Wound complications in rectal cancer patients undergoing primary closure of the perineal wound after abdominoperineal resection

Influence of additional prophylactic oral antibiotics during mechanical bowel preparation on surgical site infection in patients receiving colorectal surgery

BACKGROUND

Prophylactic antibiotics (PAs) are standard for preventing surgical site infections (SSIs) post-colorectal surgery. This study aims to compare the effect of additional empiric oral antibiotics (OAs) alongside routine PAs to identify SSI risk factors.

METHODS

A retrospective observatory analysis was conducted from January 2019 to December 2022 at Asan Medical Center, Seoul, Korea. The cohort was divided into two groups: PA given 1 h before surgery and discontinued within 24 h, and OA administered empiric OAs during mechanical bowel preparation in addition to PA.

RESULTS

From a total of 6736 patients, 3482 were in the PA group and 3254 in the OA group. SSI incidence showed no significant intergroup difference (p = 0.374) even after propensity score matching (p = 0.338). The multivariable analysis revealed male sex [odds ratio (OR): 2.153, 95% confidence interval (CI): 1.626-2.852, and p = 0.001], open surgery (OR: 3.335, 95% CI: 2.456-4.528, and p = 0.001), dirty wound (OR: 2.171, 95% CI: 1.256-3.754, and p = 0.006), and an operation time of more than 145 min (OR: 2.110, 95% CI: 1.324-3.365, and p = 0.002) as SSI risk factors. In rectal surgery subgroup, OA demonstrated a protective effect against SSI (OR: 0.613, 95% CI: 0.408-0.922, and p = 0.019) and in laparoscopic approach (OR: 0.626, 95% CI: 0.412-0.952, and p = 0.028).

CONCLUSIONS

OA did not affect SSI incidence in colorectal surgeries. Male sex, open surgery, dirty wounds, and longer operation time were risk factors for SSI. However, for rectal and laparoscopic surgery, OA was a protective factor for SSI.

Mesenchymal Stem Cells and Regenerative Therapy with Bilateral Gracilis Flaps for Perineal Reconstruction of a Wound Infection in the Setting of Anal Squamous Cell Carcinoma

ABSTRACT

Many patients are affected by HIV/AIDS, and these conditions are highly prevalent worldwide. Patients with HIV/AIDS can experience debilitating wound infections that often require flap reconstruction and become challenging for surgeons to treat. In the past 5 years, mesenchymal stem cells have been tested and used as regenerative therapy to promote the growth of tissues throughout the body because of their ability to successfully promote cellular mitogenesis. To the authors' knowledge, the use of mesenchymal stem cell grafting following necrosis of a myocutaneous gracilis flap (as part of perineal wound reconstruction) has never been reported in the literature.In addition, the use of mesenchymal stem cells and regenerative medicine combined in the setting of squamous cell carcinoma of the anus with prior radiation (along with comorbid AIDS) has not been previously documented.In this report, the authors outline the case of a 60-year-old patient who had a recipient bed (perineum) complication from prior radiation therapy. Complicating the clinical picture, the patient also developed a Pseudomonal organ space infection of the pelvis leading to the failure of a vertical rectus abdominis myocutaneous flap and myocutaneous gracilis flaps. As a result, the patient underwent serial operative debridements for source control, with the application of mesenchymal stem cells, fetal bovine dermis, porcine urinary bladder xenograft, and other regenerative medicine products, achieving a highly successful clinical outcome. A procedural description for future use and replication of this method is provided.

Closed Incisional Negative Pressure Therapy Reduces Perineal Wound Complications After Abdominoperineal Resection

BACKGROUND

Perineal wound complications after abdominoperineal resection continue to be a significant challenge. Complications, ranging from 14% up to 60%, prolong hospitalization, increase risk of readmission and reoperation, delay the start of adjuvant therapy, and place psychological stress on the patient and family.

OBJECTIVE

This study aimed to evaluate the impact of closed incision negative pressure therapy on perineal wound healing.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted in an academic community hospital.

PATIENTS

Patients who underwent abdominoperineal resection from 2012 to 2020 were included.

MAIN OUTCOME MEASURES

Perineal wound complications within 30 and 180 days were the primary outcome measures.

RESULTS

A total of 45 patients were included in the study. Of these, 31 patients were managed with closed incision negative pressure therapy. The overall perineal wound complications were less frequent in the closed incision negative pressure therapy group (10/31; 32.2%) compared to the control group (10/14; 71.4%; = 5.99 [ p = 0.01]). In the closed incision negative pressure therapy group, 2 patients (20%) did not heal within 180 days and no patient required reoperation or readmission. In the control group, 4 patients (44%) had not healed at 180 days and 1 patient required flap reconstruction. When the effect of other variables was controlled, closed incision negative pressure therapy resulted in an 85% decrease in the odds of wound complications (adjusted OR 0.15 [95% CI, 0.03-0.60]; p = 0.01).

LIMITATIONS

The nonrandomized nature and use of historical controls in this study are its limitations.

CONCLUSIONS

The ease of application and the overall reduction in the incidence and severity of complications may offer an option for perineal wound management and possibly obviate the need for more expensive therapies. Further prospective controlled trials are required to effectively study its efficacy. See Video Abstract at http://links.lww.com/DCR/B895 .

LA TERAPIA POR PRESIN NEGATIVA INCISIONAL CERRADA, REDUCE LAS COMPLICACIONES DE LA HERIDA PERINEAL DESPUS DE LA RESECCIN ABDOMINOPERINEAL

ANTECEDENTES:Las complicaciones de la herida perineal, después de la resección abdominoperineal, continúan siendo un desafío importante. Las complicaciones, que van desde el 14% hasta el 60%, prolongan la hospitalización, aumentan el riesgo de reingreso y reintervención, retrasan el inicio de la terapia adyuvante y generan estrés psicológico en el paciente y su familia.OBJETIVO:Evaluar el impacto de la terapia de presión negativa con incisión cerrada en la cicatrización de heridas perineales.DISEÑO:Estudio retrospectivo.ENTORNO CLINICO:Hospital comunitario académico.PACIENTES:Se incluyeron pacientes sometidos a resección abdominoperineal entre 2012 y 2020.PRINCIPALES MEDIDAS DE VALORACION:Las complicaciones de la herida perineal dentro de los 30 y 180 días fueron las principales medidas de valoración.RESULTADOS:Se incluyeron en el estudio a un total de 45 pacientes. De estos, 31 pacientes fueron tratados con terapia de presión negativa con incisión cerrada. Las complicaciones generales de la herida perineal fueron menos frecuentes en el grupo de terapia de presión negativa con incisión cerrada (10/31, 32,2%) en comparación con el grupo de control (10/14, 71,4%) (X_1 ^ 2 = 5,99 [ p = 0,01]). En el grupo de terapia de presión negativa con incisión cerrada, dos pacientes (20%) no cicatrizaron en 180 días y ningún paciente requirió reintervención o readmisión. En el grupo de control, cuatro pacientes (44%) no habían cicatrizado a los 180 días y un paciente requirió reconstrucción con colgajo. Cuando se controló el efecto de otras variables, la terapia de presión negativa con incisión cerrada resultó con una disminución del 85% en las probabilidades de complicaciones de la herida (OR ajustado, 0.15 [IC 95%, 0,03-0,60]; p = 0,01).LIMITACIONES:La naturaleza no aleatoria y el uso de controles históricos en este estudio, son limitaciones.CONCLUSIÓNES:La facilidad de aplicación, reducción general de la incidencia y gravedad de las complicaciones, pueden ofrecer una opción para el manejo de las heridas perineales y posiblemente obviar la necesidad de tratamientos más costosos. Se necesitan más ensayos controlados prospectivos para efectivamente estudiar la eficacia. Consulte Video Resumen en http://links.lww.com/DCR/B895 . (Traducción-Dr. Fidel Ruiz Healy ).

Case control study investigating the clinical utility of NPWT in the perineal region following abdominoperineal resection for rectal adenocarcinoma: a single center study

Background

Perineal wound complications are common after abdominoperineal resection (APR) for rectal adenocarcinoma. Delayed wound healing may postpone postoperative adjuvant therapy and, therefore, lead to a worse survival rate. Negative-pressure wound therapy (NPWT) has been suggested to improve healing, but research on this subject is limited.

Methods

The aim of this study was to assess whether NPWT reduces surgical site infections (SSI) after APR for rectal adenocarcinoma when the closure is performed with a biological mesh and a local flap. A total of 21 consecutive patients had an NPWT device (Avelle, Convatec™) applied to the perineal wound. The study patients were compared to a historical cohort in a case–control setting in relation to age, body mass index, tumor stage, and length of neoadjuvant radiotherapy. The primary outcome was the surgical site infection rate. The secondary outcomes were the wound complication rate, the severity of wound complications measured by the Clavien–Dindo classification, length of hospital stay, and surgical revision rate.

Results

The SSI rate was 33% (7/21) in the NPWT group and 48% (10/21) in the control group, p = 0.55. The overall wound complication rate was 62% (13/21) in NPWT patients and 67% (14/21) in the control group, p > 0.90. The length of hospital stay was 15 days in the NPWT group and 13 in the control group, p = 0.34. The wound severity according to the Clavien–Dindo classification was 3b in 29% (6/21) of the NPWT group and in 38% (8/21) of the control group. A surgical revision had to be performed in 29% (6/21) of the cases in the NPWT group and 38% (8/21) in the control group, p = 0.73.

Conclusion

NPWT did not statistically decrease surgical site infections or reduce wound complication severity in perineal wounds after APR in this case–control study. The results may be explained by technical difficulties in applying NPWT in the perineum, especially in female patients. NPWT devices should be further developed to suit the perineal anatomy before their full effect can be assessed.

Trial registration The study was registered as a prospective registry study (266/2018, registered 15th of November 2018)

Perineal wound healing after abdominoperineal resection for rectal cancer: a retrospective cohort study

PURPOSE

Delayed perineal wound healing is a common complication after abdominoperineal resection (APR) in rectal cancer. The primary aim of this study was to evaluate the number of patients with delayed wound healing after APR. Secondary aims were to identify risk factors, and describe treatment.

