Hemicorporectomy
for Intractable
Decubitus Ulcers Nathan W.
Pearlman, MD; Richard H. McShane, MD; Peter R. Jochimsen, MD; Siroos S. Shirazi,
\s=b\ A hemicorporectomy was successfully employed for control of intractable pelvic decubitus ulcers, osteomyelitis, and low\x=req-\ grade epidermoid cancer in a 55-year-old man with marked reduction in pulmonary functions. Strict attention to postoperative fluid balance was associated with a smooth convalescence. The operation may be more applicable to paraplegic patients with intractable pelvic decubiti than to those with advanced pelvic tumors. In view of the increased number of paraplegics who may be at risk for developing this problem, more frequent consideration of the procedure seems warranted.
(Arch Surg 111:1139-1143, 1976)
Although most decubitus ulcers 1 controlled with good nursing
are
prevented
or
and standard this will be the case. not surgical procedures, occasionally The development of a nonhealing decubitus, resistant to multiple operative attempts at control, will often be asso¬ ciated with underlying osteomyelitis or cancer. While métastases from a squamous carcinoma arising in a chronic fistula are uncommon,1 a fatal outcome may still occur if the chronic infection, associated malnutrition, and recur¬ rent septic episodes are not controlled. In the absence of any concurrent serious diseases, radical measures to relieve the patient of this source of disability will often be rewarding, both in terms of survival and improved quality of life. We have recently encountered such a situation in a patient with ischial decubiti of over 30 years' duration. Pelvic osteomyelitis, epidermoid carcinoma in fistula tracts, chronic pain necessitating narcotics, and recurring sepsis led to a state of inanition, despite multiple previous operations. Following hemicorporectomy, the patient's nutritional status rapidly improved, mobility increased, and pain was absent for the first time in years. These beneficial results led us to question whether this operation might not have more widespread application in cases such as this one. A review of the patient's course and of the literature was undertaken in an attempt to answer this care
question. REPORT OF A CASE A
55-year-old
man
was
born with
a
spontaneously healing
for publication June 3, 1976. From the Department of Surgery, University of Iowa College of Medicine, Iowa City. Reprint requests to Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242 (Dr Pearlman).
Accepted
MD
lumbosacral meningomyelocele, weak lower extremities, and absent bladder and bowel control. Ischial decubiti had developed by age 17 and never completely healed thereafter. The patient worked at various sitting jobs until age 42, when progressive lower extremity weakness and pelvic pain forced retirement. In 1970, at age 50, he first came to the University of Iowa Hospitals with draining sinuses of both buttocks and osteomyelitis of the right isehium. In the next five years, he underwent' 13 operations to control this problem. These included ischiectomy with flap rota¬ tion, disarticulation at the right hip, sigmoid colostomy, and suprapubic cystostomy. During this interval a floatation bed was used at home. Despite these endeavors, by June 1975 persistent osteomyelitis had extended to involve the right ischial remnant and pubic rami bilaterally. A pelvic abscess was draining into the bladder, scro¬ tum, anterior abdominal wall, and both buttocks. Although not evident at this time, epidermoid carcinoma had been found in several previously excised sinus tracts. The patient was in contin¬ uous
pain necessitating narcotics, anorectics, hypoalbuminemics,
and cachectics (Fig 1). Because of generalized weakness and a painful frozen pelvis with hip and knee contractures, the patient had not been able to sit up, move around in bed, or be positioned in a wheelchair for many months. Chronic lung disease and cor pulmonale necessitated the use of digoxin, diuretics, and bronchodilators. Pulmonary functions on two occasions revealed a vital capacity of 35% to 68%, forced expiratory volume in one second (FEV,) of 7% to 10%, and maximal midexpiratory flow in spirometry (MMEF) of 3% to 6%. Both the patient and his wife were willing to undergo any procedure that might improve his exis¬ tence. A hemicorporectomy was proposed and accepted. As a first stage, an ileal conduit was constructed on July 31, 1975. This was followed by several weeks of nutritional supple¬ mentation using tube feedings. After preoperative antibiotic preparation, a translumbar amputation through L-5 was carried out on Oct 3, 1975. Blood loss was 3,000 ml, operating time, 4.5 hours, and replacement fluids totalled 6,850 ml during the opera¬ tion. Postoperatively a respirator was used for the first 24 hours and a negative fluid