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Temperley HC, Shokuhi P, O'Sullivan NJ, Mac Curtain B, Waters C, Murray A, Buckley CE, O'Neill M, Mehigan B, McCormick PH, Kelly ME, Larkin JO. Primary closure versus vertical rectus abdominis myocutaneous (VRAM) flap closure of perineal wound following abdominoperineal resection-a systematic review and meta-analysis. Ir J Med Sci 2024; 193:1721-1728. [PMID: 38532236 PMCID: PMC11294374 DOI: 10.1007/s11845-024-03651-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 01/05/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE/AIM Perianal wound healing and/or complications are common following abdominoperineal resection (APR). Although primary closure is commonly undertaken, myocutaneous flap closure such as vertical rectus abdominis myocutaneous flap (VRAM) is thought to improve wound healing process and outcome. A comprehensive meta-analysis was performed to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. METHODS PubMed, MEDLINE, EMBASE, and Cochrane Central Registry of Controlled Trials were comprehensively searched until the 8th of August 2023. Included studies underwent meta-analysis to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. The primary outcome of interest was perineal wound complications, and the secondary outcomes were abdominal wound complications, dehiscence, wound healing time, length of hospital stay, and mortality. RESULTS Ten studies with 1141 patients were included. Overall, 853 patients underwent primary closure (74.8%) and 288 patients underwent VRAM (25.2%). Eight studies reported on perineal wound complications after APR: 38.2% (n = 263/688) in the primary closure group versus 32.8% (n = 80/244) in the VRAM group. Perineal complication rates were statistically significantly lower in the VRAM group versus primary closure ((M-H OR, 1.61; 95% CI 1.04-2.49; CONCLUSION We highlight the advantage of VRAM flap closure over primary closure for perineal wounds following APR. However, tailoring operative strategy based on patient and disease factors remains important in optimising outcomes.
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Affiliation(s)
- Hugo C Temperley
- Department of Surgery, St. James's Hospital, Dublin, Ireland.
- Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland.
| | - Poorya Shokuhi
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | | | - Caitlin Waters
- Department of Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Alannah Murray
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | - Maeve O'Neill
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | - Brian Mehigan
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | - Michael E Kelly
- Department of Surgery, St. James's Hospital, Dublin, Ireland
- Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland
| | - John O Larkin
- Department of Surgery, St. James's Hospital, Dublin, Ireland
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Zaussinger M, Pommer G, Freller K, Schmidt M, Huemer GM. Bilateral Superior Gluteal Artery Perforator (SGAP) Flap: Modified Concept in Perineal Reconstruction. J Clin Med 2024; 13:3825. [PMID: 38999391 PMCID: PMC11242694 DOI: 10.3390/jcm13133825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/24/2024] [Accepted: 06/28/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Perineal reconstruction after abdominoperineal excision often requires complex closures and is fraught with wound healing complications. Flap-based approaches introduce non-irradiated vascularized tissue to the area of resection to fill a large soft-tissue defect and dead space, reduce the risk of infection, and facilitate wound healing. Employing perforator flaps with their beneficial donor site properties, the authors have developed a concept of bilateral superior gluteal artery perforator (SGAP) flaps to restore extensive perineal defects. Methods: This retrospective case series was conducted between September 2015 and December 2019. We included three patients who received bilateral SGAP flap reconstruction after oncological resection. One deepithelialized SGAP flap was used for obliteration of dead space, combined with the contralateral SGAP flap for superficial defect reconstruction and wound closure. Results: Within this patient population, two male and one female patient, with a median age of 62 years (range, 52-76 years), were included. Six pedicled SGAP flaps were performed with average flap dimensions of 9 × 20 cm (range 7-9 × 19 × 21). No flap loss or no local recurrence were documented. In one case, partial tip necrosis with prolonged serous drainage was observed, which was managed by surgical debridement. No further complications were detected. Conclusions: The combination of two SGAP flaps provides maximal soft tissue for defect reconstruction and obliteration of dead space, while maintaining a very inconspicuous donor site, even with bilateral harvesting. Given these advantages, the authors recommend this promising approach for successful reconstruction of perineal defects.
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Affiliation(s)
- Maximilian Zaussinger
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
- Medical Faculty, Johannes Kepler University Linz, Altenbergerstr. 69, 4040 Linz, Austria;
- Doctoral Degree Program in Medical Science, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Gabriele Pommer
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
| | - Katrin Freller
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
| | - Manfred Schmidt
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
- Medical Faculty, Johannes Kepler University Linz, Altenbergerstr. 69, 4040 Linz, Austria;
| | - Georg M. Huemer
- Medical Faculty, Johannes Kepler University Linz, Altenbergerstr. 69, 4040 Linz, Austria;
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Riva CG, Kelly ME, Vitellaro M, Rottoli M, Aiolfi A, Ferrari D, Bonitta G, Rausa E. A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis. Tech Coloproctol 2023; 27:1351-1366. [PMID: 37843643 DOI: 10.1007/s10151-023-02868-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis. METHODS An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed. RESULTS Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap. CONCLUSIONS Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.
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Affiliation(s)
- C G Riva
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - M E Kelly
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- The Trinity St. James's Cancer Institute, Dublin, Ireland
| | - M Vitellaro
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - M Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - A Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - D Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - G Bonitta
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - E Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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Liu J, Fu C, Chen Z, Li G. Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis. Int Wound J 2023; 20:3963-3973. [PMID: 37539486 PMCID: PMC10681467 DOI: 10.1111/iwj.14284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 08/05/2023] Open
Abstract
A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.
