Immediate versus Delayed Sarcoma Reconstruction: Impact on Outcomes

Abstract

Background. Sarcoma is a rare malignancy, and more recent management algorithms emphasize a multidisciplinary approach and limb salvage, which has resulted in an increase in overall survival and limb preservation. However, limb salvage has resulted in a higher rate of wound complications. Objective. To compare the complications between immediate and delayed (>three weeks) reconstruction in the multidisciplinary limb salvage sarcoma patient population. Methods. A ten-year retrospective review of patients who underwent sarcoma resection was performed. The outcome of interest was wound complication in the postoperative period based on timing of reconstruction. We defined infection as any infection requiring intravenous antibiotics, partial flap failure as any flap requiring a debridement or revision, hematoma/seroma as any hematoma/seroma requiring drainage, and wound dehiscence as a wound that was not completely intact by three weeks postoperatively. Results. 70 (17 delayed, 53 immediate) patients who underwent sarcoma resection and reconstruction met the inclusion criteria. Delayed reconstruction significantly increased the incidence of postoperative wound infection and wound dehiscence. There was no difference in partial or total flap loss, hematoma, or seroma between the two groups. Discussion and Conclusion. Immediate reconstruction results in decreased wound complications may reduce the morbidity associated with multidisciplinary treatment in the limb salvage sarcoma patient.

A comparison of delayed versus immediate reconstruction following lower-extremity sarcoma resection

“…This study highlights that delayed flap reconstruction of the lower extremity is associated with an increased rate of wound complications compared to immediate reconstruction (100% vs. 28.0%, P = 0.001). While our study focuses specifically on the lower extremity, the results remain consistent with the available literature, which comprised of small retrospective cohort studies [2,3,6,7]. Sanniec et al [7] found that delaying reconstruction after sarcoma resection led to an increased number of infections requiring antibiotics (47.1% vs. 9.4%, P = 0.0016).…”

Working with Orthopedic Oncologists: When to Offer Immediate and when and why to Delay Definitive Reconstruction of an Extremity

“…Experience regarding the safety of margins in immediate versus delayed free tissue transfer for lower extremity salvage after surgery in cases of soft tissue sarcoma or squamous cell carcinoma, emphasizes the reliability and quality of surgical outcomes, the rate of wound complications, and faster rehabilitation. However, the data do not address outcomes in the context of long-term problems resulting from possible inadequate margins [1,7,28,29]. The timing of reconstructive surgery is frequently highlighted with the bias that immediate or early reconstruction achieves better results with lesser complication rates, however, these studies do not specify how post malignancy excision wounds were cared for in preparation for delayed intervention [4,[28][29][30].…”

“…However, the data do not address outcomes in the context of long-term problems resulting from possible inadequate margins [1,7,28,29]. The timing of reconstructive surgery is frequently highlighted with the bias that immediate or early reconstruction achieves better results with lesser complication rates, however, these studies do not specify how post malignancy excision wounds were cared for in preparation for delayed intervention [4,[28][29][30]. In the presented cohort, in order to avoid infections and subsequent complications in patients scheduled for delayed reconstruction, wounds were temporized with systems completely sealing the resected area (vacuum assisted wound closure devices or skin substitutes).…”

“…Accurate assessment of the microscopic margins requires that the specimen is presented to a pathologist as a single intact tissue segment whenever possible. Specimen orientation and the documentation of orientation for the pathologist is of critical value in the event of a positive or close margin in the specimen, since this information can be used to direct further surgery [28][29][30][31]. Even when the field is prepared for reconstruction with margins previously declared "negative," it is wise to submit any tissue removed in the process of reconstruction solely enabling reconstruction with orientation markings for the pathologist as sometimes there may be an unexpected finding (Figure 4).…”

“…In retrospect, none of the courses of the diseases nor the outcomes of patient who received delayed reconstruction indicated that immediate reconstruction could have led to a more favorable result. One has to keep in mind that certain malignancies, for example Merkel cell carcinoma of the extremities, are known to be notorious for posing problems regarding the qualitative and quantitative adequacy of margins [28][29][30]32,33].…”