balance was maintained for the first four days. Wound slough and a small degree of flap separation ap¬ peared on the tenth day. No evisceration resulted and healing was almost complete at the time of discharge. Confusion on the 14th day responded to corticosteroid therapy (later tapered). Pulmo¬ nary functions three weeks after amputation showed little change, with a vital capacity of 55%, FEV, of 18%, and MMEF of 8%. The patient was discharged seven weeks postoperatively, at which time oral intake was 2,500 ml/day of regular diet. Analge¬ sics had not been in use for several weeks and serum albumin level was normal. He was mobile in bed, using an overhead trapeze, and in a wheelchair. The pathology specimen revealed low-grade epidermoid carcinoma in the depths of multiple sinus tracts,
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
Fig 1.—Preoperative photograph.
Fig 2.—Postoperative photograph.
Fig 3—Diagram depicting proposed
osteomyelitis of ischium and pubic rami, and osteoporosis of the remaining pelvis. In the seven months since discharge, a marked improvement in the patient's state of well-being has been noted by the patient himself, his wife, and several nurses. Whereas chroni¬ cally depressed preoperatively, he now consistently appears to be happy. Transfer from bed to a wheelchair can now be accomplished without help. Excursions outside the home occur frequently, and church is attended weekly-none of these activities being pursued preoperatively. In the absence of chronic sepsis and pain, strength and appetite have increased greatly, a weight gain of 10 kg has occurred (Fig 2), and a prosthesis is now being constructed.
resection lines.
COMMENT
Translumbar amputation, or hemicorporectomy, has been employed for trauma,7 advanced pelvic tumors,1"7 and intractable pelvic decubiti associated with squamous carci¬ The radical noma or extensive pelvic osteomyelitis." nature of the undertaking, as well as the abhorrence with which the ensuing bodily changes are viewed, appears to have limited its use. While the first such amputation was performed by Kennedy et al in I960,' Miller7 reported that
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
"
Fig 4—Diagram depicting proposed transection site of muscles, (AO), vena cava (IVC), and paravertebral vessels.
aorta
Fig 5.—Diagram depicting
transection of vertebra
Fig 6.—Diagram depicting stump
&
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
closure.
(arrows)
and dura.
1970 he knew of only 18 such cases. Between 1970 and the present, we are aware of three other case reports7'7" plus another five unreported cases, which would bring the total to 26 such endeavors. Undoubtedly there have been several more unreported operations, but the infrequency of case reports remains impressive. Part of the reluctance to consider the procedure may be related to a perceived high operative risk: four of the first nine patients died in the immediate postoperative period.'-7' However, fluid overload seems to have been a major factor in all these cases. When one considers that from 30% to 50% of body weight has been removed with the amputation," the importance of fluid balance becomes obvious. Aust and Absolon7· reported that careful attention was paid to fluids administered to their patient in 1961, which was the first successful such procedure. Since then, as strict monitoring of fluids has become more common, operative risk has decreased. There have been no further reported deaths since the earlier cases, and the present operative risk has been estimated to be 10%.17 A lack of acceptable candidates has also contributed to the paucity of cases. This restriction probably applies more to advanced pelvic tumors than to decubiti, for there may be more suitable candidates with the latter condition than previously suspected. There are several reasons for this. Hemicorporectomy for a large pelvic tumor is unlikely to be curative. Most tumors reaching a size necessitating this procedure will have distant métastases present, whether occult or obvious, at the time consideration for the opera¬ tion is being made. This is borne out by Miller's observa¬ tion7 that 13 of 14 patients undergoing the procedure for a pelvic malignancy eventually died of métastases, while all those with decubiti were long-term survivors. Survival time in those dying of métastases ranged from 6 to 24 months in the patients he followed up. In addition, approx¬ imately 75% of otherwise acceptable candidates with advanced pelvic tumors refuse the operation when faced with the loss of mobility and resultant body alterations." The situation is almost totally reversed for the para¬ plegic patient. Since many of them have no other serious diseases present, the removal of an infected pelvis may allow many years of relatively normal