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Affiliation(s)
- Jiang Liu
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Chao Fu
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Zhiliang Chen
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Gang Li
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
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Gendia A, Rehman M, Lin CW, Malik K, Khalil K, Ihedioha U, Kang P, Evans J, Ahmed J. Short- and mid-term outcomes of abdominoperineal resection with perineal mesh insertion: a single-centre experience. Int J Colorectal Dis 2023; 38:220. [PMID: 37606697 DOI: 10.1007/s00384-023-04507-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging, particularly in extralevator abdominoperineal resection (ELAPR) due to gapped tissue planes. Different approaches have been attempted to improve perineal wound repair. The aim of this study is to report our 6-year experience in perineal wound closure utilising biological mesh. METHODS We conducted a retrospective study using data from our prospectively maintained database, including patients who underwent APR with perineal mesh closure between 2016 and 2021. RESULTS 49 patients underwent APR with perineal mesh reconstruction for low rectal cancer during the 6-year period. Of these, 63% were males, with a mean age of 68 (± 11), and a mean BMI of 27.9 (± 13.7). 49% (24) of patients received neoadjuvant therapy. 88% (43) of patients underwent standard "S-APR" and only 12% (6) underwent ELAPR. Majority of procedures were laparoscopic (87.8%) with conversion rate of 6.9%. Mean length of stay was 11.7 (± 11.6). The perineal wound infection rate was 30% and only two patient required mesh removal due to entero-cutaneous perineal fistula and pelvic abscess. Perineal hernia was found in only two patients (4.1%). CRM was negative in 81.6% of the patients. Mean follow-up period was 29.2 (± 16.5) months, and disease recurrence occurred in 9 (18.3%) patients with average number of months for recurrence of 21 (± 7). Overall survival during the follow-up period was 91%. CONCLUSION Our series shows a favourable short- and medium-term outcome with routine insertion of mesh for perineal wound closure.
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Affiliation(s)
- Ahmed Gendia
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK.
| | - Masood Rehman
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Cindy W Lin
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Kamran Malik
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Khalil Khalil
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Ugo Ihedioha
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Peter Kang
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - John Evans
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Jamil Ahmed
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
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Prasath V, Naides AI, Weisberger JS, Quinn PL, Ayyala HS, Lee ES, Girard AO, Chokshi RJ. Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis. Surgery 2023; 173:521-528. [PMID: 36418205 DOI: 10.1016/j.surg.2022.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/25/2022] [Accepted: 09/11/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. METHODS A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. RESULTS Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. CONCLUSION Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.
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Affiliation(s)
| | | | - Joseph S Weisberger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Patrick L Quinn
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Haripriya S Ayyala
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Division of Plastic & Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Edward S Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Alisa O Girard
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.
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Abstract
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.
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Affiliation(s)
- Connor Arquette
- From the Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA
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Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods. Plast Reconstr Surg 2021; 147:1420-1435. [PMID: 33973948 DOI: 10.1097/prs.0000000000007976] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. METHODS A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. RESULTS The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. CONCLUSIONS Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.
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Buscail E, Canivet C, Shourick J, Chantalat E, Carrere N, Duffas JP, Philis A, Berard E, Buscail L, Ghouti L, Chaput B. Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13040721. [PMID: 33578769 PMCID: PMC7916499 DOI: 10.3390/cancers13040721] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 01/13/2023] Open
Abstract
Simple Summary Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer (mainly anal and rectal cancers) require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, Group C comparing PC and VRAMf in PE. The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total and major perineal wound complications. PC was associated with a decrease in total and major perineal complications in Group C. Abstract Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusions. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.
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Affiliation(s)
- Etienne Buscail
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
- INSERM, U1220, Digestive Health Research Institute (IRSD), University of Toulouse, 31100 Toulouse, France
| | - Cindy Canivet
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
- Department of Gastroenterology and Pancreatology, Toulouse University Hospital, 31100 Toulouse, France
| | - Jason Shourick
- Department of Epidemiology and Public Health, UMR 1027 INSERM, Toulouse University Hospital, University of Toulouse, 31100 Toulouse, France; (J.S.); (E.B.)
| | - Elodie Chantalat
- Department of Surgery, Oncopole, INSERM-UPS UMR U1048, Institute of Metabolic and Cardiovascular Diseases, University of Toulouse, 31100 Toulouse, France;
| | - Nicolas Carrere
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Jean-Pierre Duffas
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Antoine Philis
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Emilie Berard
- Department of Epidemiology and Public Health, UMR 1027 INSERM, Toulouse University Hospital, University of Toulouse, 31100 Toulouse, France; (J.S.); (E.B.)
