Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 4  |  Page : 835-839

Post chemotherapy extravasation injuries: Hypogastric flap for reconstruction of wounds over dorsum of hand


1 Department of Orthopaedics, Pramukswami Medical College, Srikrishna Hospital, Karamsad, Gujarat, India
2 Plastic and Reconstructive Microvascular Services, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
3 Consultant Oncologist, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India

Date of Web Publication15-Feb-2016

Correspondence Address:
G I Nambi
Plastic and Reconstructive Microvascular Services, Kovai Medical Center and Hospital, Avinashi Road, Coimbatore - 641 014, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.144589

Rights and Permissions
 > Abstract 

Context: Management of extravasation injuries over the dorsum of hand after administration of chemotherapeutic agents.
Aim: To study the results of hypogastric flap reconstruction in chemotherapy extravasation wounds over dorsum of hand.
Settings and Design: Retrospective study.
Subjects and Methods: At our center over 3-years period, 32 patients were treated for chemotherapy extravasation wounds. Out of these 32 patients, seven had wound over dorsum of hand. There were five males and two females, and their mean age was 45 years (range, 19 - 64 years). These patients with wound over the dorsum of hand were treated with multiple debridements and hypogastric flap reconstruction.
Results: The mean interval between extravasation wound and surgical treatment was 6.28 days (range, 4 - 10). The mean size of extravasation wound defect was 14 × 8 (range, 12 × 7 to 18 × 8). Non-dominant hand was involved in six patients and dominant hand in one patient. In four patients, the hypogastric flap was supplemented with skin graft. The hypogastric flap settled well in all patients and enabled a good wound cover. Complete division of the flap and final insetting was done under local anesthesia after 3 weeks; this was followed by limb mobilization exercises. Contour difference over the dorsum of hand was present in all the cases. The range of movement of the hand was functionally restricted in one patient. No patient in current series developed wound infection.
Conclusion: Hypogastric flap is a reliable flap to cover wound over dorsum of hand after extravasation of chemotherapeutic agents.

Keywords: Chemotherapy, dorsum of hand, extravasation injuries, hypogastric flap, reconstruction, wound


How to cite this article:
Salunke AA, Nambi G I, Sudhakar N. Post chemotherapy extravasation injuries: Hypogastric flap for reconstruction of wounds over dorsum of hand. J Can Res Ther 2015;11:835-9

How to cite this URL:
Salunke AA, Nambi G I, Sudhakar N. Post chemotherapy extravasation injuries: Hypogastric flap for reconstruction of wounds over dorsum of hand. J Can Res Ther [serial online] 2015 [cited 2019 Aug 20];11:835-9. Available from: http://www.cancerjournal.net/text.asp?2015/11/4/835/144589


 > Introduction Top


Chemotherapy is the main stay of modern cancer treatment. Use of chemotherapeutic drugs is commonly associated with substantial complications. These drugs are infused in veins of dorsum of hand or antecubital fossa.

Subcutaneous extravasation is a known complication of intra-venous administration of chemotherapy agents. There are limited cancer centers throughout the globe with properly trained medical professionals. Due to lack of specialized centers and experienced medical professionals, chemotherapy infusions can lead to higher incidence of extravasation injuries. The overall incidence of extravasation injuries varies from 0.1-7%. [1],[2],[3] It is characterized by drug escaping out of the vessels in subcutaneous tissue plane due to repeated venous punctures and its cytotoxic effect of the chemotherapy drug. [1],[2],[3],[4] The infusion area over dorsum of hand is having minimal subcutaneous fat tissue and so it is more prone for severe damage by extravasation injuries; this injury can damage underlying tendon, joint, and neurovascular structures. [3],[4],[5],[6],[7],[8] The extravasation injuries are difficult to treat due to lower immune status of the patient and complexity of the wound with exposed bone or tendons.