METHODS

Prospectively collected data from the Swedish Colorectal Cancer Registry (SCRCR) was used for retrospective analysis of APR performed at Skåne University Hospital Malmö between 2013 and 2018. Medical charts were retrospectively reviewed. Delayed healing was defined as non-healed perineal wound 30 days postoperatively. Patients undergoing extralevator APR requiring reconstruction were excluded. Statistical analysis was made using SPSS. Risk factors for impaired wound healing were analyzed using a multivariable model.

RESULTS

A total of 162 patients were included, of which 114 underwent standard APR (sAPR) and 48 patients intersphincteric APR (isAPR). In the total population, 69% (111/162) were male, with median age 71 (26-87). The overall healing rate was 52% (85/162); 44% (50/114) in sAPR vs 73% (35/48) in isAPR (P < 0.001). Risk factors for impaired healing after multivariable analysis were BMI > 30 (OR 7.0; CI 95% 1.8-26.2, P = 0.004), reoperation (OR 7.9; CI 95% 1.6-39.8, P = 0.013), neoadjuvant radiotherapy (OR 5.2; CI 95% 1.02-25.1, P = 0.047) and sAPR (OR 2.598; CI 95% 1.05-6.41, P = 0.038). Eight percent (13/162) required an intervention (Clavien-Dindo ≥ 3).

CONCLUSION

Delayed perineal wound healing is a frequent complication after APR but the majority could be treated conservatively. Several risk factors were identified. Further studies aiming at interventions reducing delayed perineal wound healing after APR are warranted.

Perineal Reconstruction With the Profunda Artery Perforator Flap

BACKGROUND

Abdominoperineal resection is used to treat a variety of colorectal pathologies. Traditionally, the vertical rectus abdominis myocutaneous flap has been most commonly used for reconstruction. Here, we explore the role of the profunda artery perforator (PAP) flap for perineal reconstruction.

METHODS

A prospectively maintained database was retrospectively analyzed to identify patients who had undergone perineal reconstruction with a pedicled PAP flap. Parameters of interest included age, sex, body mass index, primary diagnosis, comorbidities, and history of radiation, and postoperative complications.

RESULTS

Fifteen patients (5 men and 10 women) with a median age of 52 years (interquartile range, 48.5-61.5 years) were included in the study. Median body mass index was 26.3 kg/m2 (interquartile range, 24.0-29.3 kg/m2). Patients underwent abdominoperineal resection for treatment of rectal cancer (n = 9, 60.0%), recurrent anal squamous cell carcinoma (n = 3, 20.0%), and Crohn's disease (n = 3, 20.0%). Twelve patients (80.0%) underwent neoadjuvant radiotherapy. Eight patients (53.3%) experienced a total of 10 complications (2 major and 8 minor). The most common complication was donor (n = 3, 20.0%)/recipient (n = 3, 20.0%) site wound dehiscence. Stable soft tissue coverage was achieved in all patients.

CONCLUSIONS

The PAP flap provides stable soft tissue coverage of perineal defects with a low donor-site morbidity. This flap should be strongly considered in the reconstructive algorithm when approaching perineal defects.

Long-term Outcomes of Minimally Invasive Versus Open Abdominoperineal Resection for Rectal Cancer: A Single Specialized Center Experience

BACKGROUND

Randomized studies have validated laparoscopic proctectomy for the treatment of rectal cancer as noninferior to an open proctectomy, but most of those studies have included sphincter-preserving resections along with abdominoperineal resection.

OBJECTIVE

This study aimed to compare perioperative and long-term oncological outcomes between minimally invasive and open abdominoperineal resection.

DESIGN

This study is a retrospective analysis of a prospectively maintained database.

SETTINGS

The study was conducted in a single specialized colorectal surgery department.

PATIENTS

All patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2016 were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the perioperative and long-term oncological outcomes.

RESULTS

We included 452 patients, 372 in the open group and 80 in the minimally invasive group, with a median follow-up time of 74 months. There were significant differences between the groups in terms of neoadjuvant radiation treatment (67.5% of the open versus 81.3% of the minimally invasive group, p = 0.01), operative time (mean of 200 minutes versus 287 minutes, p < 0.0001), and mean length of stay (9.5 days versus 6.6 days, p < 0.0001). Overall complication rates were similar between the groups (34.5% versus 27.5%, p = 0.177). There were no significant differences in the mean number of lymph nodes harvested (21.7 versus 22.2 nodes, p = 0.7), circumferential radial margins (1.48 cm versus 1.37 cm, p = 0.4), or in the rate of involved radial margins (10.8% versus 6.3%, p = 0.37). Five-year overall survival was 70% in the open group versus 80% in the minimally invasive group (p = 0.344), whereas the 5-year disease-free survival rate in the open group was 63.2% versus 77.6% in the minimally invasive group (p = 0.09).

LIMITATIONS

This study was limited because it describes a single referral institution experience.

CONCLUSIONS

Although both approaches have similar perioperative outcomes, the minimally invasive approach benefits the patients with a shorter length of stay and a lower risk for surgical wound infections. Both approaches yield similar oncological technical quality in terms of the lymph nodes harvested and margins status, and they have comparable long-term oncological outcomes. See Video Abstract at http://links.lww.com/DCR/B754.RESULTADOS A LARGO PLAZO DE LA RESECCIÓN ABDOMINOPERINEAL MÍNIMAMENTE INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: EXPERIENCIA DE UN SOLO CENTRO ESPECIALIZADOANTECEDENTES:Estudios aleatorizados han validado la proctectomía laparoscópica para el tratamiento del cáncer de recto igual a la proctectomía abierta, pero la mayoría de esos estudios han incluido resecciones con preservación del esfínter junto con resección abdominoperineal.OBJETIVO:Comparar los resultados oncológicos perioperatorios y a largo plazo entre la resección abdominoperineal abierta y mínimamente invasiva.DISEÑO:Análisis retrospectivo de una base de datos mantenida de forma prospectiva.ENTORNO CLINICO:Servicio único especializado en cirugía colorrectal.PACIENTES:Todos los pacientes que se sometieron a resección abdominoperineal por cáncer de recto primario entre 2000 y 2016.PRINCIPALES MEDIDAS DE VALORACION:Resultados oncológicos perioperatorios y a largo plazo.RESULTADOS:Se incluyeron 452 pacientes, 372 en el grupo abierto y 80 en el grupo mínimamente invasivo, con una mediana de seguimiento de 74 meses. Hubo diferencias significativas entre los grupos en términos de tratamiento con radiación neoadyuvante (67,5% del grupo abierto versus 81,3% del grupo mínimamente invasivo, p = 0,01), tiempo operatorio (media de 200 minutos versus 287 minutos, p < 0,0001) y la duración media de la estancia (9,5 días frente a 6,6 días, p < 0,0001). Las tasas generales de complicaciones fueron similares entre los grupos (34,5% versus 27,5%, p = 0,177). No hubo diferencias significativas en el número medio de ganglios linfáticos extraídos (21,7 versus 22,2 ganglios, p = 0,7), márgenes radiales circunferenciales (1,48 cm y 1,37 cm, p = 0,4), ni en la tasa de márgenes radiales afectados (10,8 cm). % versus 6,3%, p = 0,37). La supervivencia general a 5 años fue del 70% en el grupo abierto frente al 80% en el grupo mínimamente invasivo (p = 0,344), mientras que la tasa de supervivencia libre de enfermedad a 5 años en el grupo abierto fue del 63,2% frente al 77,6% en el grupo mínimamente invasivo (p = 0,09).LIMITACIONES:Experiencia en una institución de referencia única.CONCLUSIONES:Si bien ambos tienen resultados perioperatorios similares, el enfoque mínimamente invasivo, beneficia a los pacientes con estadía más corta y menor riesgo de infecciones de la herida quirúrgica. Ambos enfoques, producen una calidad técnica oncológica similar en términos de ganglios linfáticos extraídos y estado de los márgenes, y tienen resultados oncológicos comparables a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B754. (Traducción - Dr. Fidel Ruiz Healy).

Effects of Neoadjuvant Radiotherapy on Postoperative Complications in Rectal Cancer: A Meta-Analysis

Objective

Neoadjuvant radiotherapy (nRT) is an important treatment approach for rectal cancer. The relationship, however, between nRT and postoperative complications is still controversial. Here, we conducted a meta-analysis to evaluate such concerns.

Methods

The electronic literature from 1983 to 2021 was searched in PubMed, Embase, and Web of Science. Postoperative complications after nRT were included in the meta-analysis. The pooled odds ratio (OR) was calculated by the random-effects model. Statistical analysis was conducted by Review Manager 5.3 and STATA 14.

Results

A total of 23,723 patients from 49 studies were included in the meta-analysis. The pooled results showed that nRT increased the risk of anastomotic leakage (AL) compared to upfront surgery (OR = 1.23; 95% CI, 1.07-1.41; p=0.004). Subgroup analysis suggested that both long-course (OR = 1.20, 95% CI 1.03-1.40; p=0.02) and short-course radiotherapy (OR = 1.25, 95% CI, 1.02-1.53; p=0.04) increased the incidence of AL. In addition, nRT was the main risk factor for wound infection and pelvic abscess. The pooled data in randomized controlled trials, however, indicated that nRT was not associated with AL (OR = 1.01; 95% CI 0.82-1.26; p=0.91).

Conclusions

nRT may increase the risk of AL, wound infection, and pelvic abscess compared to upfront surgery among patients with rectal cancer.

A meta-analysis of low Hartmann's procedure versus abdominoperineal resection for non-restorative treatment of rectal cancer

BACKGROUND

Non-restorative surgery for rectal cancer is indicated in patients with comorbidities, advanced disease and poor continence. The aim of this meta-analysis was to compare the postoperative morbidity of Hartmann's procedure (HP) with that of extrasphincteric and intersphincteric abdominoperineal resection (APR) in the treatment of rectal cancer.

METHODS

The Medline, Embase and Cochrane databases were searched for publications comparing postoperative morbidity of HP and APR. The incidence of overall surgical complications, pelvic-perineal complications and pelvic abscess was analysed as primary endpoints. Readmissions requiring reintervention and postoperative mortality were also compared.

