ± 13,9 19,1 ± 9,8 22,5 ± 12,4 23,4 ± 13,1 Distribution in the half circle from the umbilical cord - cm 19 36 (40,5%) 55 (31,1%) 16 (40%) (21,6%)