Management of post extravasation injuries over the dorsum of hand is a challenge for reconstructive surgeons and oncologists. In this study, we have analyzed the results of reconstruction with hypogastric flap of post chemotherapy extravasation wound over dorsum of hand.


 > Subjects and methods Top


At our center over 3-years period, 32 patients were treated for chemotherapy extravasation wounds. Out of these 32 patients, seven had wound over dorsum of hand. There were five male and two females, and their mean age was 45 years (range, 19-64 years) [Table 1]. These patients with wound over the dorsum of hand were treated with multiple debridements and hypogastric flap reconstruction [Figure 1] [Figure 2] [Figure 3]. Two patients were treated with chemotherapy for carcinoma lung. Other patients were of Non-Hodgkin's lymphoma, Osteosarcoma, Breast carcinoma, Oropharanyx carcinoma, and Brain tumor.
Figure 1: Post chemotherapy extravasation wound over dorsum of hand at the time of presentation

Click here to view
Figure 2: Wound after two debridement

Click here to view
Figure 3: Wound covered with hypogastric flap, with hand and elbow comfortably placed

Click here to view
Table 1: Demographic data and chemotherapy drug causing extravastion injury


Click here to view


The clinical records of these patients were reviewed. The clinical features reviewed were; size of the wound, depth of the wound, hand dominance, presence of tendon and bone exposure, interval between onset of symptoms and presentation, range of movement [ROM] of the affected extremity. The ROM was evaluated both preoperatively and during follow-up period. Cyclophosphamide was used in four patients (81%), Doxorubicin in three patients (43%), Adriamycin in two patients (28%).

Vincristine, Prednisone, Cisplatin, 5 Flourouracil, Adriamycin, Cyclophosphamide, Docetaxel, Procarbazine, Vincristine, Lomustine was responsible for extravasation injury in other patient. The chemotherapy was continued during the surgical procedures for extravasation injury. The white blood count (WBC) was 9,000 cells/cu mm (range, 7000-14000 cells/cu mm.


 > Results Top


Non-dominant hand was involved in six patients and dominant hand was involved in one patient. The mean interval between extravasation wound and surgical treatment was 6.28 days (range, 4-10) [Table 1]. The mean size of flap used for coverage of extravasation wound defect was 14 × 8 (range, 12 × 7 to 18 × 8) [Table 1]. None of the patients had tendon rupture and joint exposure. In four patients, the hypogastric flap was supplemented with skin graft to cover areas beside exposed tendons.

The hypogastric flap settled well in all patients and enabled a good wound cover [Figure 3] [Figure 4] [Figure 5]. Complete division of the flap and final insetting was done under local anesthesia after 3 weeks followed by limb mobilization. Contour difference over the dorsum of hand was present in all the cases [Figure 4] and [Figure 5]. The range of movements of the hand was functionally restricted in one patient. None of the patients had wound infection or wound breakdown [Table 2]. In present study, surgical intervention by means of multiple debridements and flapcover decreased pain and morbidity in all patients with extravasation injuries.
Figure 4: Follow-up clinical picture with fingers in extension and a well-settled flap

Click here to view
Figure 5: Follow-up clinical picture picture with fingers in flexion

Click here to view
Table 2: Functional assessment of patients with extravasation injuries treated with hypogastric flap reconstruction


Click here to view



 > Discussion Top


Cytotoxic agents have potential of causing destruction of healthy and normal cells along with their therapeutic effects on tumor cells. Extravasation of the chemotherapy drug produces extensive necrosis of the skin and subcutaneous tissue. An extravasation injury due to chemotherapy drugs is a nightmare for the patient and the doctor. These injuries over the dorsum of hand is caused due to repeated puncture of skin, injury and irritation to the vessel wall due to needle tip and chemotherapeutic drugs. [1],[2],[3],[4],[5] The patients treated with chemotherapy have poor immune status and are prone for risk of infection. Extravasated chemotherapy agents cause injury to the tissue due to vasoconstriction and mechanical compression due to large volume of drugs. [1],[7],[8],[9],[10],[11] The chemotherapy drugs are incorporated into DNA of the cells and are slowly released by the dying cells. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Slow and sustained release of drug retards granulation tissue formation and the soft tissue healing with secondary intention and scarring. [3],[4],[5],[6],[7],[8],[9],[10],[11] The delayed and progressive skin necrosis is the necessitating cause for single or multiple debridement and soft tissue cover. [4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22]