RESULTS

A cumulative analysis showed a significantly higher rate of overall complications (odds ratio (OR) 0.553, 95% confidence interval (CI) 0.320 to 0.953 and P value 0.033) and pelvic-perineal complications (OR 0.464, 95% CI 0.250 to 0.861 and P value 0.015) after APR. The incidence of isolated pelvic abscess formation was significantly higher after HP (OR 2.523, 95% CI 1.383 to 4.602 and P value 0.003). A subgroup analysis of intersphincteric APR compared with HP did not show any significant difference in the incidence of overall complications, pelvic-perineal complications or pelvic abscess formation (P values of 0.452, 0.258 and 0.100, respectively). There was no significant difference in readmissions, reinterventions and mortality after HP and APR (P 0.992, 0.198 and 0.151).

CONCLUSION

An extrasphincteric APR is associated with higher overall and pelvic-perineal complications and may be reserved for tumours invading the anal sphincter complex. In the absence of sphincter involvement, both HP and intersphincteric APR are better alternatives with comparable morbidity.

Immediate vaginal and perineal reconstruction after abdominoperineal excision using the Inferior Gluteal Artery Perforator Flap (V-IGAP)

BACKGROUND

The fasciocutaneous inferior gluteal artery perforator (IGAP) has been previously demonstrated to be a robust reconstructive choice after abdominoperineal excision (APE), with comparably low morbidity relative to other flaps. In patients who undergo concurrent vaginectomy, we demonstrate in this retrospective cohort study how IGAP modification allows simultaneous vaginal reconstruction with a favourable complication profile and long-term return to sexual activity.

METHODS

Oncological resection was completed with the patient prone. Unilateral or bilateral IGAP flaps may be used based on vaginal defect size and surgeon preference. In this study, important features of flap design, mobilisation and inset are presented, together with a retrospective cohort study of all cases who underwent vaginal reconstruction. Clinical outcomes were determined by the length of stay, early to late complications, and quality of life assessment including a return to sexual function.

RESULTS

Over a 10-year period, 207 patients underwent abdominoperineal resection (APE) in our cross-centre study (86% subject to neoadjuvant chemoradiotherapy), with 22/84 female patients electing for vaginal reconstruction (19 partial, 3 total vaginectomies). Minor complications were observed in 6/22 cases, with two patients progressing to healing after-theatre debridement (major). The median follow-up time was 410 days. Quality of life questionnaires reported high patient satisfaction, with 70% of patients returning to sexual activity.

CONCLUSIONS

For patients undergoing APE with concurrent vaginectomy, the IGAP flap can be used alone for both perineal dead space management and neovaginal reconstruction, negating the need for an alternative second flap and avoiding significant donor morbidity. This study shows excellent long-term clinical outcomes, including a return to sexual activity.

Risk Factors for Readmission after Ileostomy Creation: an NSQIP Database Study

BACKGROUND

Ileostomy creation is associated with excess readmissions following colorectal surgery. This study identifies risk factors for readmission in patients undergoing ileostomy creation and identifies areas of clinical intervention to reduce readmission.

METHODS

We used the NSQIP dataset including colectomy specific data to include 39,380 patients who underwent ileostomy creation between 2012 and 2017. We conducted univariate and multivariable analysis to identify predictors of surgery-related 30-day readmissions. Our multivariate model included surgery type (total abdominal colectomy, partial colectomy, enterectomy, or pelvic dissection), gender, age, race, ethnicity, preoperative renal failure, dialysis, transfusion, ascites, ventilator dependence, diabetes, ASA class, functional status, emergency case, SSI, wound disruption, postoperative renal insufficiency, postoperative sepsis, discharge destination, and wound class.

RESULTS

A total of 5718 (14.52%) patients were readmitted within 30 days. After multivariate analysis, factors associated with readmission were gender, age, Hispanic ethnicity, dialysis, transfusion, ventilator dependence, diabetes, emergency case, SSI, postoperative renal insufficiency, postoperative sepsis, and discharge to a skilled facility. Patients who had enterectomy and partial colectomies were less likely to be readmitted than patients who had a pelvic procedure. Patients with postoperative renal insufficiency or renal failure were much more likely to be readmitted.

CONCLUSION

Factors associated with readmission included the type of procedure and postoperative complications such as SSI, sepsis, and renal failure. Efforts to reduce readmission should focus on patients undergoing concomitant pelvic procedures as well as avoidance and management of common complications in this group of patients.

Perineal wound complication risk factors and effects on survival after abdominoperineal resection of rectal cancer: a single-centre retrospective study

PURPOSE

This study determined the risk factors associated with perineal wound complications (PWCs) and investigated their effect on overall survival in patients with rectal cancer who underwent abdominoperineal resection (APR).

METHODS

The clinicopathologic and follow-up data of patients who underwent APR for primary rectal cancer between 1998 and 2018 were reviewed. PWCs were defined as any perineal wound that required surgical intervention, antibiotics, or delayed healing for more than 2 weeks. The primary objective was identifying the risk factors of PWC after APR. The effect of PWC on survival was also investigated as a secondary objective.

RESULTS

Two hundred and twenty patients were included in the final analyses and 49 had PWCs. An operative time of > 285 min (odds ratio: 2.440, 95% confidence interval (CI): 1.257-4.889) was found to be independently associated with PWCs. When the follow-up time was > 60 months, patients with PWCs had a significantly lower overall survival rate than patients without PWC (n = 156; mean over survival: 187 and 164 months in patients without and with PWCs, respectively; P = 0.045). Poor differentiation (hazard ratio (HR): 1.893, 95% CI: 1.127-3.179), lymph node metastasis (HR: 2.063, 95% CI: 1.228-3.467), and distant metastasis (HR: 3.046, 95% CI: 1.551-5.983) were associated with poor prognosis.

CONCLUSION

Prolonged operative time increases the risk of PWCs, and patients with PWCs have a lower long-term survival rate than patients without PWCs. Therefore, surgeons should aim to reduce the operative time to minimise the risk of PWC in patients undergoing APR for rectal cancer.

Retrospective research of neoadjuvant therapy on tumor-downstaging, post-operative complications, and prognosis in locally advanced rectal cancer

BACKGROUND

Neoadjuvant therapy (NAT) is becoming increasingly important in locally advanced rectal cancer. Hence, such research has become a problem.

AIM

To evaluate the downstaging effect of NAT, its impact on postoperative complications and its prognosis with different medical regimens.

METHODS

Seventy-seven cases from Shanghai Ruijin Hospital affiliated with Shanghai Jiaotong University School of Medicine were retrospectively collected and divided into the neoadjuvant radiochemotherapy (NRCT) group and the neoadjuvant chemotherapy (NCT) group. The differences between the two groups in tumor regression, postoperative complications, rectal function, disease-free survival, and overall survival were compared using the χ 2 test and Kaplan-Meier analysis.

RESULTS

Baseline data showed no statistical differences between the two groups, whereas the NRCT group had a higher rate of T4 (30/55 vs 5/22, P < 0.05) than the NCT groups. Twelve cases were evaluated as complete responders, and 15 cases were evaluated as tumor regression grade 0. Except for the reduction rate of T stage (NRCT 37/55 vs NCT 9/22, P < 0.05), there was no difference in effectiveness between the two groups. Preoperative radiation was not a risk factor for poor reaction or anastomotic leakage. No significant difference in postoperative complications and disease-free survival between the two groups was observed, although the NRCT group might have better long-term overall survival.

CONCLUSION

NAT can cause tumor downstaging preoperatively or even complete remission of the primary tumor. Radiochemotherapy could lead to better T downstaging and promising overall survival without more complications.

Meta-analysis of biological mesh reconstruction versus primary perineal closure after abdominoperineal excision of rectal cancer

BACKGROUND

Extralevator abdominoperineal excision (ELAPE) of rectal cancer has been proposed to achieve better oncological outcomes. The resultant wide perineal wound, however, presents a challenge for primary closure and subsequent wound healing. This meta-analysis compared the outcomes of primary perineal closure with those of biological mesh reconstruction.

METHODS

The Medline and Embase search was performed for the publications comparing primary perineal closure to biological mesh reconstruction. Early perineal wound complications (seroma, infection, dehiscence) and late perineal wound complications (perineal hernia, chronic pain, and chronic sinus) were analyzed as primary endpoints. Intraoperative blood loss, operation time, and hospital stay were compared as secondary endpoints.

RESULTS

There was no significant difference in the overall early wound complications after primary closure or biological mesh reconstruction (odds ratio (OR) of 0.575 with 95% confidence interval (CI) of 0.241 to 1.373 and a P value of 0.213). The incidence of perineal hernia after 1 year was significantly high after primary closure of the perineal wounds (OR of 0.400 with 95% CI of 0.240 to 0.665 and a P value of 0.001). No significant differences were observed among other early and late perineal wound complications. The operation time and hospital stay were shorter after primary perineal closure (p 0.001).

CONCLUSION

A lower incidence of perineal hernia and comparable early perineal wound complications after biological mesh reconstruction show a relative superiority over primary closure. More randomized studies are required before a routine biological mesh reconstruction can be recommended for closure of perineal wounds after ELAPE.

Clinical effectiveness of omental transposition in facilitating perineal wound healing after abdominoperineal resection: a systematic review

Background

Omental transposition has been used to facilitate perineal wound healing in patients undergoing abdominoperineal resection (APR). However, there is no high-level evidence supporting the effectiveness of omental transposition in this regard. This study aimed to investigate the clinical efficacy of omental transposition in facilitating perineal wound healing after APR.

Methods

In this systematic review, we systematically searched the PubMed/MEDLINE, Embase, Scopus, Cochrane Library, and Web of Science databases for literature regarding the topic of our study. Studies published since the inception of each database were considered for review. The outcomes of interest were the perineal wound healing rate at 1 and 3 months postoperatively, perineal wound infection rate, and perineal wound healing period.