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, Toulouse University Hospital, 31100 Toulouse, France
- Correspondence: ; Tel.: +33-5-61-32-30-55; Fax: +33-5-61-32-22-29
| | - Laurent Ghouti
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Benoit Chaput
- Department of Plastic and Reconstructive Surgery, Toulouse University Hospital, 31100 Toulouse, France;
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Murphy C, Stephens I, OꞌFlanagan G, OꞌByrne L, Reynolds IS, Ajmal N, O'Sullivan JB, OꞌNeill B, Deasy J, Burke JP, McNamara DA. A comparison of oncological outcomes after abdominoperineal excision before and after the implementation of a selective perineal flap closure program. J Surg Oncol 2020; 123:614-621. [PMID: 33238062 DOI: 10.1002/jso.26309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/12/2020] [Accepted: 11/08/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Abdominoperineal excision (APE) is the operation chosen when a patient has low rectal cancer unamenable to sphincter preserving surgery. Perineal flap reconstruction is associated with less wound morbidity but little is known about oncological outcomes. The objective was to compare outcomes in patients undergoing APE before and after the introduction of a program that utilized flap reconstruction of the perineum. METHODS A retrospective review of a prospectively maintained database was performed. Patients who underwent APE followed by primary closure or flap reconstruction between 1998 and 2018 were selected. The cohorts were divided according to the implementation of the flap reconstruction program in July 2009. Clinicopathological data, recurrence and survival were compared between the cohorts. RESULTS One hundred and forty nine patients underwent APE for rectal adenocarcinoma between 1998 and 2018. There were 57 patients in the pre-flap era and 92 in the post-flap era. Forty-six patients underwent flap reconstruction in the latter cohort (50%). More patients in the post-flap era underwent neoadjuvant chemoradiotherapy (85.9% vs. 63.2%; p < .01). Margin positivity rates decreased from 21.1% in the pre-flap era to 10.9% in the post-flap era (p = .10) and there was an associated improvement in incidence and time to local recurrence (p = .03). CONCLUSION The use of perineal flap reconstruction is associated with a longer median time to local recurrence. Perineal flap reconstruction may contribute to reduced margin positivity.
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Affiliation(s)
- Claudine Murphy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Ian Stephens
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Grace OꞌFlanagan
- Department of Plastic and Reconstructive Surgery, Beaumont Hospital, Dublin, Ireland
| | - Lisa OꞌByrne
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Ian S Reynolds
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland.,Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Nadeem Ajmal
- Department of Plastic and Reconstructive Surgery, Beaumont Hospital, Dublin, Ireland
| | - John Barry O'Sullivan
- Department of Plastic and Reconstructive Surgery, Beaumont Hospital, Dublin, Ireland
| | - Brian OꞌNeill
- Department of Radiation Oncology, Beaumont Hospital, Dublin, Ireland
| | - Joseph Deasy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Deborah A McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland.,Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Hellinga J, Rots M, Werker PMN, Stenekes MW. Lotus petal flap and vertical rectus abdominis myocutaneous flap in vulvoperineal reconstruction: a systematic review of differences in complications. J Plast Surg Hand Surg 2020; 55:67-82. [PMID: 33054472 DOI: 10.1080/2000656x.2020.1828902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Vulvoperineal defects resulting from surgical treatment of (pre)malignancies may result in reconstructive challenges. The vertical rectus abdominis muscle flap and, more recently, the fasciocutaneous lotus petal flap are often used for reconstruction in this area. The goal of this review is to compare the postoperative complications of application of these flaps. Methods: A comprehensive literature search of the PubMed, MEDLINE and Cochrane Library databases was performed until 6 June 2020. Search terms included the lotus petal flap, vertical rectus abdominis muscle flap and the vulvoperineal area. Articles were independently screened by two researchers according to the PRISMA-guidelines. Results: A total of 1074 citations were retrieved and reviewed, of which 55 were included for full text analysis. Following lotus petal flap reconstructions, the complication rate varied from 0.0% to 69.9%, with more complications concerning the recipient site compared with the donor site complications (26.0% versus 4.5%). Following vertical rectus abdominis muscle flap reconstructions the complication rate varied between 0.0% and 85.7% with almost twice the number of recipient site complications compared to donor site complications (37.1% versus 17.8%). Conclusions: Overall, the lotus petal flap has lower complication rates at both the donor and the recipient site compared with the vertical rectus abdominis muscle flap. When both options seem viable, the lotus petal flap procedure may be preferred on the basis of the reported lower complication rates. Abbreviations: APE: abdominoperineal excision; ELAPE: extra levator abdominoperineal excision; LP flap: lotus petal flap; NIH: National Institute of Health; NR: not reported; RCT: randomized controlled trial; VRAM flap: vertical rectus abdominis myocutaneous flap.