The chemotherapy drugs also cause tissue damage due to direct toxic effect to the tissue. [6],[7],[8],[9],[10] The clinical presentation of extravasation injuries is variable. Majority of cases of these injuries due to small volume of extravasation of chemotherapy agents leads to swelling, erythema and pain in affected area. If there is large volume of extravasted chemotherapy agent it can lead to extensive tissue and skin necrosis.

The clinical staging system used for suggested by Millam et al. in1988. [11]

The patient in stage 1 and 2 has no signs of skin damage. In stage 3 and 4, the soft tissue damage is more extensive and includes skin and underlying tissue necrosis. The patients must be treated with immediate discontinuation of the intravenous line after extravasation of chemotherapy agents. [3],[4],[5],[6],[7],[8],[9],[10],[11]

The treatment of extravasation injury following chemotherapy drugs depends on the status of the wound, granulation tissue and general condition of the patient. Erythema and skin excoriations due to extravasation injuries can be treated with conservative method; with regular dressings and wound care. [4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[20],[21],[22]

Loth et al. suggested that early surgical treatment is having higher success rate as compared to conservative treatment method for extravasation injuries. [12] The surgical treatment is necessary to reduce the morbidity, disability and early wound healing of extravasation injuries. Radical excision of the necrotic tissue and proper coverage of the ulcer area is the key of success in treatment of chemotherapy induced extravasation injuries. [12],[13],[14],[15],[16],[17],[18] Extravasation injuries with full-thickness skin necrosis cannot be treated with skin grafting as the wound is filled with necrotic area with minimal regenerative potential. [5],[6],[7],[8],[9],[10],[11],[12],[14],[15],[16],[17],[18],[19],[20],[23] Early debridement and flap cover for injuries over dorsum of hand shows better results as compared to skin grafting. [8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] Debridement of extravasation wound is an important step for preparing a proper bed for flap coverage; the debridement must be performed within first 24 hours to 7 days from presentation of the patient in the hospital. [4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[21],[22],[23]

The available reconstruction methods for covering the extravasation injuries over reconstruction of dorsum of hand wound are local rotation flaps based on forearm vessels, free tissue flaps, groin flaps, and abdominal flaps [Table 3].
Table 3: Other reconstruction methods for extravasation injuries over dorsum of hand


Click here to view


Posterior interosseous artery flap and radial forearm flap are based on distal perforators and the pedicle is situated near the site of extravasation. [24],[25] Chemotherapy drugs leads to thrombosis of adjacent veins so it makes the venous drainage difficult in these flaps. Reconstruction with microvascular free flap is difficult in the patients with extravasation injury due to morbidity of microsurgery and lack of suitable recipient vein due to venous thrombosis. [26],[27]

Groin flap is a viable option for reconstruction of extravasation wound defects. [28],[29],[30]

But there are few negative points for its use; the patients hand is placed into uncomfortable position and the ambulation of the patient is delayed due to persistent hip flexion. The groin flap donor site may require skin grafting as primary closure of donor site is difficult in few situations.