Results

Of the 1,923 studies identified, four articles representing 819 patients (omental transposition patients, n=295) were included in the final analysis. The wound healing rates at 1 and 3 months postoperatively in the omental transposition group (68.5% and 79.7%, respectively) did not significantly differ from those in the control group (57.4% and 78.7%, respectively) (p=0.759 and p=0.731, respectively). Perineal wound infection and chronic wound complication rates, including sinus, dehiscence, and fistula rates, also did not significantly differ between the omental transposition (8% and 7%, respectively) and control (11% and 7%, respectively) groups (p=0.221 and p=0.790, respectively).

Conclusion

Our results suggest that omental transposition does not affect perineal wound healing in patients who undergo APR.

Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery

AIM

Patients who undergo radical pelvic surgery often have problems with perineal wound healing and pelvic collections. While there is recognition of the perineal morbidity, there also remains uncertainty around the benefit of vertical rectus abdominus myocutaneous (VRAM) flaps due to the balance between primary healing and the complications associated with this form of reconstruction. This study aimed to evaluate factors associated with significant flap and donor site related complications following VRAM flap reconstruction for radical pelvic surgery.

METHOD

A retrospective analysis of VRAM flap related complications was undertaken from prospectively maintained databases for all patients undergoing radical pelvic surgery (2001- 2017) in two cancer centres.

RESULTS

In all, 154 patients were identified [median age 62 years (range 26-89 years), 80 (52%) men]. Thirty-three (21%) patients experienced significant donor or flap related complications. Major complications (Clavien-Dindo ≥ 3) related to the abdominal donor site occurred in nine (6%) patients, while those related to the flap or perineal site occurred in 28 (18%) patients. Only smoking (P = 0.003) and neoadjuvant radiotherapy (P = 0.047) were associated with the development of significant flap related complications on univariate analysis. Flap related complications resulted in a significantly longer hospital stay (P < 0.001).

CONCLUSION

Careful patient selection is required to balance the risks vs the benefits of VRAM flap reconstruction. Immediate VRAM reconstruction in patients undergoing radical pelvic surgery can achieve early healing and stable perineal closure; it has a low but significant morbidity. Major flap related complications are significantly associated with smoking status and neoadjuvant radiotherapy and result in a prolonged length of hospital stay.

Extralevator abdominoperineal excision versus abdominoperineal excision for low rectal cancer: a meta-analysis

BACKGROUND

Extralevator abdominoperineal excision (ELAPE) has become a popular procedure for low rectal cancer as compared with abdominoperineal excision (APE). No definitive answer has been achieved whether one is superior to the other. This study aimed to evaluate the safety and efficacy of ELAPE for low rectal cancer with meta-analysis.

METHODS

The Web of Science, Cochrane Library, Embase, and PubMed databases before September 2019 were comprehensively searched to retrieve comparative trials of ELAPE and APE for low rectal cancer. Pooled analyses of the perioperative variables, surgical complications, and oncological variables were performed. Odds ratio (OR) and mean differences (MD) from each trial were pooled using random or fixed effects model depending on the heterogeneity of the included studies. A subgroup analysis or a sensitivity analysis was conducted to explore the potential source of heterogeneity when necessary.

RESULTS

This meta-analysis included 17 studies with 4049 patients, of whom 2248 (55.5%) underwent ELAPE and 1801 (44.5%) underwent APE. There were no statistical differences regarding the circumferential resection margin positivity (13.0% vs. 16.2%, OR = 0.69, 95% CI = 0.42-1.14, P = 0.15) and post-operative perineal wound complication rate (28.9% vs. 24.1%, OR = 1.21, 95% CI = 0.75-1.94, P = 0.43). The ELAPE was associated with lower rate of intraoperative perforation (6.6% vs. 11.3%, OR = 0.50, 95% CI = 0.39-0.64, P < 0.001) and local recurrence (8.8% vs. 20.5%, OR = 0.29, 95% CI = 0.21-0.41, P < 0.001) when compared with APE.

CONCLUSIONS

The ELAPE was associated with a reduction in the rate of intra-operative perforation and local recurrence, without any increase in the circumferential resection margin positivity and post-operative perineal wound complication rate when compared with APE in the surgical treatment of low rectal cancer.

What is the advantage of rectal amputation with an initial perineal approach for primary anorectal carcinoma?

Background

Rectal amputation (RA) remains an important surgical procedure for salvage despite advances in sphincter-preserving resection, including intersphincteric resection. The aim of this study was to compare short- and long-term outcomes of RA with an initial perineal approach to those of RA with an initial abdominal approach (conventional abdominoperineal resection (APR)) for primary anorectal cancer.

Methods

We retrospectively analyzed the short- and long-term outcomes of 48 patients who underwent RA with an initial perineal approach (perineal group) and 21 patients who underwent RA with an initial abdominal approach (conventional group).

Results

For the perineal group, the operation time was shorter than that for the conventional group (313 vs. 388 min, p = 0.027). The postoperative complication rate was similar between the two groups (43.8 vs. 47.6%, p = 0.766). Perineal wound complications (PWCs) were significantly fewer in the perineal group than in the conventional group (22.9 vs. 57.1%, p = 0.006). All 69 patients underwent complete TME, but positive CRM was significantly higher in the conventional group than in the perineal group (0 vs. 19.0%, p = 0.011). There were no significant differences in the recurrence (43.8 vs. 47.6%, p = 0.689), 5-year disease-free survival (63.7% vs. 56.7%, p = 0.665) and 5-year overall survival rates (82.5% vs. 66.2%, p = 0.323) between the two groups.

Conclusion

These data suggest that RA with an initial perineal approach for selective primary anorectal carcinoma is advantageous in minimizing PWCs and positive CRMs. Further investigations on the advantages of this approach are necessary.

Risk factors for delayed perineal wound healing and its impact on prolonged hospital stay after abdominoperineal resection

Background

Perineal wound complications are a long-lasting issue for abdominoperineal resection (APR) patients. Complication rates as high as 60% have been reported, with the most common complication being delayed perineal wound healing. The aim of this study was to identify risk factors for delayed perineal wound healing and its impact on prolonged hospital stay.

Methods

We included low rectal tumor patients who underwent APR at a referral medical center from April 2002 to December 2017; a total of 229 patients were included. The basic characteristics and surgical outcomes of the patients were analyzed to identify risk factors for delayed perineal wound healing (> 30 days after APR) and prolonged hospital stay (post-APR hospital stay > 14 days).

Results

All patients received primary closure for their perineal wound. The majority of patients were diagnosed with adenocarcinoma (N = 213, 93.1%). In the univariate analysis, patients with hypoalbuminemia (albumin < 3.5 g/dL) had an increased risk of delayed wound healing (39.5% vs. 60.5%, P = 0.001), which was an independent risk factor in the multivariable analysis (OR 2.962, 95% CI 1.437–6.102, P = 0.003). Patients with delayed wound healing also had a significantly increased risk of prolonged hospital stay (OR 6.404, 95% CI 3.508–11.694, P < 0.001).

Conclusions

Hypoalbuminemia was an independent risk factor for delayed wound healing, which consequently led to a prolonged hospital stay. Further clinical trials are needed to reduce the incidence of delayed perineal wound healing by correcting albumin levels or nutritional status before APR.

Perineal Wound Complications After Extralevator Abdominoperineal Excision for Low Rectal Cancer

BACKGROUND

Reconstruction of the pelvic floor defect caused by extralevator abdominoperineal excision poses a challenge for the surgeon.

OBJECTIVE

The aim of this study was to analyze the long-term perineal wound complications in patients undergoing conventional primary closure versus biological mesh-assisted repair after extralevator abdominoperineal excision.

DESIGN

This was a single-institution retrospective observational study.

SETTINGS

The study was conducted at a tertiary academic medical center.

PATIENTS

Patients with low advanced rectal cancer undergoing extralevator abdominoperineal excision from August 2008 to December 2016 (N = 228) were included.

INTERVENTIONS

All of the patients received extralevator abdominoperineal excision operation.

MAIN OUTCOME MEASURES

The primary outcome measure was perineal wound complications after the operation.

RESULTS

Of the 228 patients who underwent extralevator abdominoperineal excision, 174 received biological mesh repair and 54 received primary closure. Preoperative radiotherapy was administered to 89 patients (51.1%) in the biological mesh group and 20 patients (37.0%) in the primary closure group. The biological mesh group had significantly lower rates of perineal wound infection (11.5% vs 22.2%; p = 0.047), perineal hernia (3.4% vs 13.0%; p = 0.022), wound dehiscence (0.6% vs 5.6%; p = 0.042), and total perineal wound complications (14.9% vs 35.2%; p = 0.001) compared with the primary closure group. Multivariable logistic regression analysis showed preoperative radiotherapy (p < 0.001), conventional primary closure (p < 0.001), and intraoperative bowel perforation (p= 0.001) to be significantly associated with perineal procedure-related complications.

LIMITATIONS

This was a single-center retrospective study.

CONCLUSIONS

Although perineal wound repair with biological mesh prolongs the operative time of perineal portion, the perineal drainage retention time, and the length of hospital stay, it may reduce perineal procedure-related complications and improve wound healing. Preoperative radiotherapy and intraoperative bowel perforation appear to be independent predictors of perineal complications. See Video Abstract at http://links.lww.com/DCR/B42. COMPLICACIONES DE LA HERIDA PERINEAL DESPUÉS DE LA EXCISIÓN ABDOMINOPERINEAL EXTRA-ELEVADORA EN CASO DE CÁNCER DE RECTO BAJO: La reconstrucción del defecto en el suelo pélvico, resultado de una resección abdominoperineal extra-elevadora plantea un desafío para el cirujano.El analisis de las complicaciones de la herida perineal a largo plazo en pacientes sometidos a un cierre primario convencional versus una reparación asistida por malla biológica después de una resección abdominoperineal extra-elevadora.Estudio retrospectivo observacional en una sola institución.Investigación realizada en un centro médico académico terciario.Se incluyeron los pacientes con cáncer rectal bajo avanzado que se sometieron a una resección abdominoperineal extra-elevadora desde agosto de 2008 hasta diciembre de 2016 (n= 228).Todos aquellos pacientes que fueron sometidos a una resección abdominoperineal extra-elevadora.Todas las complicaciones de la herida perineal en el postoperatorio.De los 228 pacientes que se sometieron a una resección abdominoperineal extra-elevadora, 174 fueron reparados con una malla biológica y 54 se beneficiaron de un cierre primario. La radioterapia preoperatoria se administró a 89 (51,1%) pacientes en el grupo de malla biológica y 20 (37,0%) pacientes en el grupo de cierre primario. El grupo de malla biológica tuvo tasas significativamente más bajas de infección de la herida perineal (11.5% vs. 22.2%; p = 0.047), hernia perineal (3.4% vs. 13.0%; p = 0.022), dehiscencia de la herida (0.6% vs. 5.6%; p = 0,042) y complicaciones perineales de la herida (14,9% frente a 35,2%; p = 0,001) en comparación con el grupo de cierre primario. El análisis de regresión logística multivariable mostró que la radioterapia preoperatoria (p <0.001), el cierre primario convencional (p <0.001) y la perforación intestinal intra-operatoria (p = 0.001) se asociaron significativamente como complicaciones relacionadas con el procedimiento perineal.Estudio retrospectivo de centro único.Aunque la reparación de la herida perineal con malla biológica prolonga el tiempo perineal de la operación, la presencia y duración del drenaje perineal y la hospitalización pueden reducir las complicaciones relacionadas con el procedimiento perineal y mejorar la cicatrización de la herida. La radioterapia preoperatoria y la perforación intestinal intra-operatorias parecen ser predictores independientes de complicaciones perineales. Vea el Resumen del Video en http://links.lww.com/DCR/B42.