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Affiliation(s)
- Joke Hellinga
- Department of Plastic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mathijs Rots
- Department of Plastic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul M N Werker
- Department of Plastic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin W Stenekes
- Department of Plastic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Ordenana C, Dalla Pozza E, Rampazzo A, Said S, McBride J, Kessler H, Bassiri Gharb B. Wide posterior gluteal-thigh propeller flap for reconstruction of perineal defects. Microsurgery 2020; 41:146-156. [PMID: 33030284 DOI: 10.1002/micr.30666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 07/11/2020] [Accepted: 09/18/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION With increasing popularity of minimally invasive approaches to abdominoperineal resection (APR), thigh-based flaps are becoming the preferred option for reconstruction. The gluteal-thigh flap provides sufficient bulk, albeit with a high complication rate. We reevaluated the vascularization and design of the gluteal-thigh flap. The purpose of this study is to highlight the importance of the vascularization of the posterior thigh skin by the descending branch of the inferior gluteal artery (IGA) and the profunda femoris artery (PFA) perforators to design a more reliable and versatile gluteal thigh flap. This flap is indicated in selected cases in which use of vertical rectus abdominis musculocutaneous flap is not feasible. METHODS Eleven fresh cadavers were used. The course, distribution, and diameter of IGA and PFA perforators were recorded. A wide posterior gluteal-thigh propeller flap (WPGTPF) was designed including the distance between the ischiatic tuberosity and greater trochanter; and extending it to within 8 cm of the popliteal fossa to improve flap reliability. Ten patients (mean age of 58.7 ± 10.6 years) underwent APR due to anal cancer (2) and rectal cancer (8); the approach was open in 3, laparoscopic in 6, and robotic in 1. All 10 patients received unilateral flap with a width of 12 ± 3.3 cm and surface of 405.5 ± 175.9 cm2 . RESULTS The descending branch of the IGA was dominant in 72.7% of the specimens. In 22.7% of the specimens, the pedicle of the flap derived from the first or second PFA perforators. In one case, there was a double vascularization. Descending branch of the IGA was mapped at 46 ± 7.96 mm on the X-axis (horizontal line from the ischial tuberosity [IT] to the greater trochanter) and -12.1 ± 17.9 mm on the Y-axis (vertical line from the IT to the Medial Femoral condyle). Its average caliber measured 2.18 ± 0.3 mm. The first and second PFA perforators were located at 101.6 ± 17.9 mm and 104.5 ± 15.5 mm on the X-axis; 35.9 ± 27.1 mm and 89.2 ± 37.6 mm on the Y-axis. Their average diameters were 1.84 ± 0.41 mm and 1.48 ± 0.3 mm. In two cases, the flap was based on the first PFA perforator, the rest were on the descending branch of the IGA. Neither complete nor partial flap necrosis was observed. One patient developed coccyx osteomyelitis treated and resolved with bone debridement and one patient developed a seroma of the lateral thigh that was treated conservatively. Three patients underwent a debulking procedure by a combination of liposuction and resection to improve the gluteal symmetry. All ten flaps survived completely. CONCLUSIONS Harvest of a wide flap that includes the PFA perforators and implementation of the propeller design increase the survival and versatility of the flap.
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Affiliation(s)
- Carlos Ordenana
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Edoardo Dalla Pozza
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sayf Said
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer McBride
- Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bahar Bassiri Gharb
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Assi H, Persson A, Palmquist I, Öberg M, Buchwald P, Lydrup ML. Sexual and functional long-term outcomes following advanced pelvic cancer and reconstruction using vertical rectus abdominis myocutaneous and gluteal myocutaneous flap. Eur J Surg Oncol 2020; 47:858-865. [PMID: 33008672 DOI: 10.1016/j.ejso.2020.09.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 08/13/2020] [Accepted: 09/21/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION After extensive pelvic surgery for cancer two flap types are used at Skåne University Hospital (SUS), Sweden for perineal reconstruction: vertical rectus abdominis myocutaneous flap and gluteal flap with or without vaginal reconstruction. The objective was to study the long-term outcomes in patients treated for advanced pelvic cancer receiving a flap. METHOD Patients with pelvic cancer subjected to surgery including perineal reconstruction between January 2010 and August 2016 at SUS were included retrospectively. Participating patients were scheduled for an out-patient visit. Questionnaires addressing quality of life, (QLQ-C30 and EQ-5D) and sexual function (FSFI and IIEF) were filled in. Sensitivity test, using monofilaments on the gluteal/posterior thigh area, neovaginal measurements using silicon gauges and muscular functionality tests (timed stands test and stairs test) were performed. RESULTS Thirty-six (24 women, 12 males) out of 71 invited patients conceded participation. Patients scored a median of 85/100 regarding global health using EQ-5D. All women reported sexual dysfunction and 75% (9/12) of men reported severe erectile dysfunction. Neovaginal measurements showed adequate reconstructions. Sensitivity test implied decreased sensitivity on the operated side compared to the unoperated side in patients with gluteal flap. Both physical tests demonstrated adequate muscular functionality in everyday life activities after reconstructions using gluteal flap. CONCLUSION This long-term follow up after extensive surgery treating pelvic cancer with perineal flap reconstruction implies high quality of life, good muscular functionality and adequate neovaginal measurements. However sexual function is impaired among both sexes and sensitivity in the surgical area of the gluteal flap is decreased.
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Affiliation(s)
- Hanin Assi
- Department of AT/ST, Skåne University Hospital, Malmö, Lund University, Sweden.
