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\begin{document}

\title{Use of bakri balloon catheter and pedicled omental flap in combination
for pelvic reconstruction after total pelvic exenteration}



\author[1]{samin almassian}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 08, 2024}


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\selectlanguage{english}
\begin{abstract}
Our case was a middle-aged woman with advanced cervical cancer that
underwent pelvic exenteration (PE) and then pelvic reconstruction (PR)
with omental flap and bakri balloon placement.%
\end{abstract}%



\sloppy


\textbf{Use of bakri balloon catheter and pedicled omental flap in
combination for pelvic reconstruction after total pelvic exenteration}

\textbf{Abstract}

Our case was a middle-aged woman with advanced cervical cancer that
underwent pelvic exenteration (PE) and then pelvic reconstruction (PR)
with omental flap and bakri balloon placement.

\textbf{Keywords}

Advanced Cervical Cancer, Pelvic Exenteration, Pelvic Reconstruction,
Omental Flap, Bakri Balloon

\textbf{1 \textbar{} Introduction}

Cervical cancer is one of the most common cause of cancer-related death
among women. {[}1{]} The only possible curative procedure for patients
who suffered from advanced pelvic malignancies is pelvic exenteration.
It is a highly invasive operation characterized by the evacuation of the
pelvic organs. {[}2{]} After PE it is necessary to fill dead space that
is called pelvic reconstruction. {[}3{]}

In our case, we tried to pelvic reconstruct with omental flap and bakri
balloon despite different applications. This article shows the
effectiveness of the use of the large-volume bakri balloon as a
supporter for omental pedicle flap.

\textbf{2 \textbar{} Case report}

A 51-year-old female, with a history of advanced cervical cancer who was
undergone total pelvic exenteration because of cancer recurrence.

Her cervical cancer was diagnosed as a 2B stage 1 year earlier for the
first time. In the beginning, she underwent neoadjuvant
chemoradiotherapy. After radiotherapy, her right kidney and right ureter
were involved as a hydroureteronephrosis, and then right nephrostomy was
placed in it.

In the middle of her last chemotherapy, abdominopelvic CT scan showed a
mass of 40*74*132 mm originated from the cervix and invaded the vagina,
rectum, ureter, bladder, pelvic wall, and piriformis muscle. So
metastasis to her pelvic wall and other pelvic organs was diagnosed and
candidate to total pelvic exenteration.

Total pelvic exenteration includes total abdominal hysterectomy with
bilateral salpingo-oophorectomy (TAH-BSO), Trachelectomy, proximal
vaginectomy, proctectomy, cystectomy, right proximal, and distal
ureterectomy, left distal ureterectomy, and urhethrectomy were done.
Left permanent colostomy after resection of the rectum and an ileal
pouch as bladder was set. Then the pelvic floor was closed with
peritoneum and omental pedicle flap to prevent visceral prolapse.
Eventually, a bakri balloon was settled through the anus and was passed
inflation port through the pelvic cavity then the balloon was inflated
gradually with sterile normal saline solution up to the minimal volume
(maximum capacity 500mL) that effectively fill the cavity. Pathology
showed basaloid squamous cell carcinoma/poorly differentiated, Right
pelvic wall mass (8*6*4 cm) involved by tumor and present lymphovascular
invasion. IHC staining showed positive reactivity for P63 and showed
negative reactivity for chromogranin and synaptophysin.

This report demonstrates the successful application of the large-volume
Bakri balloon instead of a muscular flap for supporting omental pedicle
flap.

\textbf{3 \textbar{} Discussion}

An estimated 570 000 cases of cervical cancer were diagnosed in 2018,
and 311 000 women died from this malignancy. Cervical cancer is the most
common cause of cancer-related death among women in 42 countries
especially underdeveloped and developing countries although it has been
comparatively well controlled in many developed countries {[}1{]}.

For patients who are affected by advanced primary or recurrent pelvic
malignancies, the only procedure with the possibility of cure is
surgical intervention. A pelvic exenteration (or pelvic evisceration) is
an ultra-radical operative procedure characterized by the en bloc
resection of the pelvic organs for patients with advanced primary or
recurrent pelvic neoplasms. A complete PE is a treatment that removes
all organs from a person's pelvic cavity. The distal sigmoid colon,
rectum, and anus along with the urinary bladder, urethra, and genital
organs are resected. In women, the vagina, cervix, uterus, fallopian
tubes, ovaries, and, in some cases, the vulva are also removed (Fig.1)
{[}2{]}.