Hypogastric flap reconstruction was used for extravasation injuries on dorsum of hand in present study. This method was preferred over other reconstruction methods due to its advantages and specific considerations pertaining to the dorsum of hand extravasation wounds. [31],[32],[33],[34] [Table 4]. These flaps are having their origin far away from the zone of necrosis and injury. This flap is relatively easy to harvest and allows primary closure of the donor site. [32],[34] Patient can place his affected arm in comfortable position and allows early ambulation of the patient after surgery. After reconstruction with hypogastric flap patient can be ambulant early as the flap harvest can be performed under spinal anesthesia and the debridement can be performed with help of regional axillary block anesthesia. [32],[33],[34] The results of current series justify use of hypogastric flap for reconstruction of defects following extravasation injuries and therefore hypogastric flap is a reliable flap to cover wound over dorsum of hand due to extravasation of chemotherapeutic agents.
Table 4: Advantages of hypogastric flap in reconstruction of patients with extravasation injuries over dorsum of hand


Click here to view


 
 > References Top

1.
Zatkóné Puskás G. The importance of extravasation in oncological care. Hungarian Oncol 2008;52:75-80.  Back to cited text no. 1
    
2.
Bertelli G. Prevention and management of extravasation of cytotoxic drugs. Drug Saf 1995;12:245-55.  Back to cited text no. 2
    
3.
Dorr RT. Antidotes to vesicant chemotherapy extravasations. Blood Rev 1990;4:41-60.  Back to cited text no. 3
    
4.
Burd D A, Santis G, Milward TM. Severe extravasation injury: An avoidable iatrogenic disaster? BMJ 1985;290:1579-80.  Back to cited text no. 4
    
5.
Upton J, Mulliken JB, Murray JE. Major intravenous extravasation injuries. Am J Surg 1979;137:497-506.  Back to cited text no. 5
    
6.
Thakur JS, Chauhan CG, Diwana VK, Chauhan DC, Thakur A. Extravasational side effects of cytotoxic drugs: A preventable catastrophe. Indian J Plast Surg 2008;41:145-50.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Ener RA, Meglathery SB, Styler M. Extravasation of systemic hemato-oncological therapies. Ann Oncol 2004;15:858-62.  Back to cited text no. 7
    
8.
Banerjee A, Brotherson TM, Lamberty BG, Campbell RC. Cancer chemotherapy agent induced perivenous extravasation injuries. Postgrad Med J 1987;63:5-9.  Back to cited text no. 8
    
9.
Larson DL. What is the appropriate management of tissue extravasation by anti tumour agents? Plast Reconstr Surg 1985;75:397-405.  Back to cited text no. 9
    
10.
Linder RM, Upton J, Osteen R. Management of extensive doxorubicin hydrochloride extravasation injuries. J Hand Surg Am 1983;8:32-8.  Back to cited text no. 10
    
11.
Millam DA. Managing complication of i.v. therapy. Nurs 1988;18:34-43.  Back to cited text no. 11
    
12.
Loth TS, Eversmann WW Jr. Extravasation injuries in upper extremity. Clin Orthop Relat Res 1991;272:248-54.  Back to cited text no. 12
    
13.
Khan MS, Homes JD. Reducing the morbidity from extravasation injuries. Ann Plast Surg 2002;48:628-32.  Back to cited text no. 13
    
14.
Hankin FM, Louis DS. Surgical management of doxorubicin (adriamycin) extravasation. Pediatr Orthop 1984;4:96-9.  Back to cited text no. 14
    
15.
Heitmann C, Durmus C, Ingianni G. Surgical management after doxorubicin and epirubicin extravasation. J Hand Surg Br 1998;23:666-8.  Back to cited text no. 15
    
16.
Andersonn AP, Dahlstrom KK. Clinical results after doxorubicin extravasation treated with excision guided by ß uorescence microscopy. Eur J Cancer 1993;29A: 1712-4.  Back to cited text no. 16
    
17.
MacCara ME. Extravasation: A hazard of intravenous therapy. Drug Intell Clin Pharm 1983;17:713-7.  Back to cited text no. 17
    
18.
Von Heimburg D, Pallua N. Early and late treatment of iatrogenic injection damage. Chirurg 1998;69:1378-82.  Back to cited text no. 18
    