| | - Anna Persson
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Ingrid Palmquist
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Martin Öberg
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
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Complications and Impact on Quality of Life of Vertical Rectus Abdominis Myocutaneous Flaps for Reconstruction in Pelvic Exenteration Surgery. Dis Colon Rectum 2020; 63:1225-1233. [PMID: 33216493 DOI: 10.1097/dcr.0000000000001632] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pelvic exenteration for malignancy sometimes necessitates flap reconstruction. OBJECTIVE This study's aim was to investigate flap-related morbidity. DESIGN A prospective database was reviewed from 2003 to 2016. All medical charts, correspondence, and outpatient follow-up records up to May 2017 were reviewed. SETTINGS This study was conducted at a tertiary referral unit. PATIENTS Patients who underwent pelvic exenteration surgery were selected. INTERVENTIONS Reconstruction was performed with a vertical rectus abdominis myocutaneous flap. MAIN OUTCOME MEASURES Primary outcome was flap-related complications (short or long term >3 months). Secondary outcomes were hospital stay, readmission, mortality, and quality of life (Short Form-36, Functional Assessment of Cancer Therapy for patients with colorectal cancer). RESULTS Of 519 patients undergoing pelvic exenteration surgery, 87 (17%) underwent flap reconstruction. Median follow-up was 20 months (interquartile range, 8-39 months). Median age was 60 years (interquartile range, 51-66). Flap-related complications were found in 59 patients (68%), with minor recipient-site complications diagnosed in 33 patients (38%). In the short term, 15 patients experienced major recipient-site complications (17%), including flap separation (n = 7) and partial (n = 3) or complete necrosis (n = 4). Flap removal was required in 1 patient. Obesity was the single independent risk factor for short-term flap-related complications (p = 0.02). Hospital admission was significantly longer in patients with short-term major flap complications (median 65 days, p < 0.001) compared with patients without or with minor complications. There was no 90-day mortality. Patients who required flap reconstruction reported lower baseline quality-of-life scores than patients without flap reconstruction, but both recovered over time. In the long term, minor flap-related complications occurred in 12 patients, and 11 patients had major donor-site complications. Fourteen patients developed major recipient-site complications (16%), including sacral collections, enterocutaneous fistulas, perineal ulcer, or hernia. LIMITATIONS This was a retrospective analysis of prospectively collected data. CONCLUSIONS Vertical rectus abdominis myocutaneous flaps in pelvic exenteration surgery have a high incidence of morbidity that has significant impact on hospital stay and a temporary impact on quality of life. Flap reconstruction should be used selectively in pelvic exenteration surgery. See Video Abstract at http://links.lww.com/DCR/B274. COMPLICACIONES E IMPACTO EN LA CALIDAD DE VIDA DE LOS COLGAJOS MIOCUTÁNEOS DE MUSCULO RECTO DEL ABDOMEN EN CASOS DE RECONSTRUCCIÓN DE EXENTERACIÓN PÉLVICA: La exenteración pélvica (EP) para malignidad a veces requiere reconstrucción con colgajos musculares.El propósito del presente estudio fue investigar la morbilidad relacionada con los colagajos musculares.Revisión de una base de datos prospectiva de 2003-2016. Se evaluaron todas las historias clínicas, la correspondencia y los registros de seguimiento de pacientes ambulatorios hasta mayo de 2017.Unidad de referencia terciaria.Todos aquellas personas con cirugía de exenteración pélvica.Reconstrucción con colgajo miocutáneo de musculo recto vertical del abdomen.El resultado primario fueron las complicaciones relacionadas con el colgajo (a corto o largo plazo >3 meses). Los resultados secundarios fueron la estadía hospitalaria, la readmisión, la mortalidad y la calidad de vida (QOL; SF-36, FACT-C).De 519 pacientes sometidos a EP, 87 (17%) se sometieron a reconstrucción con colgajos miocutáneos. La mediana de seguimiento fue de 20 meses (RIC 8-39 meses). La mediana de edad fue de 60 años (IQR 51-66). Se encontraron complicaciones relacionadas con el colgajo en 59 pacientes (68%), con complicaciones menores en el sitio del receptor diagnosticadas en 33 pacientes (38%). A corto plazo, quince pacientes sufrieron complicaciones mayores en el sitio del receptor (17%), incluida la separación del colgajo (n = 7), necrosis parcial (n = 3) o necrosis completa (n = 4). Se requirió la extracción del colgajo en un paciente. La obesidad fue el único factor de riesgo independiente para complicaciones relacionadas con el colgajo a corto plazo (p = 0.02). El ingreso hospitalario fue significativamente mayor en pacientes con complicaciones de colgajos mayores a corto plazo (mediana 65 días p <0.001) en comparación con pacientes sin complicaciones menores o con complicaciones menores. No hubo mortalidad a los 90 días. Los pacientes que requirieron reconstrucción con colgajo informaron puntajes de calidad de vida basales más bajos que los pacientes sin reconstrucción con colgajo, pero ambos se recuperaron con el tiempo. A largo plazo, ocurrieron complicaciones menores relacionadas con el colgajo en 12 pacientes y 11 pacientes tuvieron complicaciones mayores en el sitio donante. Catorce pacientes desarrollaron complicaciones mayores en el sitio del receptor (16%), incluidas colecciones sacras, fístulas enterocutáneas, úlceras perineales o herniación.Análisis retrospectivo de datos recolectados prospectivamente.Los colgajos miocutáneos del musculo recto vertical del abdomen en casos de cirugía de exenteración pélvica tienen una alta incidencia de morbilidad conllevando a un impacto significativo en la estadía hospitalaria y un impacto temporal en la calidad de vida. Las reconstrucciones con colgajos deben aplicarse muy selectivamente en la cirugía de exenteración pélvica. Consulte Video Resumen en http://links.lww.com/DCR/B274.