Does one size fit all? Risks and benefits of neoadjuvant chemoradiation in patients with clinical stage IIA rectal cancer requiring abdominoperineal resection

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) has become the standard of care for locally advanced rectal cancer, decreasing locoregional recurrence, yet with an unclear survival advantage. We aimed to assess the benefit of nCRT on oncologic and perioperative outcomes of patients with clinical stage IIA rectal adenocarcinoma treated with abdominoperineal resection (APR).

METHODS

Patients with clinical T3N0 rectal adenocarcinoma that underwent APR between 1995 and 2014 were included. Patients who received nCRT were compared with patients who did not. Multivariate analysis was conducted to compare oncological and perioperative outcomes between the groups.

RESULTS

127 patients were included, of which 94 received nCRT. Median follow-up was 11.9 years. There was no difference in circumferential margins, postoperative morbidity, and complication rates between the groups. There was no difference in 5-year oncological outcomes between the groups.

CONCLUSIONS

No difference was found in 5-year oncological outcomes between patients with clinical T3N0 rectal adenocarcinoma necessitating an APR who received nCRT and those not receiving nCRT, with similar overall complication rates.

Excluding the ischiorectal fossa irradiation during neoadjuvant chemoradiotherapy with intensity-modulated radiotherapy followed by abdominoperineal resection decreases perineal complications in patients with lower rectal cancer

BACKGROUND

The aim of this study was to explore the impact of including or excluding the ischiorectal fossa (IRF) within the clinical target volume during neoadjuvant chemoradiotherapy (NCRT) using intensity modulated radiotherapy, in locally advanced lower rectal cancer (LALRC).

METHODS

We retrospectively analysed the data of 220 LALRC patients who received NCRT followed by abdominoperineal resection between January 2009 and January 2015. Six patients were excluded because of loss to follow-up, 90 patients received IRF irradiation (IRF group) while 124 patients did not (NIRF group). Survival, patterns of recurrence, and treatment toxicities were compared between the two groups.

RESULTS

Overall, patient/treatment variables were well balanced except for surgical technique. Perineal wound complications in the IRF and NIRF groups, were 40.0 and 24.2%, respectively (p = 0.010); corresponding 3-year perineal recurrence rates, local recurrence free survival, overall survival, and distant relapse free survival were 4.4% vs. 2.4% (p = 0.670), 88.1% vs. 95.0% (p = 0.079), 82.6% vs. 88.4% (p = 0.087), and 61.9% vs. 81.0% (p = 0.026), respectively. Multivariate analyses demonstrated the following factors to be significantly related to perineal wound complications: irradiation of the IRF (odds ratio [OR] 2.892, p = 0.002), anaemia (OR 3.776, p = 0.010), operation duration > 180 min (OR 2.486, p = 0.007), and interval between radiotherapy and surgery > 8 weeks (OR 2.400, p = 0.010).

CONCLUSIONS

Exclusion of the IRF from the clinical target volume during NCRT using intensity-modulated radiotherapy in LALRC could lower the incidence of perineal wound complications after abdominoperineal resection, without compromising oncological outcomes.

Frequency and timing of short-term complications following abdominoperineal resection

BACKGROUND

Abdominoperineal resection (APR) is primarily used for rectal cancer and is associated with a high rate of complications. Though the majority of APRs are performed as open procedures, laparoscopic APRs have become more popular. The differences in short-term complications between open and laparoscopic APR are poorly characterized.

METHODS

We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to determine the frequency and timing of onset of 30-d postoperative complications after APR and identify differences between open and laparoscopic APR.

RESULTS

A total of 7681 patients undergoing laparoscopic or open APR between 2011 and 2015 were identified. The total complication rate for APR was high (45.4%). APRs were commonly complicated by blood transfusion (20.1%), surgical site infection (19.3%), and readmission (12.3%). Laparoscopic APR was associated with a 14% lower total complication rate compared to open APR (36.0% versus 50.1%, P < 0.001). This was primarily driven by a decreased rate of transfusion (10.7% versus 24.9%, P < 0.001) and surgical site infection (15.5% versus 21.2%, P < 0.001). Laparoscopic APR had shorter length of stay and decreased reoperation rate but similar rates of readmission and death. Cardiopulmonary complications occurred earlier in the postoperative period after APR, whereas infectious complications occurred later.

CONCLUSIONS

Short-term complications following APR are common and occur more frequently in patients who undergo open APR. This, along with factors such as risk of positive pathologic margins, surgeon skill set, and patient characteristics, should contribute to the decision-making process when planning rectal cancer surgery.

The application of incisional negative pressure wound therapy for perineal wounds: A systematic review

Impaired perineal wound healing is a major source of morbidity after abdominoperineal resection. Incisional negative pressure wound therapy can improve healing, prevent infections, and decrease the frequency of dehiscence. Our objective was to summarise existing evidence on the use of incisional negative pressure wound therapy on perineal wounds after abdominoperineal resection and to determine the effect on perineal wound complications. Electronic databases were searched in January 2017. Studies describing the use of incisional negative pressure wound therapy on primarily closed perineal wounds after abdominoperineal resection were included. Of the 278 identified articles, 5 were retrieved for inclusion in the systematic review (n = 169 patients). A significant decrease in perineal wound complications when using incisional negative pressure wound therapy was demonstrated, with surgical site infection rates as low as 9% (vs 41% in control groups). The major limitation of this systematic review was a small number of retrieved studies with small patient populations, high heterogeneity, and methodological issues. This review suggests that incisional negative pressure wound therapy decreases perineal wound complications after abdominoperineal resection. Further prospective trials with larger patient populations would be needed to confirm this association and delineate which patients might benefit most from the intervention.

Extended pelvic resection for rectal and anal canal tumors is a significant risk factor for perineal wound infection: a retrospective cohort study

PURPOSE

Perineal wound infection (PWI) rates are high after abdominoperineal resection (APR) and total pelvic exenteration (TPE). This study identified risk factors for PWI after surgery for anorectal tumors and examined the relationship between the surgical excision volume with the PWI degree.

METHODS

A retrospective review involving 135 patients who underwent surgical excision of anorectal tumors was performed. Superficial PWI included cellulitis and superficial dehiscence; deep PWI included major dehiscence, perineal abscess, and presacral abscess. The adjacent organ resection type was classified according to the dead space size formed by surgical excision.

RESULTS

Of the 135 patients, 119 underwent APR, and 16 underwent TPE. PWI occurred in 75 patients (superficial PWI, 44; deep PWI, 31). Adjacent organ resection was an independent risk factor for PWI. The cases with adjacent organ resection were classified into small-defect APR, large-defect APR, and TPE. Large-defect APR and TPE cases had significantly higher rates of deep PWI than APR cases without adjacent organ resection.

CONCLUSIONS

Adjacent organ resection involving the removal of one or more organs and that involving wide-range muscle resection are strong risk factors for deep PWI.

Local excision results in comparable survival to radical resection for early-stage rectal carcinoid

BACKGROUND

Controversy exists regarding current National Comprehensive Cancer Network guidelines, which recommend local excision for rectal carcinoids ≤2 cm and radical resection for tumors >2 cm. Given the limited data examining optimal surgical approach for these lesions, we queried a national database to determine the impact of extent of resection on survival.

METHODS

Patients undergoing treatment for clinical stage I and II rectal carcinoid (RC) were identified from the National Cancer Data Base (1998-2012). The association between extent of surgery, tumor size, and the likelihood of pathologic lymph node positivity was examined. Kaplan-Meier analysis was used to compare overall survival.

RESULTS

In total, 1900 patients were identified, of whom 1644 (86.5%) were treated with local excision, and 256 (13.5%) were treated with radical resection. A significant majority of patients with tumors ≤2.0 cm (89.0%) and nearly half with tumors 2.1-4.0 cm (44.8%) or >4.0 cm (45.8%) underwent local excision. Nodal positivity was correlated with tumor size (7.1% positivity with ≤2.0 cm tumors, 31.3% with 2.1-4.0 cm tumors, and 50.0% with >4 cm tumors). However, 5-y survival was equivalent between surgical approaches for tumors ≤2 cm (93.0% versus 93.0%) and tumors 2.1-4.0 cm (76.0% versus 76.0%).

CONCLUSIONS

We demonstrate in early-stage RC that nearly half of intermediate and large tumors are being treated with local excision outside National Comprehensive Cancer Network guidelines. In addition, radical resection does not appear to be associated with improved overall survival for tumors of any size. These findings suggest that the preferred approach to early-stage RCs without aggressive biological characteristics is local excision due to the decreased morbidity and mortality versus radical resection.