Whereas PE is an aggressive operative procedure that left a large dead
space, it is necessary to fill that pelvic defect. This procedure is
called pelvic reconstruction {[}3{]}.

One of the most common types of PR is a soft-tissue reconstruction of
the pelvis with vascularized tissue flaps. The best type of flaps is
performed to transfer tissue from a donor site to a recipient site to
efface dead space, return function and figure, provide structural
support for the pelvic viscera, and guarantee proper wound healing and
closure. The vertical rectus abdominis myocutaneous flap (VRAM) and the
omental pedicle flap are the most commonly used pedicle flaps in tandem
for pelvic reconstruction following these oncologic interventions
{[}4{]}.

We placed an omental pedicle flap used to fill the pelvic dead space and
bakri balloon catheter used for closure of perineal and vaginal defects.
The Bakri balloon is a silicone balloon designed for the treatment of
uterine bleeding in postpartum hemorrhage (Fig.2). In our patient VRAM
flap is not a perfect choice because of many reasons such as recent
radiation, non-bulking VRAM, past surgery in that area, etc. Instead of
this bakri balloon catheter was placed to support the omental pedicle
flap and prevent it from visceral pressure and rupture and ischemia.
Moreover, it gives time to create a granulation tissue and fill dead
space to prevent visceral prolapse. We would like to empty the balloon
gradually, but we had to remove it almost 20 days after surgery. because
despite its benefits bakri balloon as a foreign body has a high chance
to infect and forming a biofilm. On the other hand, because of pelvic
manipulation, the probability of fasciitis and clostridium contamination
is high, so the infection management was hard.

It recommends studying more about drains containing an antimicrobial
coating.

This method has a bright future for pelvic reconstruction without
muscular flaps and prevents prolapsing.

Figure 1

Figure 2

\textbf{References}

1. Karen Canfell, Jane J Kim, Marc Brisson, Adam Keane, Kate T Simms,
Michael Caruana, Emily A Burger, Dave Martin, Diep T N Nguyen, \selectlanguage{ngerman}Élodie
Bénard, Stephen Sy, Catherine Regan, Mélanie Drolet, Guillaume Gingras,
Jean-Francois Laprise, Julie Torode, Megan A Smith, Elena Fidarova,
Dario Trapani, Freddie Bray, Andre Ilbawi, Nathalie Broutet, and Raymond
Hutubessy. Mortality impact of achieving WHO cervical cancer elimination
targets: a comparative modelling analysis in 78 low-income and
lower-middle-income countries. Lancet. 2020 Feb 22; 395(10224):
591--603. doi:~10.1016/S0140-6736(20)30157-4. PMCID:PMC7043006. PMID:
32007142.

2. W R. Grimes,~Michael Stratton. Pelvic Exenteration. In: StatPearls
{[}Internet{]}. Treasure Island (FL): StatPearls Publishing; 2020 Jan.
2020 Oct 12. PMID: 33085416. Bookshelf ID:NBK563269.

3. Anna Myriam Perrone, Alessandra Livi, Milena Fini, Elena Bondioli,
Sergio Concetti, Alessio Giuseppe Morganti, Federico Contedini, and
Pierandrea De Iaco\textsuperscript{.} A surgical multi-layer technique
for pelvic reconstruction after total exenteration using a combination
of pedicled omental flap, human acellular dermal matrix and autologous
adipose derived cells. Gynecol Oncol Rep. 2016 Nov; 18: 36--39.
Published online 2016 Oct 27. doi:10.1016/j.gore.2016.10.006.
PMCID:PMC5097956. PMID: 27844048.

4. Tara L. Sagebiel, Silvana C. Faria, Aparna Balachandran, Justin M.
Sacks, Y. Nancy You, Priya R. Bhosale. Pelvic Reconstruction with
Omental and VRAM Flaps: Anatomy, Surgical Technique, Normal
Post-operative Findings, and Complications. Nov-Dec 2011;31(7):2005-19.
doi: 10.1148/rg.317115112. PMID: 22084184.

Figure captions

Figure : pelvic exenteration

Figure - bakri balloon\selectlanguage{english}
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