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15
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Hellinga J, Stenekes MW, Werker PMN, Janse M, Fleer J, van Etten B. Quality of Life, Sexual Functioning, and Physical Functioning Following Perineal Reconstruction with the Lotus Petal Flap. Ann Surg Oncol 2020; 27:5279-5285. [PMID: 32617757 PMCID: PMC7669788 DOI: 10.1245/s10434-020-08771-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Lotus petal flaps (LPF) may be used for the reconstruction of extralevator abdominoperineal defects that cannot be closed primarily. Limited data are available on how perineal reconstruction with the LPF impacts on patients' quality of life (QoL), sexual functioning, and physical functioning. METHODS A cross-sectional study was performed following perineal reconstruction with the LPF. The QoL of patients having undergone LPF reconstruction was compared with a control group in which perineal defects were closed without flaps. Sexual and physical functioning (presence of perineal herniation and range of motion [ROM] of the hip joints) could only be evaluated in the LPF group. Psychometrically sound questionnaires were used. Physical functioning was evaluated subjectively with binary questions and objectively by physical examination. RESULTS Of the 23 patients asked to participate, 15 (65%) completed the questionnaires and 11 (47%) underwent physical examination. In the control group, 16 patients were included. There were no significant differences in QoL between the LPF and control groups. Within the LPF group, 33% of patients were sexually active postoperatively compared with 87% preoperatively. No perineal herniation was found. The ROM of the hip joints was bilaterally smaller compared with the generally accepted values. CONCLUSIONS Conclusions should be made with care given the small sample size. Despite a supposedly larger resection area in the LPF group, QoL was comparable in both groups. Nonetheless, reconstruction seemed to affect sexual function and physical function, not hampering overall satisfaction.
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Affiliation(s)
- Joke Hellinga
- Department of Plastic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin W Stenekes
- Department of Plastic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Paul M N Werker
- Department of Plastic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Moniek Janse
- Department of Health Sciences, Section Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joke Fleer
- Department of Health Sciences, Section Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Boudewijn van Etten
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2733. [PMID: 32440406 PMCID: PMC7209827 DOI: 10.1097/gox.0000000000002733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
Background: Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author’s (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration. Methods: Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate. Results: A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49–71 years) and 24.9 kg/m2 (IQR: 24.2–26.7 kg/m2) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn’s disease, and 1 (4.3%) with Paget’s disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient. Conclusions: The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.
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Blok RD, Kaçmaz E, Hompes R, Lapid O, Bemelman WA, Tanis PJ. Gluteal turnover flap for perineal reconstruction following abdominoperineal resection for rectal cancer - a video vignette. Colorectal Dis 2019; 21:1094-1095. [PMID: 31116492 DOI: 10.1111/codi.14715] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/10/2019] [Indexed: 02/08/2023]
Affiliation(s)
- R D Blok
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,LEXOR, Centre for Experimental and Molecular Medicine, Oncode Institute, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Kaçmaz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - O Lapid
- Department of Plastic and Reconstructive Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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18
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Quality of Life and Sexual Functioning After Vulvar Reconstruction With the Lotus Petal Flap. Int J Gynecol Cancer 2019; 28:1728-1736. [PMID: 30157166 DOI: 10.1097/igc.0000000000001340] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Resection of (pre) malignant lesions in the vulvoperineal area may result in large defects that cannot be closed primarily. The lotus petal flap technique is widely used for reconstruction. The aim of this study was to evaluate both quality of life (QoL) and sexual functioning of patients who underwent the lotus petal flap procedure, because no data are available on this topic. METHODS A cross-sectional study was performed on all eligible patients (N = 38) who underwent the lotus petal flap procedure between 2005 and 2016. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, Female Sexual Function Index, and Body Image Scale were used to evaluate QoL and sexual functioning. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and Female Sexual Function Index scores were compared with scores of age-matched healthy women. RESULTS Twenty-six patients (68%) responded. The mean (SD) age was 65.5 (16.3) years, and the median follow-up time was 38.5 months (range 16-141 months). Quality of life scores were lower compared with healthy women in the domains physical, role, and social functioning. Sexual activity rates were comparable with healthy women; however, sexual functioning was worse. Although patients were satisfied about their sexual life, pain was reported. CONCLUSIONS Patients who underwent vulvar reconstructive surgery with lotus petal flaps seem to have a lower QoL compared with healthy women. Patients report more pain during sexual activity but are satisfied about their sexual functioning. These results should be included in preoperative counseling and follow-up of future patients eligible for vulvar reconstruction with a lotus petal flap.
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Yang XY, Wei MT, Yang XT, He YZ, Hao Y, Zhang XB, Deng XB, Wang ZQ, Zhou ZQ. Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis. Colorectal Dis 2019; 21:138-155. [PMID: 30428157 DOI: 10.1111/codi.14471] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/29/2018] [Indexed: 02/05/2023]
Abstract
AIM Perineal wound complications after abdominoperineal resection (APR) have become a major clinical challenge. Myocutaneous flap closure has been proposed in place of primary closure to improve wound healing. We conducted this comprehensive meta-analysis to evaluate the current scientific evidence of primary closure vs myocutaneous flap closure of perineal defects following APR for colorectal disease. METHODS We systematically searched the MEDLINE, Embase, PubMed, Web of Science and Cochrane Library databases to identify all relevant studies. After data extraction from the included studies, meta-analysis was performed to compare perioperative outcomes of primary closure and myocutaneous flap closure. RESULTS Eighteen studies with a total of 17 913 patients (16 346 primary closure vs 1567 myocutaneous flap closure) were included. We found that primary closure was significantly associated with higher total perineal wound complications (P = 0.007), major perineal wound complications (P < 0.001) and perineal wound infection (P = 0.001). On the other hand, myocutaneous flap closure takes more operation time (P < 0.001) and increases the risk of perineal wound dehiscence (P = 0.01), deep surgical site infection (P < 0.001), enterocutaneous fistulas (P = 0.03) and return to the operating room (P = 0.0005). There were no significant differences between the two groups for other outcomes. CONCLUSIONS This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure of perineal defects after APR for colorectal disease. Although taking more operation time and an increased risk of specific complications, the pooled results have validated the use of myocutaneous flaps for reducing total/major perineal wound complications. More investigations are needed to draw definitive conclusions on this dilemma.