health. Whereas loss of mobility and body image alteration are threatening to the ambulatory patient, the paraplegic may often find his status improved after the operation. This type of patient depends on upper body strength, or others, for movement and repositioning. Removal of a deformed, heavy, and contracted lower body decreases the weight needed to be lifted, facilitating increased mobility in bed, as well as easier positioning in a wheelchair. Other benefits include the absence of malodorous drainage, an increase in appe¬ tite, and relief from recurrent septic episodes, all of which decrease nursing needs, improve the state of nutrition and well-being, and may even change overall body image for the better. Finally, the potential number of candidates for this procedure may increase as improved nursing and medical care keep more paraplegic patients alive than in previous times. Once the operation has been decided on, antibiotic
by
vl"
preparation is mandatory and prior construction of urinary
and fecal diversions is desirable. Technical details of the amputation are straightforward. The anterior flap runs between iliac crests and the posterior flap is fashioned according to the planned level of vertebral division (Fig 3); L-2 through L-5 are satisfactory. After entering the ab¬ domen and retracting the bowel to be retained out of the pelvis, the aorta is divided near its bifurcation. Autotrans¬ fusion can then be carried out, if desired, by elevating the lower part of the body for several minutes before ligating the vena cava. As one approaches the vertebral column, the posterolateral musculature is divided and hemoclips or suture ligatures are used on the paravertebral veins (Fig
4).
Division next proceeds through the disk space (or verte¬ bral body) and pedicles with an osteotome. "Cracking open" the spine at this point increases exposure to the spinal cord, which may then be encircled with a large ligature and divided, or transected and oversewn with fine suture material (Fig 5). Tailoring of the spinous processes to avoid pressure points and facilitate closure without tension may be needed. Bleeding from the paraspinal vessels in the bony canal can be controlled with a muscle or hemostatic plug. Flap approximation with heavy fullthickness sutures over soft rubber drains completes the procedure (Fig 6). Blood loss is variable, but averages 2,500 to 3,000 ml.2·43·7-810 Hypothermia may appear during the latter stages of the operation. Postoperatively, strict monitoring of fluid balance is critical. A negative balance for several days may be needed if large volumes of fluid have been given during the amputation. Wound breakdown seems to occur not in¬ frequently,7 but healing by secondary intention can be anticipated. A "failure to thrive" secondary to loss of gonads may appear in the second or third week, and will respond to exogenous hormones. As reported by Grimby and Stener,7 pulmonary function may decrease postoperatively; however, poor functions beforehand are not necessarily a contraindication to the procedure, as exemplified by this case. Although the patient presently uses pillows for support, a bucket prosthesis following amputation is available. With it, unaided sitting and even an occasional form of walking "
possible.7"1'7" procedures such as total thigh flaps have been employed for intractable decubiti somewhat less advanced are
Other
than in this case."17' These involve removal of the bone from a lower extremity, preserving skin and soft tissue and allowing coverage of extensive sacral and ischial decubiti that would be otherwise impossible. An earlier application of this approach in this patient might have prevented the destructive changes in the pelvis later seen. Retention of the pelvis, however, carries the risk of recurrent decubiti from pressure points in the pelvic ring. If the ischial rami are removed bilaterally, as would have been necessary in this patient, there would not seem to be much difference in functional result from that seen follow¬ ing hemicorporectomy. By employing a translumbar ampu¬ tation, thick, well-vascularized flaps that healed well even
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
after
degree of necrosis were obtained, and the only remaining pressure points are the thoracic spinous some
processes. CONCLUSION
This operation may be more applicable to paraplegic patients with intractable decubiti than to ambulatory patients with large pelvic tumors. With proper fluid
management the procedure appears to be relatively safe even in debilitated patients. In view of the increased
number of paraplegic patients who now may live long enough to develop intractable pelvic decubiti, and the benefits possible following hemicorporectomy, more frequent consideration of the procedure seems war¬ ranted.