19.
Laurie SW, Wilson KL, Kernahan DA, Bauer GS, Vistnes LM. Intravenous extravasation injuries: The effectiveness of hyaluronidase in their treatment. Ann Plast Surg 1984;13:191-4.  Back to cited text no. 19
    
20.
Dufresne RG Jr. Skin necrosis from intravenous infused materials. Cutis 1987;39:197-8. Raszka WV Jr, Kueser TK, Smith FR, Bass JW. The use of hyaluronidase in the treatment of intravenous extravasation injuries. J Perinatol 1990;10:146-9.  Back to cited text no. 20
    
21.
Casanova D, Bardot J, Magalon G. Emergency treatment of accidental infusion leakage in the newborn: Report of 14 cases. Br J Plast Surg 2001;54:396-9.  Back to cited text no. 21
    
22.
Cohen FJ, Manguro J, Bezozo RC. Identification of involved tissue during surgical treatment of doxorubicin-induced extravasation necrosis. J Hand Surg Am 1983;8:43-5.  Back to cited text no. 22
    
23.
Vandeweyer E, Heymans O, Deraemaecker R. Extravasation injuries and emergency suction as treatment. Plast Reconstr Surg 2000;105:109-10.  Back to cited text no. 23
    
24.
Hansen AJ, Duncan SF, Smith AA, Shin AY, Moran SL, Bishop AT. Reverse radial forearm fascial flap with radial artery preservation.Hand (N Y) 2007;2:159-63.  Back to cited text no. 24
    
25.
Bayon P, Pho RW. Anatomical basis of dorsal forearm flap. Based on posterior interosseous vessels. J Hand Surg (Br) 1988;13:435-9.  Back to cited text no. 25
    
26.
Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, et al. Choice of flap and incidence of free flap success. Plast Reconstr Surg 1996;98:459-63.  Back to cited text no. 26
    
27.
Khouri RK. Avoiding free flap failure. Clin Plast Surg 1992;19:773-81.  Back to cited text no. 27
    
28.
Blondeel N, Vanderstraeten GG, Monstrey SJ, Van Landuyt K, Tonnard P, Lysens R, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997;50:322-30.  Back to cited text no. 28
    
29.
Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678-83.  Back to cited text no. 29
    
30.
Brooks TM, Jarman AT, Olson JL. A bilobed groin flap for coverage of traumatic injury to both thevolar and dorsal hand surfaces. Can J Plast Surg 2007;15:49-51.  Back to cited text no. 30
    
31.
Choi JY, Chung KC. The combined use of a pedicled superficial inferior epigastric artery flap and a groin flap for reconstruction of a dorsal and volar hand blast injury. Hand 2008;3:375-80.  Back to cited text no. 31
    
32.
Urushidate S, Yotsuyanagi T, Yamauchi M, Mikami M, Ezoe K, Saito T, et al. Modified thin abdominal wall flap (glove flap) for the treatment of acute burns to the hands and fingers. J Plast Reconstr Aesthet Surg 2010;63:693-9.  Back to cited text no. 32
    
33.
Kelleher JC, Sullivan JG, Baibak GJ, Dean RK. Use of a tailored abdominal pedicle flap for surgical reconstruction of the hand. J Bone Joint Surg 1970;52A: 1552-62.  Back to cited text no. 33
    
34.
Kleinman WB, Dustman JA. The preservation of function following complete degloving injuries to the hand; use of simultaneous groin flap, random abdominal flap and partial thickness skin graft. J Hand Surg 1981;2:156-60.  Back to cited text no. 34
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
 
  Search
 
Similar in PUBMED
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  >Abstract>Introduction>Subjects and methods>Results>Discussion>Article Figures>Article Tables
  In this article
>References

 Article Access Statistics
    Viewed3476    
    Printed51    
    Emailed0    
    PDF Downloaded149    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]