Impact of Body Mass Index on Surgical and Oncological Outcomes in Laparoscopic Total Mesorectal Excision for Locally Advanced Rectal Cancer after Neoadjuvant 5-Fluorouracil-Based Chemoradiotherapy

Aims

To evaluate the impact of body mass index (BMI) on the surgical outcome of laparoscopic total mesorectal excision (laTME) for locally advanced rectal cancer (LARC, clinically staged as UICC stage II/III) after neoadjuvant chemoradiotherapy (nCRT).

Methods

312 LARC patients undergoing laTME after nCRT were divided into nonobese (BMI < 25.0 kg/m², n = 249) and obese (BMI ≥ 25.0 kg/m², n = 63) groups. Preoperative radiotherapy was delivered in 45–50.4 Gy/25f, 5 days/week, and concurrent chemotherapy using FOLFOX or CapeOX. Technical feasibility, postoperative and oncological outcome were compared between groups.

Results

Obese patients had significantly longer operative time (P = 0.004). There was no significant difference regarding estimated blood loss, conversion, postoperative recovery, and morbidities. Multivariate analysis demonstrated that higher ASA score and abdominoperineal resection were risk factors for postoperative complications and diverting stoma was a protective factor. The length of resection margin, circumferential resection margin involvement, and number of lymph node retrieved were comparable. With a median follow-up time of 55 months (ranging 20–102 months), oncological outcome was comparable in terms of overall survival, local recurrence, and distant metastasis.

Conclusions

Obesity does not affect surgical or oncological outcome of laTME after nCRT. LaTME may be feasible and safe to obese LARC patients after nCRT in a specialized center.

Effect of Neoadjuvant Chemoradiotherapy on Locally Advanced Rectal Mucinous Adenocarcinoma: A Propensity Score-Matched Study

Aims. To compare the surgical and oncological outcomes of rectal mucinous adenocarcinomas treated with neoadjuvant chemoradiotherapy versus surgery alone. Methods. A total of 167 locally advanced rectal mucinous adenocarcinoma patients treated with neoadjuvant chemoradiotherapy and surgery alone between 2008 and 2014 were matched using propensity score; the surgical and oncological outcomes were compared. Results. Ninety-six patients were matched. Postoperative morbidity was similar between groups. Sphincter preservation rate was higher in patients receiving neoadjuvant chemoradiotherapy (79.2% versus 60.4%, P = 0.045), especially for tumors ≥ 3 cm but ≤5 cm from the anal verge (75.0% versus 44.0%, P = 0.036). With a median follow-up of 54.8 months, the 5-year overall survival rate (neoadjuvant chemoradiotherapy versus surgery alone: 79.6% versus 67.1%; P = 0.599) and disease-free survival rate (75.6% versus 64.2%; P = 0.888) were similar. The 5-year local recurrence rate was lower in patients receiving neoadjuvant chemoradiotherapy (7.7% versus 26.0%, P = 0.036), while no difference was observed in distant metastasis. A poor response to chemoradiation was associated with higher local recurrence (P = 0.037). Conclusions. Compared with surgery alone, neoadjuvant chemoradiotherapy was found to increase the sphincter preservation rate and reduce local recurrence, thus being beneficial for locally advanced rectal mucinous adenocarcinoma patients.

Risk factors for perineal wound infection after abdominoperineal resection of advanced lower rectal cancer

PURPOSE

Abdominoperineal resection (APR) of advanced lower rectal cancer carries a high incidence of perineal wound infection. The aim of this study was to retrospectively evaluate risk factors for perineal wound infection after APR.

METHODS

The study group comprised 154 patients who underwent APR for advanced lower rectal cancer in our department from January 1990 through December 2012. The following 15 variables were studied as potential risk factors for perineal wound infection: sex, age, body-mass index, American Society of Anesthesiologists score, diabetes mellitus, preoperative albumin level, preoperative hemoglobin level, neoadjuvant chemoradiotherapy(NCRT), surgical procedure (open surgery vs. laparoscopic surgery), operation time, bleeding volume, intraoperative transfusion, tumor diameter, invasion depth, and histopathological stage.

RESULTS

Among the 154 patients, 30 (19%) had perineal wound infection. Univariate analysis showed that a hemoglobin level of ≤11 g/dL (p = 0.001) and NCRT (p = 0.001) were significantly related to perineal wound infection. On multivariate analysis including the preoperative albumin level (≤3.5 g/dL) in addition to the above 2 variables, neoadjuvant chemoradiotherapy (NCRT) was the only independent risk factor for perineal wound infection. Perineal wound infection developed in 31% of patients who received NCRT, as compared with 10% of patients who did not receive NCRT. The relative risk of perineal infection in the former group was 4.092 as compared with the latter group (p = 0.0002).

CONCLUSIONS

NCRT is a risk factor for perineal wound infection after APR in patients with advanced lower rectal cancer.

Prophylactic Mesh Application during Colostomy to Prevent Parastomal Hernia: A Meta-Analysis

Background. Parastomal hernia is a common complication after stoma formation, especially in permanent colostomy. The present meta-analysis aimed to evaluate the effectiveness of prophylactic mesh application during permanent colostomy for preventing parastomal hernia. Methods. Randomized controlled trials comparing outcomes in patients who underwent colostomy with or without prophylactic mesh application were identified from PubMed, EMBASE, Science Citation Index, and the Cochrane Libraries. Results. This meta-analysis included 8 randomized controlled trials with 522 participants. Our pooled results showed that prophylactic mesh application (mesh group) reduced the incidence of clinically detected parastomal hernia (risk ratio [RR]: 0.22; 95% confidence interval [CI]: 0.13-0.38; P < 0.00001), radiologically detected parastomal hernia (RR: 0.62; 95% CI: 0.47-0.82; P = 0.0008), and surgical repair for herniation (RR: 0.34; 95% CI: 0.14-0.83; P = 0.02) when compared with conventional permanent colostomy formation (control group). The incidence of complications, including wound infection, peristomal infection, mesh infection, stomal necrosis and stenosis, stoma site pain, and fistula, was not higher in the mesh group than in the control group. Conclusions. Our meta-analysis demonstrated that prophylactic mesh application at the time of primary colostomy formation is a promising method for the prevention of parastomal herniation.

Wound Complications and Perineal Pain After Extralevator Versus Standard Abdominoperineal Excision: A Nationwide Study

BACKGROUND

Extralevator abdominoperineal excision was introduced as an alternative to conventional abdominoperineal excision for low rectal cancers. The perineal dissection is more extensive with extralevator abdominoperineal excision and leaves a greater defect.

OBJECTIVE

The aim of this study was to evaluate, on a national basis, the risk of perineal wound complications, pain, and hernia after conventional and extralevator abdominoperineal excision performed for low rectal cancer.

DESIGN

This was a retrospective study collecting data from the Danish Colorectal Cancer Group database and from electronic medical files of patients.

SETTINGS

The study was conducted at Danish surgical departments.

PATIENTS

A total of 445 patients operated between 2009 and 2012 with extralevator or conventional abdominoperineal excision were included.

MAIN OUTCOME MEASURES

The main end points of this study were perineal wound complications and pain lasting for >30 days after the operation.

RESULTS

The 2 groups were demographically similar except for a higher ASA score in the conventional group. In the extralevator group, neoadjuvant chemoradiation was more frequent (71% vs 41%; p < 0.001), T stage was higher (more T3 tumors; 52% vs 38%; p = 0.006), and more tumors were fixed (21% vs 12%; p = 0.02). Perineal wound complications and pain were more frequent after extralevator versus conventional excision (44% vs 25%; p < 0.001 and 38% vs 22%; p < 0.001). After multivariate analyses, neoadjuvant chemoradiation, extralevator excision, and operation early in the study period were found to have a significant influence on the risk of long-term wound complications. Neoadjuvant chemoradiation and wound complications were significant risk factors for long-term perineal pain. Results were similar after subgroup analyses on low tumors only.

LIMITATIONS

This was a retrospective study. The 2 groups were not completely comparable at baseline.

CONCLUSIONS

Neoadjuvant chemoradiation, extralevator compared with conventional excision, and operation early in the study period were significant factors for predicting perineal wound complications. Neoadjuvant chemoradiation and wound complications were predictors of long-term perineal pain.

Neoadjuvant Radiotherapy: A Risk Factor for Short-Term Wound Complications after Radical Resection for Rectal Cancer?

BACKGROUND

Neoadjuvant radiotherapy (RT) for rectal cancer may increase wound complications after oncologic proctectomy. We aimed to assess the relationship between neoadjuvant RT and 30-day wound complications after radical surgery for rectal cancer.

STUDY DESIGN

We identified rectal cancer patients (International Classification of Diseases, revision-9 [ICD-9] code 154.1) who underwent radical resection, using NSQIP from 2005 to 2010. Patients were stratified into preoperative radiation vs no radiation groups. Our primary outcome was any wound complication. The association between preoperative RT and postoperative wound complication rate was assessed by univariate, multivariable, and propensity score analyses.

RESULTS

Of 242,670 colorectal cases, 6,297 patients were included. Of these, 2,476 (39%) received RT within 90 days preoperatively. The RT group, compared with the no RT group, received more chemotherapy within 30 days preoperatively (15.0% vs 2.5%, p < 0.0001), and had less laparoscopic (18.9% vs 25.1%, p < 0.0001) or sphincter-preserving surgery (61.8% vs 67.1%, p < 0.0001). In the univariate analyses, there was no difference in wound complications (19.6% vs 18.7%, p = 0.42) between groups. Similarly, there was no difference in overall complications (29.6% vs 29.8%, p = 0.89), return to operating room (6.7% vs 6.7%, p = 0.96), or length of stay (8.4 vs 8.4 days, p = 0.72) between the RT and no RT groups, respectively. The mortality rate in the RT group was lower on univariate analysis (0.7% vs 1.4%, p = 0.008), but was not significantly different in the multivariable analyses. Multivariable and propensity score analyses were consistent with the lack of association between preoperative RT and postoperative wound complications.

CONCLUSIONS

Neoadjuvant radiotherapy does not appear to be an independent risk factor for wound complications after radical surgery for rectal cancer.

Vacuum-assisted closure therapy for infected perineal wounds after abdominoperineal resection. A retrospective cohort study

INTRODUCTION

Perineal wound complications are a main problem after abdominoperineal resection (APR). There is little evidence concerning perineal wound management. This study describes and evaluates the role of vacuum-assisted closure (VAC) therapy in wound management strategies of perineal wound infections after APR.