References 1.
Lidgren
L:
Neoplasia in chronic fistulating osteitis. Acta Orthop Scand
44:152-156, 1973. 2. Baker TC, Berkowitz T, Hankins HV: Hemicorporectomy. Br J Surg 57:471-476, 1970. 3. Grimby G, Stener B: Physical performance and cardiorespiratory function after hemicorporectomy. Scand J Rehabil Med 5:124-129, 1973. 4. Kennedy CS, Miller EB, McLean DC, et al: Lumbar amputation or
hemicorporectomy for advanced malignancy of the lower half of the body. Surgery 48:357-365, 1960. 5. Lamis PA, Richards AJ, Weidner MG: Hemicorporectomy: Hemodynamic and metabolic problems. Am Surg 33:443-448, 1969. 6. Miller TR, Mackenzie AR, Randall HT: Translumbar amputation for advanced cancer: Indications and physiologic alterations in four cases. Ann Surg 164:514-519, 1966. 7. Miller TR: The results of radical surgery for cancer of the extremities. Aktuel Probl Chir 14:689-692, 1970. 8. Aust JB, Absolon KB: A successful lumbosacral amputation, hemicor-
porectomy. Surgery 52:756-759, 1962. 9. Norris JEC, Kwon YB, Puangsuvan S, et al: Hemicorporectomy: A case report. Am Surg 39:344-348, 1973. 10. Williams RD, Fish JC: Translumbar amputation. Cancer 23:416-418, 1969. 11.
Yancey AC, Ryan HF, Blasingame JT: An experience with hemicorporectomy. J Natl Med Assoc 56:323, 1964.
12. Leichtentritt KG: Rehabilitation after hemicorporectomy. Am J Proctol 23:408-412, 1972. 13. Easton JKM, Aust JB, Dawson JW, et al: Fitting of a prosthesis on a patient after hemicorporectomy. Arch Phys Med Rehabil 44:335-337, 1963. 14. Burkhardt BR: An alternative to total thigh flap for coverage of massive decubitus ulcers. Plast Reconstr Surg 49:433-438, 1972. 15. Royer J, Pickrell K, Georgiade N, et al: Total thigh flaps for extensive decubitus ulcers: A 16-year review of 41 total thigh flaps. Plast Reconstr Surg 44:109-118, 1969.
Invited Editorial Comment
Hemicorporectomy
is not
a new
procedure,
but the authors
are
adding another case to the now over two dozen reported since the original description published in 1960. A majority of the successful operations have been performed for the complications of meningomyelocele, in which the loss of "body image" is less of an emotional hurdle. These patients have never known normally functioning or normally appearing lower extremities. In one reported series of patients suitable for this procedure, less than 20% were willing to accept the amputation. This is an awesome operation with emotional overtones for the patient and also for the surgeon. Perusal of the literature reveals a variety of doubts expressed by those discussing the several reports, doubts empha-
sizing the limited application of the procedure, the desirability of their concentration in a few centers, and the absolute necessity of facilities for a lifelong program of extensive rehabilitation. An interesting observation, logical but overlooked in the early reported cases, concerns the metabolic problems involved. Because of the extensive reduction in body mass, the risk of water overloading, rapid fluctuations in acid-base balance, and the alterations in oxygen consumption, careful monitoring is required. In this case the authors anticipated these problems and dealt with them effectively.
