Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps

BACKGROUND

Perineal wound complications following abdominoperineal excision (APE) for low rectal tumours remain an important cause of morbidity and prolonged hospital stay, particularly after chemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator (IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors' previous experience and published literature on myocutaneous flaps.

METHODS

A series of patients who underwent immediate IGAP flap reconstruction after APE between April 2008 and December 2010 were examined retrospectively to determine patient demographics, length of operation, complications (perineal wound and general) and length of hospital stay.

RESULTS

Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwent immediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvant chemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APE plus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patients had multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacral resection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and four major flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Median length of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAP flaps. Late complications occurred in two patients who had vaginal reconstruction and developed perineal hernias requiring revisional surgery.

CONCLUSION

Although operating times are long, the IGAP flap is robust, with no flap necrosis observed in this series.

Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps2

Background

Perineal wound complications following abdominoperineal excision (APE) for low rectal tumours remain an important cause of morbidity and prolonged hospital stay, particularly after chemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator (IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors' previous experience and published literature on myocutaneous flaps.

Methods

A series of patients who underwent immediate IGAP flap reconstruction after APE between April 2008 and December 2010 were examined retrospectively to determine patient demographics, length of operation, complications (perineal wound and general) and length of hospital stay.

Results

Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwent immediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvant chemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APE plus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patients had multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacral resection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and four major flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Median length of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAP flaps. Late complications occurred in two patients who had vaginal reconstruction and developed perineal hernias requiring revisional surgery.

Conclusion

Although operating times are long, the IGAP flap is robust, with no flap necrosis observed in this series.

Protein tyrosine kinase 7: a novel surface marker for human recent thymic emigrants with potential clinical utility

Recent thymic emigrants (RTEs) are antigenically naive T cells that have recently completed intrathymic maturation and have emigrated from the thymus to the periphery. RTEs are clinically and immunologically important as they are essential for maintaining peripheral T cells in sufficient numbers in order to recognize, by their αβT-cell receptors (TCRs), a diverse array of foreign peptide antigens. However, RTE frequency and function has been poorly understood because of a lack of surface markers to distinguish them from older non-RTE naive T cells. This review summarizes the biology of the intrathymic generation and function of RTEs, including the recent identification of protein tyrosine kinase 7 (PTK7) as a novel marker for human RTEs of the CD4 (helper) T-cell lineage. PTK7+ RTEs in adults have a reduced capacity for activation-induced proliferation and cytokine production (interleukin-2 and interferon-γ) than older PTK7- naive CD4 T cells. Importantly, this immaturity in CD4 RTE effector function may contribute to the reduced adaptive immune responses observed in situations in which CD4 RTEs predominate, including the fetus, neonate and young infant, and following immune reconstitution, such as post-hematopoietic stem cell transplant. The ability to identify viable CD4+ RTEs based on PTK7 surface staining may be particularly useful in the infant for better defining the impact of nutritional and environmental factors on thymic output, peripheral T-cell function and adaptive immune responses to vaccination and infection.

Use of myocutaneous flaps for perineal closure following abdominoperineal excision of the rectum for adenocarcinoma

INTRODUCTION

Abdominoperineal excision (APE) following radiotherapy is associated with a high rate of perineal wound complications. The use of myocutaneous flaps may improve wound healing. We present our experience using myocutaneous flaps for immediate reconstruction.

METHOD

Prospective data were collected on patients undergoing APE from October 2003 to December 2008. Patient demographics, operating time, wound complications and length of stay were recorded.

RESULTS

Fifty-one patients underwent APE for rectal adenocarcinoma, 21 had primary closure and 30 had myocutaneous flap closure (24 VRAM, 6 gracilis). The proportion of patients undergoing preoperative radiotherapy in each group were 62% and 93% respectively (P = 0.011). There were no major complications following primary closure of the unirradiated perineum. Major perineal wound complications requiring reoperation or debridement were seen in three (14%) patients following primary closure and five (17%) patients with flap closure. After radiotherapy, closure with a flap reduced the length of stay from 20 to 15 days, but this difference was not statistically significant (P = 0.36).

CONCLUSION

The use of flap closure in irradiated patients is associated with fewer perineal complications and a shorter hospital stay.