METHODS

Patients undergoing APR for malignant disease between January 2007 and January 2013 were identified retrospectively. Data regarding occurrence and management of perineal wound complications were collected. Perineal wound infections were classified into minor or major complications and time to wound healing was measured. Time to wound healing was compared between patients receiving routine care or with additional VAC therapy.

RESULTS

Of 171 included patients, 76 (44.4%) had minor and 36 (21.1%) major perineal wound infections. Management of major infected perineal wounds consisted of drainage (n = 16), debridement (n = 4), drainage combined with debridement (n = 4), VAC therapy alone (n = 5), or VAC therapy combined with other treatments (n = 7). Median duration of perineal wound healing in major infected wounds was 141 days (range 17-739). Median time to wound healing was not different in patients treated with (172 days, range 23-368) or without VAC therapy (131 days, range 17-739).

DISCUSSION AND CONCLUSION

In this study, VAC therapy did not shorten time to wound healing. However, prospective studies are required to investigate the role of VAC therapy in management of infected perineal wounds after APR. Up to then, wound management will remain to be based on clinical perception and 'gut-feeling'.

Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options

Fournier’s gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.

Abdominoperineal Resection, Pelvic Exenteration, and Additional Organ Resection Increase the Risk of Surgical Site Infection after Elective Colorectal Surgery: An American College of Surgeons National Surgical Quality Improvement Program Analysis

BACKGROUND

Determining predictors of surgical site infection (SSI) in a large cohort is important for the design of accurate SSI surveillance programs. We hypothesized that additional organ resection and pelvic exenterative procedures are associated independently with a higher risk of SSI.

METHODS

Patients in the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®; American College of Surgeons, Chicago, IL) database (2005-2012) were identified (n=112,282). Surgical site infection (superficial or deep SSI) at 30 d was the primary outcome. Using primary and secondary CPT® codes (American Medical Association, Chicago, IL) pelvic exenteration was defined and additional organ resection was defined as: bladder resection/repair, hysterectomy, partial vaginectomy, additional segmental colectomy, small bowel, gastric, or diaphragm resection. Univariable analysis of patient and procedure factors identified significant (p<0.05) predictors, which were modeled using stepwise logistic regression.

RESULTS

The rate of SSI was 9.2%. After adjusting for operative duration, predictors of SSI were body mass index (BMI) 25-29.9 (odds ratio [OR]: 1.3), BMI 30-34.9 (OR: 1.59), BMI 35-39.9 (OR: 2.11), BMI>40 (OR: 2.51), pulmonary comorbidities (OR: 1.22), smoking (OR: 1.24), bowel obstruction (OR: 1.40), wound classification 3 or 4 (OR: 1.18), and abdominoperineal resection (OR: 1.58). Laparoscopic or laparoscopically assisted procedures offered a protective effect against incision infection (OR: 0.55). Additional organ resection (OR: 1.08) was also associated independently with SSI, but the magnitude of the effect was decreased after accounting for operative duration. In the analysis that excludes operative duration, pelvic exenteration is associated with SSI (OR: 1.38), but incorporating operative duration into the model results in this variable becoming non-significant.

CONCLUSIONS

In addition to other factors, obesity, surgery for bowel obstruction, abdominoperineal resection, and additional organ resection are independently associated with a higher risk of SSI. Surgical site infection risk in pelvic exenteration and multiple organ resection cases appears to be mediated by prolonged operative duration. In these established high-risk sub-groups of patients, aggressive interventions to prevent SSI should be implemented.

Short-term outcomes of the modified extralevator abdominoperineal resection for low rectal cancer (with videos)

BACKGROUND

Extralevator abdominoperineal resection had oncologic superiority with reduced local recurrence and improving survival rates. However, extended perineal resection resulted in complicated perineal reconstructions. Therefore, a new surgical technique to overcome previous limitations is required. This study aims to demonstrate a surgical procedure and outcomes of the modified extralevator abdominoperineal resection, which satisfies both an extended cylindrical resection and a convenient perineal wound closure by modification of the surgical dissection plane.

METHODS

From September 2011 to February 2014, 12 consecutive patients (five males and seven females) who underwent the modified extralevator abdominoperineal resection for low rectal cancer were evaluated. Intraoperative and postoperative outcomes were assessed. Pathologic outcomes were evaluated for the oncologic results.

RESULTS

The mean age was 55.3 ± 15.1 years, and body mass index was 21.8 ± 3.1 kg/m(2). Ten patients (83.3%) received preoperative chemoradiotherapy. The operations were performed by five cases of laparoscopic surgery, six cases of open surgery and one case of robotic surgery. The mean operation time was 258.8 ± 58.0 min. There were no conversions and no tumor perforations. Days to first soft diet was 4.7 ± 3.4 days, and the mean hospital stay was 11.2 ± 4.7 days. Postoperative complications were two cases of grade I, two cases of grade II and one case of grade III. There was one patient (8.3%) with a positive circumferential resection margin, and there was one case of local recurrence.

CONCLUSIONS

The modified extralevator abdominoperineal resection was feasible and safe for patients with low rectal cancer with extended perineal dissection and convenient direct wound closure.

Current aspects and future prospects of total anorectal reconstruction--a critical and comprehensive review of the literature

PURPOSE

Many rectal cancer patients undergo abdominoperineal excision worldwide every year. Various procedures to restore perineal (pseudo-) continence, referred to as total anorectal reconstruction, have been proposed. The best technique, however, has not yet been defined. In this study, the different reconstruction techniques with regard to morbidity, functional outcome and quality of life were analysed. Technical and timing issues (i.e. whether the definitive procedure should be performed synchronously or be delayed), oncological safety, economical aspects as well as possible future improvements are further discussed.

METHODS

A MEDLINE and EMBASE search was conducted to identify the pertinent multilingual literature between 1989 and 2013. All publications meeting the defined inclusion/exclusion criteria were eligible for analysis.

RESULTS

Dynamic graciloplasty, artificial bowel sphincter, circular smooth muscle cuff or gluteoplasty result in median resting and squeezing neo-anal pressures that equate to the measurements found in incontinent patients. However, quality of life was generally stated to be good by patients who had undergone the procedures, despite imperfect continence, faecal evacuation problems and a considerable associated morbidity. Many patients developed an alternative perception for the urge to defecate that decisively improved functional outcome. Theoretical calculations suggested cost-effectiveness of total anorectal reconstruction compared well to life with a permanent colostomy.

CONCLUSIONS

Many patients would be highly motivated to have their abdominal replaced by a functional perineal colostomy. Given the considerable morbidity and questionable functional outcome of current reconstruction technique improvements are required. Tissue engineering might be an option to design an anatomically and physiologically matured, and customised continence organ.

Efficacy and safety of neoadjuvant intensity-modulated radiotherapy with concurrent capecitabine for locally advanced rectal cancer

BACKGROUND

We previously conducted a prospective phase II clinical trial studying a unique 22-fraction neoadjuvant intensity-modulated radiotherapy with concurrent capecitabine treatment followed by total mesorectal excision for locally advanced rectal cancer.

OBJECTIVE

The objective of this study was to retrospectively review the efficacy, toxicity, and surgical complications following intensity-modulated radiotherapy in patients who have rectal cancer.

DESIGN

This was a retrospective study.

SETTING

Data were gathered from a surgical database.

PATIENTS

This study included patients who underwent intensity-modulated radiotherapy with gross tumor volume/clinical target volume of 50.6/41.8 Gy in 22 fractions with concurrent capecitabine treatment over a period of 30 days, after which the patients underwent surgery for rectal cancer in Peking University Cancer Hospital (2007-2013).

MAIN OUTCOME MEASURES

The primary end points were acute toxicity, postoperative complications, and complete response rate.

RESULTS

A total of 260 patients were included in our analysis. The median age was 55 years (range, 21-87 years), and 68.5% of the patients were male. The yield complete response rate was 18.5% (48/260). There were no grade 4 toxicity and perioperative mortality. The grade 3 toxicity rate was 5.8%, which included diarrhea (4.2%), neutropenia (1.2%), and radiation dermatitis (0.4%). The 30-day postoperative and severe complication (≥grade 3) rates were 23.1% and 2.7%. The anastomotic leakage rate was 3.3% (5/152). Perineal wound complications (29.2%, 28/96) represented the most common problem following abdominoperineal resection. The estimated 3-year local recurrence-free survival, cancer-specific survival, and disease-free survival rates were 94.2% (95% CI, 90.1%-98.3%), 92.2% (95% CI, 87.5%-97.0%), and 81.4% (95% CI, 75.4%-87.4%).

LIMITATION

The retrospective nature and the single-arm design was the limitation of the study.

CONCLUSION

The 22-fraction neoadjuvant intensity-modulated radiotherapy regimen used to treat rectal cancer in this study has a high efficacy rate and a low toxicity rate. Further studies are needed to better define the role of intensity-modulated radiotherapy for rectal cancer treatment in a neoadjuvant setting.

Risk factors for wound complications in patients undergoing primary closure of the perineal defect after total proctectomy

PURPOSE

Perineal wounds after complete proctectomy are at risk for failure, with dramatic consequences on patients' health and quality of life. This study is aimed at identifying risk factors for wound complications in patients undergoing primary closure of the perineal defect after total proctectomy.

METHODS

Data from 284 patients undergoing total proctectomy from 2002 to 2012 either at the University of Chicago Medical Center or the Catholic University of Rome Hospital were collected and analyzed.

RESULTS

Overall, the perineal wound complication rate was 21.8%. Successful conservative management was accomplished in 45.2% of cases. Complications occurred significantly more often in patients with a higher Charlson score index, with the diagnosis of rectal cancer, who had received preoperative radiation and who had a surgical drain placed at the time of initial surgery. Neoadjuvant radiation was the only significant risk factor at multivariate analysis (OR 4.40). In the rectal cancer subgroup, younger age, female gender, and preoperative radiation were predictors of wound complications. Based on that, a 3-point score (radiation, age, and gender (RAG)) was developed. Patients with a score of 3 had a 50% risk of developing a perineal wound complication.