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
Bradford Boston
Cannon, MD
for Intractable
Decubitus Ulcers Nathan W.
Pearlman, MD; Richard H. McShane, MD; Peter R. Jochimsen, MD; Siroos S. Shirazi,
\s=b\ A hemicorporectomy was successfully employed for control of intractable pelvic decubitus ulcers, osteomyelitis, and low\x=req-\ grade epidermoid cancer in a 55-year-old man with marked reduction in pulmonary functions. Strict attention to postoperative fluid balance was associated with a smooth convalescence. The operation may be more applicable to paraplegic patients with intractable pelvic decubiti than to those with advanced pelvic tumors. In view of the increased number of paraplegics who may be at risk for developing this problem, more frequent consideration of the procedure seems warranted.
(Arch Surg 111:1139-1143, 1976)
Although most decubitus ulcers 1 controlled with good nursing
are
prevented
or
and standard this will be the case. not surgical procedures, occasionally The development of a nonhealing decubitus, resistant to multiple operative attempts at control, will often be asso¬ ciated with underlying osteomyelitis or cancer. While métastases from a squamous carcinoma arising in a chronic fistula are uncommon,1 a fatal outcome may still occur if the chronic infection, associated malnutrition, and recur¬ rent septic episodes are not controlled. In the absence of any concurrent serious diseases, radical measures to relieve the patient of this source of disability will often be rewarding, both in terms of survival and improved quality of life. We have recently encountered such a situation in a patient with ischial decubiti of over 30 years' duration. Pelvic osteomyelitis, epidermoid carcinoma in fistula tracts, chronic pain necessitating narcotics, and recurring sepsis led to a state of inanition, despite multiple previous operations. Following hemicorporectomy, the patient's nutritional status rapidly improved, mobility increased, and pain was absent for the first time in years. These beneficial results led us to question whether this operation might not have more widespread application in cases such as this one. A review of the patient's course and of the literature was undertaken in an attempt to answer this care
question. REPORT OF A CASE A
55-year-old
man
was
born with
a
spontaneously healing
for publication June 3, 1976. From the Department of Surgery, University of Iowa College of Medicine, Iowa City. Reprint requests to Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242 (Dr Pearlman).
Accepted
MD
lumbosacral meningomyelocele, weak lower extremities, and absent bladder and bowel control. Ischial decubiti had developed by age 17 and never completely healed thereafter. The patient worked at various sitting jobs until age 42, when progressive lower extremity weakness and pelvic pain forced retirement. In 1970, at age 50, he first came to the University of Iowa Hospitals with draining sinuses of both buttocks and osteomyelitis of the right isehium. In the next five years, he underwent' 13 operations to control this problem. These included ischiectomy with flap rota¬ tion, disarticulation at the right hip, sigmoid colostomy, and suprapubic cystostomy. During this interval a floatation bed was used at home. Despite these endeavors, by June 1975 persistent osteomyelitis had extended to involve the right ischial remnant and pubic rami bilaterally. A pelvic abscess was draining into the bladder, scro¬ tum, anterior abdominal wall, and both buttocks. Although not evident at this time, epidermoid carcinoma had been found in several previously excised sinus tracts. The patient was in contin¬ uous
pain necessitating narcotics, anorectics, hypoalbuminemics,
and cachectics (Fig 1). Because of generalized weakness and a painful frozen pelvis with hip and knee contractures, the patient had not been able to sit up, move around in bed, or be positioned in a wheelchair for many months. Chronic lung disease and cor pulmonale necessitated the use of digoxin, diuretics, and bronchodilators. Pulmonary functions on two occasions revealed a vital capacity of 35% to 68%, forced expiratory volume in one second (FEV,) of 7% to 10%, and maximal midexpiratory flow in spirometry (MMEF) of 3% to 6%. Both the patient and his wife were willing to undergo any procedure that might improve his exis¬ tence. A hemicorporectomy was proposed and accepted. As a first stage, an ileal conduit was constructed on July 31, 1975. This was followed by several weeks of nutritional supple¬ mentation using tube feedings. After preoperative antibiotic preparation, a translumbar amputation through L-5 was carried out on Oct 3, 1975. Blood loss was 3,000 ml, operating time, 4.5 hours, and replacement fluids totalled 6,850 ml during the opera¬ tion. Postoperatively a respirator was used for the first 24 hours and a negative fluid balance was maintained for the first four days. Wound slough and a small degree of flap separation ap¬ peared on the tenth day. No evisceration resulted and healing was almost complete at the time of discharge. Confusion on the 14th day responded to corticosteroid therapy (later tapered). Pulmo¬ nary functions three weeks after amputation showed little change, with a vital capacity of 55%, FEV, of 18%, and MMEF of 8%. The patient was discharged seven weeks postoperatively, at which time oral intake was 2,500 ml/day of regular diet. Analge¬ sics had not been in use for several weeks and serum albumin level was normal. He was mobile in bed, using an overhead trapeze, and in a wheelchair. The pathology specimen revealed low-grade epidermoid carcinoma in the depths of multiple sinus tracts,
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
Fig 1.—Preoperative photograph.
