Biomedical subjects
S H Pursell
Publications and source records attributed to S H Pursell.
Vaginal reconstruction with rectus abdominis myocutaneous flap: CT findings.
The distally based rectus abdominis myocutaneous flap is used in a new technique for vaginal reconstruction after pelvic exenteration for malignant disease. We identified 27 patients who underwent this procedure, of whom eight had a total of 14 postoperative CT scans and two CT-directed biopsies. The myocutaneous flap appeared as a unilateral arcuate band of soft tissue extending from the linea alba to the rectal fascia or sacrum. Additional CT findings included asymmetric thinning of the ventral abdominal wall (7/8), fluid collections (2/8), vaginal breakdown (1/8), presacral soft-tissue thickening (6/8), and tumor recurrence (3/8). The postoperative CT scan reflects the altered anatomy produced by the surgery. Complications and recurrent disease can be recognized as deviations from the normal postoperative appearance.
Distally based rectus abdominis flap for reconstruction in radical gynecologic procedures.
The distally based rectus abdominis myocutaneous flap is an important adjunct to radical pelvic surgery. It can be used to fashion a functional neovagina or to create a patch to cover perineal defects created by exenterative surgery. This report reviews the technical aspects of the creation of this flap and our experience with 22 patients who have undergone this procedure. The flap has been found to be technically easy to create. It is reliable with little tissue loss, and donor site complications are acceptable. Healing is aided by filling the pelvic dead space, thereby decreasing bowel complications, and by bringing a new blood supply into the operative site which has often been heavily irradiated. Operative time is minimized since the procedure requires only unilateral mobilization. Subsequent abdominal surgery has been performed without fascial complications.
Refinements in vaginal reconstruction using rectus abdominis flaps.
An improved method for vaginal reconstruction after pelvic exenteration or abdominal perineal resection is provided by the distally based rectus abdominis flap. This extended flap carries a skin paddle from the upper abdomen on the rectus abdominis muscle and deep inferior epigastric vascular pedicle. The skin paddle is inversely tubed to form a vaginal pouch and delivered transpelvically to the perineum. In addition to providing a vaginal reconstruction for sexual function, this reconstruction lessens pelvic wound complications in the exenteration patient by filling endopelvic dead space and revascularizing these frequently irradiated wounds. This method provides a neovagina with a single flap and does not involve additional donor sites in the thighs. Transpelvic passage from above not only fills endopelvic dead space better than thigh flaps, but also it allows retention of a vaginal cuff in supralevator resections. Another significant advantage of this reconstruction is its great reliability with minimal incidence of paddle loss. This flap design illustrates a type of flap refinement in which specific flaps can carry tissue from adjacent vascular territories because of anastomotic vessels between the two vascular territories, such as the vascular watershed between the deep inferior epigastric and superior epigastric vessels in this case.
Adjuvant chemotherapy in a pregnant patient with endodermal sinus tumor of the ovary.
The development of germ cell carcinoma of the ovary during pregnancy is a rare occurrence. Recent advances in chemotherapy have improved significantly the prognosis for patients with early stage disease. Use of cytotoxic agents in pregnancy traditionally has been avoided because of possible teratogenic effects. We describe a pregnant patient who was found to have endodermal sinus tumor of the ovary, stage I, at 13 weeks gestation. She received five courses of adjuvant VAC chemotherapy, beginning with her 17th week of gestation, prior to delivery of a normal infant at term. After an additional seven courses of chemotherapy, a second-look laparotomy revealed no evidence of disease. The infant is developmentally normal at 1 year. A comprehensive review of the literature describing use of chemotherapeutic agents in pregnancy is presented.