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Affiliation(s)
- X Y Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - M T Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X T Yang
- Wound Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Y Z He
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Y Hao
- West China School of Public Health, Sichuan University, Chengdu, China
| | - X B Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X B Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Z Q Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Z Q Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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Foster JD, Tou S, Curtis NJ, Smart NJ, Acheson A, Maxwell-Armstrong C, Watts A, Singh B, Francis NK. Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement. Colorectal Dis 2018; 20 Suppl 5:5-23. [PMID: 30182511 DOI: 10.1111/codi.14348] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/16/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE). METHODS A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations. RESULTS Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications. CONCLUSION This position statement updates clinicians on current evidence around perineal closure after APE surgery.
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Affiliation(s)
- J D Foster
- Department of General Surgery, Poole Hospital NHS Foundation Trust, Poole, Dorset, UK
| | - S Tou
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - N J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, Somerset, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - N J Smart
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - A Acheson
- Department of Colorectal Surgery, Nottingham University Hospital, Nottingham, UK
| | - C Maxwell-Armstrong
- Department of Colorectal Surgery, Nottingham University Hospital, Nottingham, UK
| | - A Watts
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - B Singh
- Department of General Surgery, Leicester General Hospital, Leicester, UK
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Spasojevic M, Mariathasan AB, Goscinski M, Thorgersen EB, Solbakken AM, Gullestad HP, Ryder T, Flatmark K, Larsen SG. Vertical Rectus Abdominis Musculocutaneous Flap Repair Improves Perineal Wound Healing after Abdominoperineal Resection for Irradiated Locally Advanced Rectal Cancer. Ann Surg Oncol 2018; 25:1357-1365. [DOI: 10.1245/s10434-018-6363-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Indexed: 01/07/2023]
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Woodfield J, Hulme-Moir M, Ly J. A comparison of the cost of primary closure or rectus abdominis myocutaneous flap closure of the perineum after abdominoperineal excision. Colorectal Dis 2017; 19:934-941. [PMID: 28436214 DOI: 10.1111/codi.13690] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 01/30/2017] [Indexed: 12/13/2022]
Abstract
AIM Perineal wound complications following abdominoperineal resection continue to be a major challenge. The aim of this study was to compare the clinical outcomes and cost of primary closure (PC) and rectus abdominis myocutaneous (RAM) flap reconstruction. METHOD This was a retrospective case review of consecutive patients by one surgeon over 11 years. Patient demographics, risk factors, operative details and complications were identified. Inpatient and outpatient costs were calculated. RESULTS A total of 31 patients underwent a RAM reconstruction and 37 a PC. There were no significant differences in the incidence of wound complications or in the overall costs for either method of perineal closure. When there were no complications the mean costs were significantly higher in the RAM group ($20 948 vs $17 189, P = 0.005), mainly because of the longer operating time. However, the costs of perineal wound complications were greater in the PC group (8394 vs 25 911, P = 0.012). These wounds took longer to heal (median 2 months vs 5.5 months, P = 0.005) and more often required a further reconstructive surgical procedure (RAM 0 vs PC 8, P = 0.006). CONCLUSION This is the first study reporting on the cost implications of PC and RAM flap reconstruction. The overall costs were similar. This implies appropriate clinical selection when choosing between procedures. While the RAM flap is more expensive to perform, the finding that it decreases the clinical severity and cost of perineal wound complications supports its use when there is a high risk of perineal wound complications.
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Affiliation(s)
- J Woodfield
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - M Hulme-Moir
- Department of Surgery, North Shore Hospital, Waitakere District Health Board, Auckland, New Zealand
| | - J Ly
- Department of Surgery, North Shore Hospital, Waitakere District Health Board, Auckland, New Zealand
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Mortensen AR, Grossmann I, Rosenkilde M, Wara P, Laurberg S, Christensen P. Double-blind randomized controlled trial of collagen mesh for the prevention of abdominal incisional hernia in patients having a vertical rectus abdominis myocutaneus flap during surgery for advanced pelvic malignancy. Colorectal Dis 2017; 19:491-500. [PMID: 27805791 DOI: 10.1111/codi.13552] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/18/2016] [Indexed: 02/08/2023]
Abstract
AIM The study investigated the effect of collagen mesh-assisted closure at the donor site in preventing the formation of incisional hernia following construction of a vertical rectus abdominis myocutaneus (VRAM) flap as part of pelvic surgery for recurrent colorectal cancer. METHOD The study was a double-blinded randomized controlled superiority trial that was designed and performed according to the Consolidated Standards of Reporting Trials (CONSORT) Statement. Eligible patients undergoing surgery that included a VRAM flap for advanced colorectal pelvic malignancy were prospectively randomized to conventional abdominal wound closure or collagen mesh-assisted closure. The primary end-point was incisional herniation at 1 year confirmed by CT. Secondary end-points were CT-verified incisional herniation at 3 and 36 months, clinically recognizable incisional herniation, donor-site and reconstructive-site complications, surgical mortality, postoperative morbidity, postoperative recovery and survival. RESULTS In total, 58 (29 conventional closure; 29 mesh-assisted closure) patients were included. At 1 year, incisional herniation on the CT scan was found in 12 (50%) of 24 patients in the conventional closure group, and in 8 (33%) of 24 in the mesh-assisted closure group (P = 0.38). No significant difference between the groups was found in surgical mortality, early or late complications or survival. Donor-site morbidity was comparable between the two groups. CONCLUSION No preventative effect of collagen mesh-assisted closure was observed following VRAM flap reconstruction.