Fig 2.—Postoperative photograph.
Fig 3—Diagram depicting proposed
osteomyelitis of ischium and pubic rami, and osteoporosis of the remaining pelvis. In the seven months since discharge, a marked improvement in the patient's state of well-being has been noted by the patient himself, his wife, and several nurses. Whereas chroni¬ cally depressed preoperatively, he now consistently appears to be happy. Transfer from bed to a wheelchair can now be accomplished without help. Excursions outside the home occur frequently, and church is attended weekly-none of these activities being pursued preoperatively. In the absence of chronic sepsis and pain, strength and appetite have increased greatly, a weight gain of 10 kg has occurred (Fig 2), and a prosthesis is now being constructed.
resection lines.
COMMENT
Translumbar amputation, or hemicorporectomy, has been employed for trauma,7 advanced pelvic tumors,1"7 and intractable pelvic decubiti associated with squamous carci¬ The radical noma or extensive pelvic osteomyelitis." nature of the undertaking, as well as the abhorrence with which the ensuing bodily changes are viewed, appears to have limited its use. While the first such amputation was performed by Kennedy et al in I960,' Miller7 reported that
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
"
Fig 4—Diagram depicting proposed transection site of muscles, (AO), vena cava (IVC), and paravertebral vessels.
aorta
Fig 5.—Diagram depicting
transection of vertebra
Fig 6.—Diagram depicting stump
&
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
closure.
(arrows)
and dura.
1970 he knew of only 18 such cases. Between 1970 and the present, we are aware of three other case reports7'7" plus another five unreported cases, which would bring the total to 26 such endeavors. Undoubtedly there have been several more unreported operations, but the infrequency of case reports remains impressive. Part of the reluctance to consider the procedure may be related to a perceived high operative risk: four of the first nine patients died in the immediate postoperative period.'-7' However, fluid overload seems to have been a major factor in all these cases. When one considers that from 30% to 50% of body weight has been removed with the amputation," the importance of fluid balance becomes obvious. Aust and Absolon7· reported that careful attention was paid to fluids administered to their patient in 1961, which was the first successful such procedure. Since then, as strict monitoring of fluids has become more common, operative risk has decreased. There have been no further reported deaths since the earlier cases, and the present operative risk has been estimated to be 10%.17 A lack of acceptable candidates has also contributed to the paucity of cases. This restriction probably applies more to advanced pelvic tumors than to decubiti, for there may be more suitable candidates with the latter condition than previously suspected. There are several reasons for this. Hemicorporectomy for a large pelvic tumor is unlikely to be curative. Most tumors reaching a size necessitating this procedure will have distant métastases present, whether occult or obvious, at the time consideration for the opera¬ tion is being made. This is borne out by Miller's observa¬ tion7 that 13 of 14 patients undergoing the procedure for a pelvic malignancy eventually died of métastases, while all those with decubiti were long-term survivors. Survival time in those dying of métastases ranged from 6 to 24 months in the patients he followed up. In addition, approx¬ imately 75% of otherwise acceptable candidates with advanced pelvic tumors refuse the operation when faced with the loss of mobility and resultant body alterations." The situation is almost totally reversed for the para¬ plegic patient. Since many of them have no other serious diseases present, the removal of an infected pelvis may allow many years of relatively normal health. Whereas loss of mobility and body image alteration are threatening to the ambulatory patient, the paraplegic may often find his status improved after the operation. This type of patient depends on upper body strength, or others, for movement and repositioning. Removal of a deformed, heavy, and contracted lower body decreases the weight needed to be lifted, facilitating increased mobility in bed, as well as easier positioning in a wheelchair. Other benefits include the absence of malodorous drainage, an increase in appe¬ tite, and relief from recurrent septic episodes, all of which decrease nursing needs, improve the state of nutrition and well-being, and may even change overall body image for the better. Finally, the potential number of candidates for this procedure may increase as improved nursing and medical care keep more paraplegic patients alive than in previous times. Once the operation has been decided on, antibiotic