CONCLUSIONS

Perineal wound complications are a common and burdensome problem after total proctectomy. Preoperative radiation is the single most significant and controllable risk factor predicting perineal wound failure. In the presence of multiple, non-modifiable risk factors, alternative approaches to primary closure should be considered in managing complex perineal defects.

Omentoplasty to assist perineal defect closure following laparoscopic abdominoperineal resection

AIM

This technical note describes laparoscopic production of a well vascularized, omental flap of adequate size to fill the pelvic floor defect in the course of laparoscopic abdominoperineal resection (LAPR).

METHOD

The omentum is laparoscopically mobilized and transposed to the pelvis following full LAPR in three discrete stages.

RESULTS

Laparoscopic omental mobilization, transfer and buttressing of a primary perineal repair reduces pelvic dead space and facilitates closure following LAPR with minimal additional operative time or complications and a potential reduction in perineal wound associated morbidity.

CONCLUSION

Laparoscopic omental mobilization is technically feasible and provides a safe method to aid perineal wound closure.

Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis

BACKGROUND

Impaired perineal wound healing has become a significant clinical problem after abdominoperineal resection for rectal cancer. The increased use of neoadjuvant radiotherapy and wider excisions might have contributed to this problem.

OBJECTIVE

The primary aim of this systematic review with meta-analysis was to determine the impact of radiotherapy and an extralevator approach on perineal wound healing after abdominoperineal resection for rectal cancer.

DATA SOURCES

In March 2014, electronic databases were searched.

STUDY SELECTION AND INTERVENTIONS

Studies describing any outcome measure on perineal wound healing after abdominoperineal resection for rectal cancer were included.

MAIN OUTCOME MEASURES

The primary end point was overall perineal wound problems within 30 days after conventional or extralevator abdominoperineal resection with or without neoadjuvant radiotherapy. Secondary end points were primary wound healing, perineal hernia rate, and the effect of biological mesh closure on perineal wound problems.

RESULTS

A total of 32 studies were included. The pooled percentage of perineal wound problems after primary perineal wound closure in patients who did not undergo neoadjuvant radiotherapy was 15.3% (95% CI, 12.1-19.2) after conventional abdominoperineal resection and 14.8% (95% CI, 9.5-22.4) after extralevator abdominoperineal resection. After neoadjuvant radiotherapy, perineal wound problems occurred in 30.2% (95% CI, 19.2-44.0) after conventional abdominoperineal resection and in 37.6% (95% CI, 18.6-61.4) after extralevator abdominoperineal resection. Radiotherapy significantly increased perineal wound problems after abdominoperineal resection (OR, 2.22; 95% CI, 1.45-3.40; p < 0.001). After biological mesh closure of the pelvic floor following extralevator abdominoperineal resection with neoadjuvant radiotherapy, the percentage of perineal wound problems was 7.3% (95% CI, 1.5-29.3).

LIMITATIONS

Heterogeneity was high for some analyses.

CONCLUSION

Neoadjuvant radiotherapy significantly increases perineal wound problems after abdominoperineal resection for rectal cancer, whereas the extralevator approach seems not to be of significant importance.

Perineal wound healing after abdominoperineal resection for rectal cancer: a two-centre experience in the era of intensified oncological treatment

PURPOSE

Intensified treatment for distal rectal cancer has improved oncological outcome, but at the expense of more perineal wound complications in patients undergoing an abdominoperineal resection (APR). The aim of this study was to analyse perineal wound healing after APR with primary perineal wound closure over time.

METHOD

All patients undergoing APR for primary rectal cancer with primary wound closure between 2000 and 2013 were included and analysed in three consecutive time periods. Both early (<30 days postoperatively) and late perineal wound complications were determined. Independent risk factors of early perineal wound complications were identified using multivariable analysis.

RESULTS

A total of 136 patients were identified, of whom 129 patients underwent primary perineal wound closure. The use of neo-adjuvant (chemo)radiotherapy increased from 72 to 91%, and the use of an extralevator approach increased from 9 to 19%. The rate of early perineal wound complications increased from 18 to 31% and was independently associated with an extralevator approach [odds ratio (OR) 3.17; 95% confidence interval (CI) 1.16-8.66] and intra-operative perforation (OR 3.35; 95% CI 1.06-10.57). Perineal wound complications had no impact on local recurrence or 3-year overall survival rate. During a median follow-up of 28 months [interquartile range (IQR) 14-56], a persistent presacral sinus was diagnosed in 10%, and a perineal hernia occurred in 8% of the patients.

CONCLUSION

The increased use of an extralevator APR for rectal cancer significantly increased the risk of perineal wound complications over time. Intra-operative perforation was also independently associated with impaired perineal wound healing.

Randomized controlled multicentre study comparing biological mesh closure of the pelvic floor with primary perineal wound closure after extralevator abdominoperineal resection for rectal cancer (BIOPEX-study)

BACKGROUND

Primary perineal wound closure after conventional abdominoperineal resection (cAPR) for rectal cancer has been the standard of care for many years. Since the introduction of neo-adjuvant radiotherapy and the extralevator APR (eAPR), oncological outcome has been improved, but at the cost of increased rates of perineal wound healing problems and perineal hernia. This has progressively increased the use of biological meshes, although not supported by sufficient evidence. The aim of this study is to determine the effectiveness of pelvic floor reconstruction using a biological mesh after standardized eAPR with neo-adjuvant (chemo)radiotherapy compared to primary perineal wound closure.

METHODS/DESIGN

In this multicentre randomized controlled trial, patients with a clinical diagnosis of primary rectal cancer who are scheduled for eAPR after neo-adjuvant (chemo)radiotherapy will be considered eligible. Exclusion criteria are prior radiotherapy, sacral resection above S4/S5, allergy to pig products or polysorbate, collagen disorders, and severe systemic diseases affecting wound healing, except for diabetes. After informed consent, 104 patients will be randomized between standard care using primary wound closure of the perineum and the experimental arm consisting of suturing a biological mesh derived from porcine dermis in the pelvic floor defect, followed by perineal closure similar to the control arm. Patients will be followed for one year after the intervention and outcome assessors and patients will be blinded for the study treatment. The primary endpoint is the percentage of uncomplicated perineal wound healing, defined as a Southampton wound score of less than II on day 30. Secondary endpoints are hospital stay, incidence of perineal hernia, quality of life, and costs.

DISCUSSION

The BIOPEX-study is the first randomized controlled multicentre study to determine the additive value of using a biological mesh for perineal wound closure after eAPR with neo-adjuvant radiotherapy compared to primary perineal wound closure with regard to perineal wound healing and the occurrence of perineal hernia.

TRAIL REGISTRATION NUMBER

NCT01927497 (Clinicaltrial.gov).

Incisional negative pressure wound therapy decreases the frequency of postoperative perineal surgical site infections: a cohort study

BACKGROUND

Abdominoperineal resection is a procedure associated with high rates of perineal surgical site infections, causing distress to the patient, costs to the hospital system, and delays in further treatment.

OBJECTIVE

The aim of this study was to investigate the role of incisional negative pressure wound therapy in decreasing the rates of perineal surgical site infection.

DESIGN

This retrospective cohort study had a historical, consecutively sampled control group.

SETTINGS

This study was conducted at a single-institution tertiary care academic institution.

PATIENTS

All patients undergoing an abdominoperineal resection between 2008 and 2012 were assessed.

INTERVENTIONS

Perineal incisional negative pressure wound therapy was applied to all patients following an abdominoperineal resection between 2010 and 2012 at 125 mmHg continuous suction for 5 days postoperatively.

MAIN OUTCOME MEASURES

The development of a perineal surgical site infection within the first 30 days postoperatively was the primary outcome measured.

RESULTS

Fifty-nine patients were included: 27 in the incisional negative pressure wound therapy group and 32 in the control group. A statistically lower proportion of perineal surgical site infections were detected in the incisional negative pressure wound therapy group than in the standard dressing group (15% vs 41%; p = 0.02). Both populations were similar in perioperative risk factors, with the exception of increased levels of blood urea nitrogen, a higher proportion of hypertensive patients, and a longer mean operative time in the incisional negative pressure wound therapy group. Additionally, an increased length of stay was observed in the incisional negative pressure wound therapy group (11 vs 8 days; p = 0.03). After adjusting for confounders, including the type of perineal dissection, incisional negative pressure wound therapy was found to be an independent predictor of not developing an surgical site infection (adjusted OR, 0.11; 95% CI, 0.04-0.66; p = 0.01).

LIMITATIONS

The study's retrospective nature limits the results because of the risk of interpreter bias, although this was addressed in part by reviewing data in duplicate. We controlled for the potential for selection bias with our consecutive sampling model.

CONCLUSIONS

Our study demonstrates a role for incisional negative pressure wound therapy in decreasing rates of perineal surgical site infection following abdominoperineal resection. Prospective randomized trials will be required to further investigate this intervention.

A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration

PURPOSE

We analysed the outcomes of a series of 100 consecutive patients with anorectal cancer with neoadjuvant radiochemotherapy and abdominoperineal exstirpation or total pelvic exenteration, who received a transpelvic vertical rectus abdominis myocutaneous (VRAM) flap for pelvic, vaginal and/or perineal reconstruction and compare a cohort to patients without VRAM flaps.

METHODS

Within a 10-year period (2003-2013) in our institution 924 patients with rectal cancer stage y0 to y IV were surgically treated. Data of those 100 consecutive patients who received a transpelvic VRAM flap were collected and compared to patients without flaps.

RESULTS

In 100 consecutive patients with transpelvic VRAM flaps, major donor site complications occurred in 6 %, VRAM-specific perineal wound complications were observed in 11 % of the patients and overall 30-day mortality was 2 %.

CONCLUSIONS

The VRAM flap is a reliable and safe method for pelvic reconstruction in patients with advanced disease requiring pelvic exenteration and irradiation, with a relatively low rate of donor and recipient site complications. In this first study, to compare a large number of patients with VRAM flap reconstruction to patients without pelvic VRAM flap reconstruction, a clear advantage of simultaneous pelvic reconstruction is demonstrated.