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Affiliation(s)
- A R Mortensen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - I Grossmann
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - M Rosenkilde
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - P Wara
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - P Christensen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
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Kehrer A, Lamby P, Miranda BH, Prantl L, Dolderer JH. Flap design and perfusion are keys of success: Axial fasciocutaneous posterior thigh flaps for deep small pelvic defect reconstruction. Clin Hemorheol Microcirc 2017; 64:305-318. [DOI: 10.3233/ch-168105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andreas Kehrer
- Department of Plastic, Hand- and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Philipp Lamby
- Department of Plastic, Hand- and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Benjamin H. Miranda
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Lukas Prantl
- Department of Plastic, Hand- and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Juergen H. Dolderer
- Department of Plastic, Hand- and Reconstructive Surgery, University Medical Center Regensburg, Germany
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Althumairi AA, Canner JK, Ahuja N, Sacks JM, Safar B, Efron JE. Time to Chemotherapy After Abdominoperineal Resection: Comparison Between Primary Closure and Perineal Flap Reconstruction. World J Surg 2016; 40:225-30. [PMID: 26336877 DOI: 10.1007/s00268-015-3224-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Wound complications are frequent flowing abdominoperineal resection (APR); this can lengthen the time to chemotherapy. Flap reconstruction is being used in an attempt to improve wound healing. OBJECTIVES To assess the effect of flap reconstruction after APR on time to perineal wound healing and administration of adjuvant chemotherapy in patients with rectal adenocarcinoma. METHODS A retrospective review of patients who underwent APR for rectal adenocarcinoma between 2002 and 2012 was performed. Patients were divided into two groups based on type of perineal wound closure (primary vs. flap). Patients were compared for time to perineal wound healing, and time to adjuvant chemotherapy. RESULTS 115 patients were identified; of whom 67 received adjuvant chemotherapy. 56 (84%) patients underwent primary closure while 11 (16%) underwent flap reconstruction. There was no difference in time to perineal wound healing (6.8 vs. 6.3 weeks, p = 0.40) and time to receive adjuvant chemotherapy (9.3 vs. 10.7 weeks, p = 0.79) between the primary closure and flap reconstruction groups, respectively. 25 (45%) of the primary closure group had a delay in receiving adjuvant chemotherapy versus 6 (55%) of the flap reconstruction group (p = 0.55). Delay in receiving adjuvant chemotherapy because of perineal wound complications occurred in 18 (32%) patients with primary closure versus 3 (28%) patients with flap reconstruction (p = 0.14). CONCLUSIONS Flap reconstruction does not reduce the length of time to initiating chemotherapy; there was no difference in length of healing between the two groups. Therefore, flap reconstruction should be selectively used based on the size of the perineal defect.
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Affiliation(s)
- Azah A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nita Ahuja
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
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Abdominoperineal resection and perineal wound healing in recurrent, persistent, or primary anal carcinoma. Int J Colorectal Dis 2016; 31:1197-203. [PMID: 27033699 DOI: 10.1007/s00384-016-2575-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Chemoradiotherapy is the standard treatment for squamous cell anal cancer. Salvage abdominoperineal resection (APR) is usually reserved for patients presenting with recurrent or persistent disease. Aim of our study was to review the outcomes of salvage surgery and perineal wound healing with or without a vertical rectus abdominis myocutaneous (VRAM) flap in a single institution over a 6-year period. METHODS Data of all patients with biopsy-proven squamous cell anal cancer treated with chemoradiation at the University Medical Center Mannheim were recorded prospectively. Medical records of all patients who underwent salvage surgery for anal carcinoma between June 2008 and June 2014 were reviewed with regard to surgical and oncological outcomes. RESULTS One hundred twenty-four patients received chemoradiation with a 5-year overall survival of 79 %. Seventeen patients required (salvage) APR for recurrent (n = 8), persistent (n = 7), or primary anal carcinoma (n = 2). Median overall survival was 33.4 months. Median duration until completion of perineal wound healing was shorter in the VRAM group (17 vs. 24.5 weeks; p = 0.0541). CONCLUSIONS Salvage APR has a reasonable chance of long-time survival. Perineal reconstruction with a VRAM flap may reduce the duration until completion of perineal wound healing.
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Mori S, Sassaroli C, Di Monta G, Romano GM. Transpelvic Rectus Abdominis Flap Reconstruction Following Abdominoperineal Resection. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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