by
vl"
preparation is mandatory and prior construction of urinary
and fecal diversions is desirable. Technical details of the amputation are straightforward. The anterior flap runs between iliac crests and the posterior flap is fashioned according to the planned level of vertebral division (Fig 3); L-2 through L-5 are satisfactory. After entering the ab¬ domen and retracting the bowel to be retained out of the pelvis, the aorta is divided near its bifurcation. Autotrans¬ fusion can then be carried out, if desired, by elevating the lower part of the body for several minutes before ligating the vena cava. As one approaches the vertebral column, the posterolateral musculature is divided and hemoclips or suture ligatures are used on the paravertebral veins (Fig
4).
Division next proceeds through the disk space (or verte¬ bral body) and pedicles with an osteotome. "Cracking open" the spine at this point increases exposure to the spinal cord, which may then be encircled with a large ligature and divided, or transected and oversewn with fine suture material (Fig 5). Tailoring of the spinous processes to avoid pressure points and facilitate closure without tension may be needed. Bleeding from the paraspinal vessels in the bony canal can be controlled with a muscle or hemostatic plug. Flap approximation with heavy fullthickness sutures over soft rubber drains completes the procedure (Fig 6). Blood loss is variable, but averages 2,500 to 3,000 ml.2·43·7-810 Hypothermia may appear during the latter stages of the operation. Postoperatively, strict monitoring of fluid balance is critical. A negative balance for several days may be needed if large volumes of fluid have been given during the amputation. Wound breakdown seems to occur not in¬ frequently,7 but healing by secondary intention can be anticipated. A "failure to thrive" secondary to loss of gonads may appear in the second or third week, and will respond to exogenous hormones. As reported by Grimby and Stener,7 pulmonary function may decrease postoperatively; however, poor functions beforehand are not necessarily a contraindication to the procedure, as exemplified by this case. Although the patient presently uses pillows for support, a bucket prosthesis following amputation is available. With it, unaided sitting and even an occasional form of walking "
possible.7"1'7" procedures such as total thigh flaps have been employed for intractable decubiti somewhat less advanced are
Other
than in this case."17' These involve removal of the bone from a lower extremity, preserving skin and soft tissue and allowing coverage of extensive sacral and ischial decubiti that would be otherwise impossible. An earlier application of this approach in this patient might have prevented the destructive changes in the pelvis later seen. Retention of the pelvis, however, carries the risk of recurrent decubiti from pressure points in the pelvic ring. If the ischial rami are removed bilaterally, as would have been necessary in this patient, there would not seem to be much difference in functional result from that seen follow¬ ing hemicorporectomy. By employing a translumbar ampu¬ tation, thick, well-vascularized flaps that healed well even
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/17/2015
after
degree of necrosis were obtained, and the only remaining pressure points are the thoracic spinous some
processes. CONCLUSION
This operation may be more applicable to paraplegic patients with intractable decubiti than to ambulatory patients with large pelvic tumors. With proper fluid
management the procedure appears to be relatively safe even in debilitated patients. In view of the increased
number of paraplegic patients who now may live long enough to develop intractable pelvic decubiti, and the benefits possible following hemicorporectomy, more frequent consideration of the procedure seems war¬ ranted.
