Comment on, Complications and impact on quality of life of vertical rectus abdominis myocutaneous flaps for reconstruction in pelvic exenteration surgery

摘要

We read with interest the article by van Ramshorst et al 1; however, it gives rise to many concerns:1.Such a high (68%) complication rate with the vertical rectus abdominis myocutaneous (VRAM) flap is surprising, because others have shown significantly lower rates.2.The authors conclude that this flap should be used “selectively,” but they do not discuss patient selection at all. Paradoxically, VRAM is needed in exactly those patients who develop higher complications, that is, those with locally advanced disease, wider excision, more dead space, and an irradiated operative field needing a supple autologous vascularized bed to provide support to the pelvic structures, thus preventing complications.3. So what is the solution to this conundrum?The authors indirectly compare patients with and without VRAM flaps, which is unfair because patients with VRAM flaps had more advanced disease that resulted in bigger defects.The authors do not consider whether complications were due to flap surgery per se or worse local and systemic conditions caused by advanced disease and treatment (wider excision/preoperative radiotherapy).The authors have not suggested any technical refinements to reduce such a high complication rate, nor have they discussed alternatives to minimize abdominal wall morbidity such as the use of the anterolateral thigh flap.4.The use of anterior rectus sheath sparing VRAM could have reduced donor site morbidity, especially mesh placement and its related complications.5.Residual dead space even after VRAM flap placement has been blamed for many complications and placement of multiple vacuum suction drains has been advised to mitigate this problem~6.