References 1.
Lidgren
L:
Neoplasia in chronic fistulating osteitis. Acta Orthop Scand
44:152-156, 1973. 2. Baker TC, Berkowitz T, Hankins HV: Hemicorporectomy. Br J Surg 57:471-476, 1970. 3. Grimby G, Stener B: Physical performance and cardiorespiratory function after hemicorporectomy. Scand J Rehabil Med 5:124-129, 1973. 4. Kennedy CS, Miller EB, McLean DC, et al: Lumbar amputation or
hemicorporectomy for advanced malignancy of the lower half of the body. Surgery 48:357-365, 1960. 5. Lamis PA, Richards AJ, Weidner MG: Hemicorporectomy: Hemodynamic and metabolic problems. Am Surg 33:443-448, 1969. 6. Miller TR, Mackenzie AR, Randall HT: Translumbar amputation for advanced cancer: Indications and physiologic alterations in four cases. Ann Surg 164:514-519, 1966. 7. Miller TR: The results of radical surgery for cancer of the extremities. Aktuel Probl Chir 14:689-692, 1970. 8. Aust JB, Absolon KB: A successful lumbosacral amputation, hemicor-
porectomy. Surgery 52:756-759, 1962. 9. Norris JEC, Kwon YB, Puangsuvan S, et al: Hemicorporectomy: A case report. Am Surg 39:344-348, 1973. 10. Williams RD, Fish JC: Translumbar amputation. Cancer 23:416-418, 1969. 11.
Yancey AC, Ryan HF, Blasingame JT: An experience with hemicorporectomy. J Natl Med Assoc 56:323, 1964.
12. Leichtentritt KG: Rehabilitation after hemicorporectomy. Am J Proctol 23:408-412, 1972. 13. Easton JKM, Aust JB, Dawson JW, et al: Fitting of a prosthesis on a patient after hemicorporectomy. Arch Phys Med Rehabil 44:335-337, 1963. 14. Burkhardt BR: An alternative to total thigh flap for coverage of massive decubitus ulcers. Plast Reconstr Surg 49:433-438, 1972. 15. Royer J, Pickrell K, Georgiade N, et al: Total thigh flaps for extensive decubitus ulcers: A 16-year review of 41 total thigh flaps. Plast Reconstr Surg 44:109-118, 1969.
Invited Editorial Comment
Hemicorporectomy
is not
a new
procedure,
but the authors
are
adding another case to the now over two dozen reported since the original description published in 1960. A majority of the successful operations have been performed for the complications of meningomyelocele, in which the loss of "body image" is less of an emotional hurdle. These patients have never known normally functioning or normally appearing lower extremities. In one reported series of patients suitable for this procedure, less than 20% were willing to accept the amputation. This is an awesome operation with emotional overtones for the patient and also for the surgeon. Perusal of the literature reveals a variety of doubts expressed by those discussing the several reports, doubts empha-
sizing the limited application of the procedure, the desirability of their concentration in a few centers, and the absolute necessity of facilities for a lifelong program of extensive rehabilitation. An interesting observation, logical but overlooked in the early reported cases, concerns the metabolic problems involved. Because of the extensive reduction in body mass, the risk of water overloading, rapid fluctuations in acid-base balance, and the alterations in oxygen consumption, careful monitoring is required. In this case the authors anticipated these problems and dealt with them effectively.
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Bradford Boston
Cannon, MD
